Low-stress handling for long-term wound care

Veterinary practices are presented with a diverse range of conditions. Some conditions, such as cases involving wound care, can be unpredictable in both the duration of recovery and the outcome. Patients may have to undergo a number of visits to the practice and experience a range of procedures in regards to the long-term care of wounds including, but not limited to:

• Initial consultation
• Bandage/dressing changes
• Surgery
• Suture removal
• Aftercare and follow-up appointments.

Some veterinary professionals believe that it is normal for pets to be scared while at the veterinary practice and Lloyd (2017) states that it has become customary to accept that negative responses to the veterinary environment are typical. As veterinary professionals, veterinary nurses should be creating positive patient experiences, to ensure that they are reducing patient stress and doing no harm. Utilising low-stress handling (Box 1) can avoid undesirable behaviours, provide a safer working environment and promote a higher standard of animal welfare.

Box 1.Low-stress handling

• Support the animal well, do not let it feel off balance
• Be aware that unnatural positions can cause them to resist handling
• Wait until the pet is relaxed before starting a procedure
• Use minimum restraint suitable for the individual
• Use distraction and rewards when appropriate
• Adjust your handling based on the animal and its response

Wilink, 2016

Problems that can occur in patients receiving long-term care

Mariti et al (2017) discovered that dogs which were uncomfortable with their owners carrying out procedures at home would also be intolerant of the veterinary nurse or surgeon doing the same in the consultation room. The veterinary nurse can therefore have the advantage of determining which patients will need additional support throughout a bandage change on a sensitive area, such as the tail, by completing a thorough history with the client prior to under-taking the procedure. Throughout this time the veterinary nurse can phrase questions, such as ‘How tolerant is he/she of you going near the wound?’ to determine their course of action. Preventing a negative experience from occurring is an essential role of the veterinary nurse (Edwards et al, 2019), and anything that can be done to prevent a stress response from escalating disproportionately during long-term treatment will benefit the welfare of the animal.

Balsa and Culp (2015), Calder (2014) and Bellah (2006) explained that the success of a bandage can be limited by the movement of the area and the tension of the bandage applied. Immobilising the patient when applying the bandage is therefore especially important because incorrect application can cause bandages to move (Bellah, 2006). This, when coupled with the fact that it could be an area that cannot be prevented from moving in itself, can make for a challenging situation. Methods, such as, forcing the animal into unnatural positions via physical restraint should be avoided because they restrict patient choice (Ryan, 2018), therefore increasing the chances of an animal reacting adversely to the situation they find themselves in. Chemical restraint can be used to prevent the animal developing negative associations with the treatment (Hargrave, 2017), and Edwards et al (2019) found that chemical restraint can be more beneficial to some animals than manual restraint because it allows for improvements in their co-operation and behaviour. Ultimately, however, it is imperative that the veterinary team find the best method of control for each individual patient while working in a calm and professional manner.

An aspect of successful wound management, in long-term cases, is the relationship between the patient, owner and veterinary team (Edwards et al, 2019). From the owner's point of view, a veterinary nurse who shows compassion and respect towards the pet must therefore understand the animal and its needs (Lloyd, 2017). It is imperative that veterinary nurses refer to their declaration (Table 1) and are constantly trying to reduce fear and anxiety in animals thus instilling a comfortable nurse-pet-client relationship (Lloyd, 2017). A visit to a veterinary environment can be extremely stressful for the animal (Arhant et al, 2019) and patients that repeatedly visit a practice because of long-term treatment may develop anxiety. Anxiety can lead to undesirable behaviours developing in response to their experiences, for example, refusing to exit the car on arrival at the practice or withdrawing when the veterinary professional approaches. If these behaviours are left unchecked then they can become harder to train out at a later date and a qualified trainer/behaviourist may have to be sought.

When dealing with patients that are undergoing long-term treatment the veterinary team need to be aware of potential signs of stress. Knowledge of these stress signs and appropriate low-stress handling techniques are a vital aspect of the team's education to ensure that they are able to respond appropriately and skilfully in these situations. Low-stress handling can help towards maintaining relationships between the veterinary professional and the patients while the patient is adjusting to the novel environment they find themselves in, thereby preventing anxieties from becoming phobias (Figure 1). Lloyd (2017) explained that owners are often unwilling to put themselves or their pets through potentially stressful situations. The veterinary nurse is therefore ideally placed to endorse ways in which the animal's, and therefore the owner's, welfare (Lloyd, 2017) can be promoted, and make procedures, such as bandage changes, more agreeable.

Signs of stress

Overall (2013) emphasised that negative experiences in the veterinary practice can lead to long-lasting anxiety in the patient. Reducing stress while undergoing treatment can therefore improve the welfare of patients, staff and owners (Edwards et al, 2019). Stress can present itself in many different ways (Table 2) and the effects it can have on the patient may vary. Stress can impair physical wellbeing and social relationships (animal and human) and reduce the animal's ability to relax (Hargrave, 2015). The physiology and psychology of the animal must be considered (Williams, 2016; Lloyd, 2017) because parameters and behaviours displayed, when undergoing long-term treatment, may not be ‘normal’ for that animal. It is also essential for the veterinary team to remember that an animal might be in pain, which on its own or coupled with anxiety can lead to unpredictable behaviours from the animal (Mariti et al, 2017), such as, aggression or avoidance and escape strategies. Muzzles or chemical restraint may therefore be necessary to safeguard those working with the patient. Interventions such as these must be assessed on an individual basis because each animal will respond differently and even the same animal's responses can vary from visit to visit. The veterinary team must always be aware of the importance of every interaction that the animal has in the practice and how undesirable behaviours can affect current and future visits (Hargrave, 2017). Hargrave (2017) and McMillan (2002) suggested that the way to minimise stress in animals is to make experiences as enjoyable as possible. Ryan (2018) suggested the use of positive reinforcement techniques, such as praise and food-based rewards, and responding appropriately to the patient's emotional needs.

Solutions

The management of wounds requires an understanding of the healing process, the area affected and treatment processes being carried out. Tail wounds can be particularly difficult to manage (Box 2) because of their vulnerable location and the fact that they can easily be contaminated by urine and faeces (Bellah, 2006). It is important therefore to ensure that the patient remains mentally stimulated so it does not begin interfering with the bandage due to boredom during recovery. Lick mats can be used in both the home and veterinary setting to distract patients while undergoing long-term treatment. These can be placed on the wall or floor in front of the animal and covered with a palatable paste; allowing for treatment to occur with the minimum of fuss. Interactive feeders filled with frozen or fresh fillings, such as peanut butter or soaked dog food, can also be used; however, they are not static and stable like lick mats and their use might therefore need additional supervision. Lick mats are preferable if the dog needs to be immobilised. The distraction provided by the food may also allow the low-stress handling to be established in a calm environment.

Box 2.Case study‘Gin’ a 3-year-old entire female working gun dog Labrador had a traumatic tail tip injury following numerous incidents during the shooting season. Initially the tail was bandaged to promote healing and an antibacterial cream was applied (FiltaBac, Aniwell). The owner was not keen on tail amputation so conservative management, including therapeutic laser and bandage changes, were utilised over the following weeks.After several weeks of unsuccessful conservative management, it was decided that amputation of 3 cm of her tail at the distal tip was necessary. Dressings, ranging from Allevyn (Smith & Nephew) to silver impregnated dressings were used following surgery and the wound was assessed every 48 hours to check for signs of infection. Unfortunately, the wound became infected during the healing process and antibiotics were then introduced (1.5 x 50mg amoxycilin twice daily for 2weeks increasing to 1 x 500 mg amoxycillin twice daily). Once the healing process was established the wound was left open to granulate. At the onset of treatment Gin was compliant, however, as treatment progressed she began to withdraw whenever the bandage material was produced. To prevent this sign of anxiety developing a low-stress technique was devised to distract her during the treatment. Gin was provided with a lick mat, her body language changed remarkably on the production of this and negative associations were prevented from developing during the lengthy treatment and recovery. Following the use of this technique Gin was able to tolerate the bandage changes both at home and in the veterinary environment and no longer withdraw from the bandage materials.

‘Gin’ being distracted during low-stress handling.

‘Gin’ working.

Patient should be given multiple opportunities to adapt to new experiences of sights, smells and people (McMillan, 2002), and mental stimulation can be a useful tool at this time. Devising short exercises that can be repeated throughout the day can keep the animal's mind active and stave off boredom in the hospitalised patient — and these can repeated at home. Equipment for these purposes can be prepared by the veterinary nurse in advance and includes grooming implements, feed puzzles and games (Jefferies, 2016; McMillan, 2002). Sprinkle feeding can provide more stimulation during feeding times for an animal on restricted exercise by not only making the actual activity of eating last longer, but also providing environmental enrichment to distract the patient from their wound (McMillan, 2002). During times of potential stress, the nurse can provide the patient with these mental stimulation activities to distract from the situation while conducting low-stress handling of the animal.

The owner should be considered throughout the treatment of the animal (Jefferies, 2016) to ensure their concordance with bandage care and therefore hopefully enable a smoother and quicker recovery for the patient. Barry (2018) stated that the education of owners by the veterinary team can dramatically increase compliance with treatment in relation to medical illnesses. This idea can be transferred to wound care and recovery by ensuring that the treatment is discussed fully with the owner (Barry, 2018). The veterinary nurse should understand their own role in the owner's education (Jefferies, 2016) throughout the process and be able to demonstrate low-stress handling techniques and be confident discussing its benefits.

The veterinary nurse should also ensure that the process of changing the bandage is pain free by familiarising themselves with the different wound care materials available and scheduling bandage changes at appropriate intervals for the individual wound. Recognition of infection is also an essential skill for a veterinary nurse to prevent wounds from deteriorating.

Conclusion

Veterinary nurses should play an active part in ensuring that patients are as comfortable as possible throughout the different procedures that they may encounter at the veterinary practice. Utilising opportunities for low-stress handling should always be considered, especially in situations that involve long or repeated treatments. Providing occasions during which the patient can become acclimatised to potentially stressful situations, can lead to decreased anxiety when being approached for treatment. Incorporating low-stress techniques could therefore lead to both the animal and the owner being more relaxed in the veterinary environment, leading to quicker and less stressful consultations. Veterinary professionals have a diverse range of low-stress techniques available to them and must ensure that they consider the individual animal throughout the process.

KEY POINTS

• Low-stress handling is an important skill for veterinary nurses to accomplish to ensure the welfare of their patients.
• Stress and anxiety can cause animals to behave out of character, especially when in uncertain surroundings.
• Distraction techniques can be utilised to help create a more comfortable environment for the patient.
• Each patient must be considered individually when devising low-stress handling solutions.
• Distraction techniques can be developed to provide mental stimulation for animals undergoing long-term treatment.