The patient was presented to a first opinion veterinary practice following a recent diagnosis of feline diabetes mellitus (FDM). The owner brought her cat to be admitted and hospitalised for a blood glucose curve (BGC) and later to a nurse clinic on diabetes management.
Signalment
Species: Feline
Breed: Domestic shorthair
Age: 10 years 5 month
Sex: Male (neutered)
Weight: 1.9 kg
Patient assessment
On presentation the patient was bright, alert and responsive. Patient's heart rate was 172 beats per minute (bpm) (normal range 100–180 bpm) with normal pulses, mucous membranes pale pink, capillary refill time less than 2 seconds, respiratory rate 50 breaths per minute (normal range 20–30 bpm) and rectal temperature 38.2°C (normal range 38.2–38.6oC) (Goddard and Phillips, 2011). No abnormalities noted on thoracic auscultation and abdominal palpation. The patient had body condition score of 2/9.
Veterinary investigations
On presentation initial blood glucose check revealed hyperglycaemia (glucose 27.1 mmol/litre (3.3–6 mmol/litre)). Urinalysis shown severe glycosuria (>2000 mg/dl (0 mg/dl)) and very dilute urine (specific gravity 1.010 (1.035–1.060)) (Irwin, 2011). The patient was fed and 4iu of porcine lente insulin (Caninsulin®, MSD Animal Health) was administered subcutaneously. Following that, blood glucose checks were performed every hour for the next 9 hours.
Discussion of nursing interventions
FDM is one of the most common endocrine disorders in cats (Rand and Marshall, 2005). Although the exact prevalence is unknown due to a lack of consistency in data published, most veterinary specialists in this field agreed that the incidence of FDM is increasing (Reusch, 2015). Registered veterinary nurses (RVNs) play a huge role in management of these feline patients by helping with diagnostics, performing blood glucose curves (BGC), administering medication, providing skilled nursing care during the time of hospitalisation as well as educating and advising the clients. Therefore, a good knowledge of this medical condition and most common treatment protocols is essential in order to fulfil this role (Hamlin, 2010). This patient was admitted and hospitalised for a 10 hour BGC followed by discharge and discussion with the owner about further treatment plan. The key nursing interventions were management of stress associated with hospitalisation and blood glucose sampling, patient monitoring and client education.
Stress management
BGC is one of the most important tools in monitoring diabetic cats (Reusch, 2015). Therefore, an accurately produced BGC was essential in deciding on further treatment and insulin dosages for the patient. However, cats are prone to stress hyperglycaemia which can pose a real challenge in these situations (Rand, 2012). Ellis (2015) identified a range of potential stressors for feline patients visiting or staying at the veterinary practice. These included: unpredictability of situations such as handling or specific procedures; discomfort from travelling to the practice; novelty of smells, sounds, sights or environment; adverse sensory stimulations such as machine noise or smell of disinfectants. A lack of control, inability to escape or hide, experiencing pain and seeing dogs were also identified as common stressors to cats. Keeping this in mind, various nursing interventions were planned in order to reduce the stress as much as possible.
The first consideration was the environment in which the patient was housed. A recommendation for ideal veterinary hospital set out is to have a separate dog and cat ward (Mercado, 2009). However, it is not always possible in small general practices and, unfortunately, this was the case in the author's practice. Despite this, all efforts were made to keep the patient away from dogs which meant choosing the last kennel at the back of the ward. The cage above the floor level was chosen because cats prefer staying on elevated surfaces which adds to their perceived sense of security (Ellis, 2015). Also, the cage was big enough to separate the resources such as food, water, bed and litter tray. This was identified as the second most important environmental need for cats by Ellis et al (2013). A study conducted by Kry and Casey (2007) showed that a significant stress reduction (measured using stress scores, approach tests and sample cortisol scans) was achieved in cats that were provided with hiding places in their kennels, as hiding behaviour is one of the feline coping mechanisms. Therefore, providing a hiding option, such as a box or a partially covered kennel, is advocated by numerous articles on stress management in hospitalised feline patients (Mercado, 2009; Trevorrow, 2013; Herron and Shreyer, 2014). An empty cardboard box with a hole cut in front was added to the kennel to provide a safe hiding place for this patient. The top of the box also provided an elevated surface area if the patient wanted to rest on top of it.
Various articles recommend the use of synthetic feline pheromones in veterinary hospital environment in order to help feline patients to cope with the stress (Mills, 2005; Ellis, 2009; Scotney, 2010; Trevorrow, 2013; Herron and Shreyer, 2014). It is also a part of the Feline-Friendly Handling Guidelines (Rodan et al, 2011) and Feline Environmental Needs Guidelines (Ellis et al, 2013) produced by The American Association of Feline Practitioners (AAFP) and The International Society of Feline Medicine (ISFM). Therefore, the practice used a feline facial pheromone analogue (Feliway®, Ceva) plug-in diffuser in the ward and a spray that was applied to the patient's bedding. Herron and Shreyer (2014) also suggested that playing classical music in the wards has been shown to promote relaxation in animals, which the author's practice might consider introducing in the future; however, this was not available at the time. Despite that, some other suggestions by the same authors, such as speaking softly and calmly to the patient and keeping sudden movements to a minimum, were adopted. Ellis (2015) and Scotney (2010) also reminded that human tactile interaction provides valuable stress alleviation to socialised companion animals. Therefore, nursing interventions, such as grooming, petting and tender loving care, were a part of the care plan for this patient.
Last but not least nursing consideration was given to how to make an hourly blood sample collection as comfortable as possible. Studies by Wess and Reausch (2000) and Thompson et al (2002) concluded that accurate blood glucose measurements could be taken using capillary blood. Both studies did not find a significant difference between blood samples taken from the ear and those obtained by venepuncture. A more recent study by Zeugswetter et al (2010) suggested that metacarpal and metatarsal pads could also be used to obtain the capillary blood sample. Ears, meta-carpal and metatarsal pads are currently recommended for sampling by most recent textbooks (Rand, 2012; Nelson and Couto, 2014; Reusch, 2015) as they require minimal to no restrain, are very well tolerated by most cats and blood sampling can be performed in the kennel without taking the patient out. Following these recommendations, the RVN obtained hourly blood samples by ear prick while the patient stayed in the kennel. The practice used a glucometer (AlphaTRAK®, Zoetis) specially marketed for veterinary use that required a very small drop of blood.
To minimise the sharp pain associated with needle prick, the RVN used lidocaine 2.5% prilocaine 2.5% (EMLA®, AstraZeneca) cream that was constantly applied to the ear. As a result, the patient tolerated hourly blood sampling very well and did not show any signs of discomfort or stress. EMLA® cream has been proven to numb the skin before the painful procedure in humans (Gwetu and Chhagan, 2015; Kucukoglu et al, 2015) and in animals (Flecknell et al, 1990; Keating et al, 2012). Wagner et al (2005) has also tested EMLA® cream in ill cats and concluded that it was safe to use.
Patient monitoring and care
Cats with FDM have persistent high blood glucose (above 15 mmol/litre) concentration that is above the renal threshold and therefore causing glycosuria and consequent water loss (Rand, 2012). This causes signs of polyuria and polydipsia. Therefore, it is very important to provide a constant water supply for these patients and clean their litter tray regularly. The nursing care plan included hourly checks of water bowl and litter tray done at the same time as blood sample collection. As cats are very clean animals and most of them are not used to eating, sleeping and toileting in the same area at home, leaving the litter tray dirty can cause stress (Mercado, 2009). Water intake and urine production was also monitored every 4 hours. Water intake was measured by filling the bowl with 200 ml water and measuring the amount of water left 4 hours later. Urine production was monitored by using non-absorbable litter and collecting urine produced every 4 hours.
Hourly blood glucose measuring was also a part of the patient monitoring because insulin therapy can have adverse effects. The most common and life threatening adverse effect is hypoglycaemia (Rand, 2012). As well as being aware of normal blood glucose values, the RVN must have a good knowledge of hypoglycaemia clinical signs. These include seizures, weakness, collapse or ataxia (Nelson and Couto, 2014). Therefore, frequent patient observation was also an important nursing intervention.
Patient discharge and client education
Once a further treatment plan has been decided and the diabetic patient goes home, the most important part of successful disease management becomes client compliance. Therefore, VNs have a crucial role to play in facilitating a good relationship with client and providing ongoing support (Hamlin, 2010). In human medicine nurses are becoming key players in diabetic patient management with nurse-led clinics becoming a standard of care (Aubert et al, 1998; Chan et al, 2006; Peterson and Virden, 2013). Good communication with the client is a vital component in establishing a good relationship and gaining trust. Cornell and Kopcha (2007) introduced a 4-E communication model adapted from human to veterinary medicine (Table 1). Four communication steps were essential to combine medical tasks of the interview with establishing connection and successful interaction with the client. These steps were engagement, empathy, education and enlistment. Therefore, this theory was used by the RVN in order to conduct a successful diabetic discharge appointment.
Table 1. The 4-E communication model
| 4 E's | How it was used |
|---|---|
| Engagement | The nurse engaged with the client by asking open ended questions and listened to the client's point of view. The information about the client's and pet's daily routine was gained. This stage established nurse-client connection, gained the client's trust and enabled the nurse to see what client understood about diabetes mellitus in their cat |
| Empathy | The nurse acknowledged the client's feelings and verbally expressed this acknowledgement. During this stage the nurse had to understand the client's rationale for possible fears, doubts or worries and assure the client that she knows how they feel |
| Education | Once nurse-client connection has been established and client's trust gained, the nurse could educate the client about the disease management and answer any questions they may have |
| Enlistment | In the final step the nurse enlisted the client's participation in the decision-making process about management of their cat's disease and encouraged their continuous involvement. The client was given the nurse's email address and encouraged to contact the clinic should they ever had any difficulties. |
Engaging the client included asking open-ended question about the client's daily routine and lifestyle. As Howie (2007) explained, the VN should remember that treatment of diabetes includes a change of lifestyle and diet for the pet and routine for the owner. Therefore, it is important to get as much information as possible about the owner's lifestyle in order to create a good treatment plan and increase the compliance. Maltman (2009) and Ristic (2011) stressed the importance of making sure the owner knows how to correctly store the insulin, draw up the dose and administer it to the animal as failure in one of these can result in poor glycaemic control. Therefore, the RVN went through these steps with the client and asked the client to demonstrate it back.
The client was worried that the relationship with their cat would be impaired by the daily administration of injections, therefore, it was very important to show empathy and support. The RVN assured the client that they could contact the practice at any time if they needed help. Howie (2007) acknowledged that most owners will be very nervous when starting to inject their pets and their body language will change accordingly. This could be picked up by their pet and cause them stress. Therefore, advising the owner to be calm and relaxed before injecting the cat was very important.
The RVN also talked with the owner about common complications such as diabetic ketoacidosis and hypoglycaemia; what clinical signs to watch for and what to do in the event of complication. The owner was also advised to start a low-carbohydrate and high-protein diet as research has shown that this type of diet combined with insulin therapy resulted in higher remission rates (Kirk, 2006). As the patient was already underweight this type of diet was also beneficial in restoring the lost muscle mass (Zoran and Rand, 2013). The end of consultation included listing the goals of the treatment and providing the client with a written information sheet which was the enlistment phase of 4-E model, as mentioned by Cornell and Kopcha (2007).
Conclusion
Cats with FDM are commonly seen in veterinary practices and RVNs have a vital role to play in their management. It is essential that VNs have a good knowledge of this medical condition, treatment protocols, common complications and are aware of constantly emerging new research. When caring for feline patients admitted for BGC, stress management is of paramount importance due to incidence of stress hyperglycaemia in cats. Patient monitoring while in hospital and well-planned educational discharge appointment with the owner are also very important nursing considerations.
Key points
- Registered veterinary nurses play a huge role in management of FDM, therefore, it is essential that they have a good understanding of this disease and most common treatment protocols.
- Blood glucose curve (BGC) monitoring is one of the key steps in successful management of feline diabetes mellitus (FDM).
- The main nursing considerations during BGC monitoring in hospitalised feline patients are stress management and careful patient monitoring.
- Client education and support during initial stages of disease management are the key factors that determine client compliance and successful disease management at home.
- RVNs should use approved communication models in order to establish connection with the client and build a nurse-client relationship that will lead to successful patient outcome.
- il est, qui dollicatur, omnis sa que laborem dem si conseque rem ut latur