INTENSIVE CARE NURSING CASE Chris Strike.DipAVN(Surg)VN Nursing a Dog following Gastrotomy.

1. INTENSIVE CARE NURSING CASEChris Strike.DipAVN(Surg)VNNursing a Dog following Gastrotomy. Patient- Labrador Retriever. Age- 8yrs 5mths. Sex- Male. Weight- 26.6KgReason for Admission -Supportive therapy & investigation.

2. Presenting history- • Missing for 3 days (back in owners possession 24 hrs) • Deviation from normal behaviourNot responsive, Apparent wt loss. Refusal to eat. • Drinking water but bringing it back within 5 to10 mins. • Other owner observations No defaecation to their knowledge. Urine had been passed. Clinical Findings- Patient's appearance Lethargic. Stood reluctantly with abdomen "tucked in". No abnormality detected in the abdomen,but was very uncomfortable on palpation. The eyes appeared sunken.The skin tented noticeably. No faecal material on the thermometer. Rectum dry & "tacky". T slightly sub-normal. 100.8 F/ 34.C Respirations shallow,rapid & dyspnoeic 42r/min Tachycardia, but normal heart sounds. Pulse 92 bpm Mucus membranes sticky & congested. Capillary refill time 3secs Initial Diagnosis-Suspect Gastric Foreign Body Relevant blood results Elevated PCV- 50.2%; Raised urea- 12mmol/L; Creatinine 130umol/L;Low glucose- 2.5mmol/L Indicators to confirm dehydration & some degree of starvation.

3. Supportive Treatment (pre-operatively)- I/V Catheter placement 22g over-the-needle placed in right cephalic vein AFTER sampling from jugular Fluid therapy Rapid infusion of 1 litre lactated Ringer's(Hartmann's) at rate of 22ml per min. Calculation of Fluid Deficit Using PCV: FORMULA USED- (Present PCV - Normal PCV) x Wt(Kg) x 10 =(D)mls Choice of Fluid To replace initial losses-ISOTONIC to both plasma & other fluid compartments Allows rapid correction of both circulation & tissue dehydration. The lactate content as precursor to bicarbonate will act as buffer to any metabolic ketoacidosis resulting from starvation The fluid was warmed to 40 C & maintained at this temperature with a thermal jacket Placement of Urinary Catheter 6Fg male dog urinary catheter,held in place with butterfly of 1cm zinc oxide tape, attached to prepuce with tissue glue & connected to empty fluid bag via a sterile giving set. This permits monitoring of urine out-put & keeps the recumbent patient dry. Sterile connection reduces risk of ascending infection.Continued Fluid TherapyOn completion of the Hartman's: Second fluid choice is 4% dextrose:0.18% sodium chloride(Aqupharm 18) Given initially at 22ml/min until calculated deficit replenished then slowed to 45mls/hr This meets the patients fluid needs of 40ml/Kg/Hr & electrolyte levels for the next 24hrs 30ml Amino acid/glucose/electrolyte solution were added at this point for nutritional support. Slower flow rate is delivered by infusion pump.

4. Monitoring the Pre-op Critical Patient- Urine out-put After 10 mins of RAPID infusion the collecting bag was checked for evidence of out-put. If ANURIC the drip would be HALTED! Urine production was then measured on an hourly basis & SG checked.Capillary refill time evaluated as guide to restored circulatory pressure Electrolyte values re-assessed after Hartmann's: potassium content could cause deviations if kidney function was impaired by hypovolaemia/hypotension from dehydration Radiography- Not possible conscious Although lethargic, was uncomfortable:objected to manipulation Deferred until patient considered stable enough to withstand sedation. Analgesic/sedative selected 18mg Pethidine I/M.Good analgesic but inadequate sedative After 20mins an I/V bolus of 15mg Diazepam(delayed to prevent excitability when used alone) Accompanied by rapid flush from giving set to reduce possible thrombophlebitis. Lateral radiographs of caudal & cranial abdomen. NO OBVIOUS FB!!!! Most cranial aspect of cranial view showed a radio-dense mass adjacent to diaphragm?

5. Lateral radiograph of thorax........ • Lesson---Always take two views of larger breeds.

6. Oesophageal Endoscopy(GA with propofol)- Reveals vertebral end of large chop bone & damage to mucosa Removal of Foreign Body( GA maintained on Isoflurane)- Too large to remove with endoscope tools Risk of perforation if pushed into stomach!! Surgery Required Midline Laparotomy/gastrotomy performed Bone carefully manipulated by hand from distal oesophagus Progress monitored by endoscope checking condition of oesophageal lining

7. Percutaneous gastrostomy tube fitted- Prior to closure of gastrotomy,through independant incision Reduces discomforted of main surgical wound when adhesions form (is held in place with chinese finger suture) Permits enteral feeding avoiding damaged oesophagus Dressing the site after closure Stoma covered with sterile non-adherant antibiotic impregnated tulle,split to fit phlange Vaseline applied to skin directly below stoma to protect from discharge Cotton wool padding placed between tube & skin to reduce pressure & absorb exudate All held against body by wide cohesive bandage(superflex) Leave feeding point accessible under last turn of the bandage Post-operative Support of the Critical Patient- Immediately post-op Placed on "Vet-bed" over a heated pad covered with pre-warmed blankets; bubble-wrap on extremities, ears & top of head covered Vital signs noted at 15min intervals for first 2 hours Then half-hourly for following 2 hours.Thereafter hourly. Twice daily on subsequent days prior to feeding(will elevate values) Urinary Catheter left in place until able to go out to urinate Urine volume & chemistry recorded mid-day until removal Twice daily grooming & massage while recumbent on dependant side

8. Enteral Feeding & Fluid Provision- Daily attention to tube ESSENTIAL to prevent infection & patient discomfort Will be moist 24-48 hrs post-op Gastric secretions & peritoneal fluid. Check/clean at each feed. Seepage will reduce as adhesions form between abdominal wall & gastric mucosa Clean twice daily Scrub up AFTER removing the dirty dressing Use NO STRONGER than1% povidone iodine solution & sterile gauze swabs Dry the skin well before re-dressing Check the phlange is not causing pressure necrosis of skin • Tube remains in place minimum 5 days • to permit adhesions to form between gastric mucosa & abdominal muscle wall • Nutritional requirement calculated as twice basal/resting energy requirements • Calculate using 525(Wt/Kg)0.75 or instructions on Concentrated liquid diet x 2 • Achieve this gradually over 2 to 3 days Permits toleranceObserve faeces • Feed in small boluses every 3 hours Time for gastric emptying & assess response • First feed 26Kg dog- 20ml liquid diet + 40ml sterile water Warmed to 38 C • 20ml to check tube patency & leakage/ 20ml to flush tube before sealing • < 60ml over 24hrs then 100ml day 2 (300ml overnight).<160ml day 3 • Fluids- I/V + water used to flush until considered safe to have water by mouth • Not given via tube as risk of overdistension of stomach. • Rinse mouth, moisten tongue

9. Resumption of oral nutrition • Day 4 • Water first,then liquid diet • Small amounts of daily allowance(the remains given by tube)I/V stops • Semi-solid food Day 5 • Still supplemented by tube but reducing • Monitor for regurgitation • Check weight daily • Confirms nutritional needs are being met + hydration • Monitor faecal out-put • Colour, consistency etc • Gatrostomy tube removed day 6 • under moderate sedation & wound closed

10. Other 24 hour Nursing Support Provided • TPR twice daily • before feeding(as mentioned previously) • Monitored for marked increases + restlessness = discomfort • > pulse + > CRT + high urine production of low SG = I/V over-load • PCV checked daily until I/V fluids stop • Broad spectrum anti-biotic s/c daily • ANALGESIA 12 hourly post-op,then daily • Elizabethan Collar Fitted • Checked for comfort & wiped out • Removed when gastrostomy incision closed • Monitored for wound interferrance before going home • Hand Fed when oral diet first introduced • Lots of TLC + Owner contact when appropriate