As veterinary medicine is continuously evolving, so are the expectations for the level of patient care. In the veterinary emergency and critical care setting, patient care checklists can be utilised to optimise patient care quality and standards. Check-lists create a step-by-step process of evidence-based interventions and procedures that help prevent medical oversights (Berenholtz et al, 2002; Fulbrook and Mooney, 2003).
Kirby's Rule of 20 is a checklist created by Rebecca Kirby, DVM, DACVIM, DACVECC that includes 20 patient parameters that should be evaluated daily in critically ill patients. Kirby's Rule of 20 was created as a reminder for veterinarians and veterinary nurses to examine the status of critically ill patients, including organ systems involved, clinical parameters, diagnostic parameters, and treatment goals in order to optimise patient survival (Kirby, 2017). Following the Kirby's Rule of 20 checklist allows veterinary nurses to assess the overall clinical picture of a patient (taking a holistic approach), implement critical thinking skills, elevate the quality of patient care, set standards for patient care, and decrease morbidity and mortality which results in improved patient outcomes (Berenholtz et al, 2002; Fulbrook and Mooney, 2003).
The patient parameters in the Kirby's Rule of 20 check-list are:
- Fluid balance
- Albumin and oncotic pull
- Electrolyte and acid–base
- Mentation
- Heart rate, rhythm and contractility
- Blood pressure
- Body temperature
- Oxygenation and ventilation
- Red blood cells and haemoglobin
- Coagulation cascade
- Renal function
- Gastrointestinal motility and integrity
- Nutrition
- Glucose
- Immune status and antibiotics
- Wound healing and bandages
- Drug dosage and metabolism
- Pain control
- Nursing care
- Tender loving care (TLC).
To allow enough detail for each parameter, part 4 will focus on the physiology, clinical application, and monitoring of patient parameters 16–20.
Wound care and bandages
In the critical care setting, insult to the musculoskeletal and integumentary systems occurs from traumatic injuries. These wounds can be caused by many external factors and their classification takes into consideration their etiology, location, type of injury, and clinical appearance (depth, tissue loss) (Devey et al, 2017).
The predominant goal in wound healing is to facilitate closure and to minimise or prevent infection and/or necrosis (Rivituso, 2019). The healing process involves activation of the haemostatic system followed by the four phases of inflammation, debridement, proliferation (repair), and maturation (Scalf, 2014). Immediately after injury, blood vessels flood the wound to remove surface bacteria, vasoconstriction and platelet aggregation prevents excessive bleeding by adhering to the injury site, and activation of coagulation and clot formation stops further bleeding. During the inflammation phase, there is a protective tissue response in which leukocytes, endothelial cells, and inflammatory mediators enter the wound to cause a local inflammatory response. During the debridement phase, leukocytes migrate to the wound to initiate phagocytosis of bacteria and damaged tissue debris to minimise risk of infection. Additionally, macrophages enter the wound to further assist in removal of pathogens and damaged tissue and modulate growth factors in preparation for wound repair. During the proliferation phase, the processes of angiogenesis (blood vessel creation), fibroplasia (formation of collagen deposits), and epithelialisation (skin cell formation) result in the development of granulation tissue, contribute to wound contraction, and promote wound healing. During the maturation phase, collagen continues to be deposited around the wound as it fully contracts (Scalf, 2014; Devey et al, 2017; Rivituso, 2019).
The goals of wound care include preserving viable tissue, restoring damaged tissue back to normal, providing an environment that promotes strength and function, and avoiding infection (Devey et al, 2017). Wound care involves carefully clipping the area around the wound, aseptically cleaning the wound, and fully lavaging/irrigating to prevent further contamination (Rivituso, 2019).
Monitoring of healing wounds includes assessment of patient parameters (heart rate, respiratory rate, blood pressure, fluid balance, nutritional status), evaluating the immune system response (leukogram), and daily evaluation of the wound for signs of infection (discolouration, discharge, odour, swelling, heat) or dehiscence (Figure 1) (Scalf, 2014; Devey, 2016).
Bandaging involves the external application of dressing material to wounds (for example lacerations, abrasions, surgical). The goals of bandaging are to provide a warm and moist environment to facilitate wound healing, protect the wound from additional contamination, provide compression to alleviate oedema and haemorrhage, and stabilise or immobilise the injured area to prevent disruption of the healing process (Scalf, 2014).
For traumatic wounds, the three bandage layers include the primary layer (direct contact), secondary layer (padding and absorbent), and tertiary layer (securing and protectant) (Benasutti, 2012). The specific type of bandage application will be dependent on the various wound factors discussed above. For non-traumatic surgical wounds, such as incision sites, bandages are applied as a topical dressing using only a nonadherent primary layer and adhesive tertiary layer (Figure 2).
Monitoring of dressings and bandages includes assessment of the patient (comfort, mobility) and daily evaluation of the dressing/bandage for signs of mal positioning, tightness, strike-through, or soiling from bodily fluids, any of which would require changing of the dressing/bandage (Benasutti, 2012).
Drug dosage and metabolism
The goal of drug therapy for critically ill patients is to induce a desired pharmacological response for a period of time (Boothe, 2017). Initiating a drug therapy protocol requires specific knowledge of drug pharmacokinetics and pharmacodynamics to ensure the protocol is right for a critically ill patient and their disease process.
Pharmacokinetics is the branch of pharmacology that is concerned with how drugs move within the body. The processes of drug movement includes absorption, distribution, metabolism, and excretion (Quandt and Olmstead, 2012). Absorption refers to movement of a drug from the site of administration to the systemic circulation. Factors that affect absorption include rate of drug absorption, extent of absorption, and bioavailability of the drug once in the systemic circulation. Distribution refers to movement of a drug from the systemic circulation to the intended site of action, such as the tissue/organ system, in order to produce a physiologic effect. Factors that affect distribution include regional blood flow, drug-tissue binding, transport proteins, and drug solubility. Metabolism refers to the bio-transformation of a drug through specialised enzymatic systems (primarily via the hepatic system). Factors that affect biotransformation include hepatic blood flow and protein-binding of a drug. Excretion refers to movement of a drug out of the body (primarily via the renal system). Factors that affect excretion include renal blood flow, glomerular filtration rate, and transport proteins (Scalf, 2014; Boothe, 2017).
Pharmacodynamics is the branch of pharmacology that is concerned with the drug's physiologic effect on the body (Quandt and Olmstead, 2012). The degree of response to a drug is determined by the concentration of drug in the body and the affinity of the drug to its target receptors (Boothe, 2017). Factors that affect pharmacodynamics in-clude receptor sensitivity, receptor binding, and biochemical interactions.
When initiating a drug therapy plan, there are five ‘rights’ of drug administration that need to be followed. The five rights are: the right drug; the right patient; the right dose; the right route; and the right time (Quandt and Olmstead, 2012). In the human critical care field, there are an additional two rights: right reason and right documentation (Liss and Norkus, 2019). Before administering any drug, the five rights should be reviewed and verified to prevent medical errors and potential patient harm.
Drug therapy monitoring involves assessment of drug response, drug interactions, adverse drug reactions, and daily review of the drug therapy plan (Babyak and Backus, 2019). Drug response refers to the expected response from administering the drug and needs to be assessed to ensure the appropriate response occurs. Drug interactions refer to the need to review how multiple drugs interact within the body (compatibility versus incompatibility) and with other drugs. Adverse drug reactions refer to evaluating for an unexpected and/or undesirable effect of the drug following administration. Reviewing a patient's drug therapy plan in-cludes monitoring what drugs the patient is on, the correct drug doses and frequency, and if any adjustments need to be made (for eample recalculation based on current daily weight, changes in dosage or frequency, de-escalation, discontinuation) (Boothe, 2017; Liss and Norkus, 2019).
Pain control
Pain is defined by the International Veterinary Academy of Pain Management (IVAPM) as an unpleasant sensory and emotional experience associated with actual or potential tissue damage (Gottlieb, 2019). Pain control is important because if left unidentified or untreated, it leads to greater morbidity, mortality, and patient suffering (Scalf, 2014; Gottlieb, 2019).
The pathophysiology of pain is a neurophysiological event that involves nociception followed by the processes of transduction, transmission, modulation, projection, and perception (pain pathway). Nociception refers to the perception of noxious stimuli at the site of tissue injury via nociceptors (pain receptors) that are present throughout the nervous system. Transduction refers to the noxious stimuli being mediated by nociceptors and converted to an electrical impulse. Transmission refers to the electrical impulse being propagated from the site of tissue injury to the spinal cord (peripheral nervous system). Modulation refers to the electrical signal being either amplified or suppressed by interneurons. Projection refers to the electrical signal traveling to the brain (central nervous system). Perception refers to the integration and processing of nociceptive information to recognise the stimulus as painful (the feeling of pain) (Valtolina and Goggs, 2012; Scalf, 2014; Pigott, 2017).
Physiological consequences of pain occur from the body's increase in sympathetic tone, which is an involuntary response to stressful situations (fight or flight response). These consequences include increased myocardial oxygen demand, decreased tidal volume, peripheral vasoconstriction, decreased tissue oxygen delivery (leads to shock), increased temperature, increased metabolic rate, stress hormone release, decreased gastrointestinal blood flow, increased blood viscosity, and immunosuppression (Scalf, 2014; Shaffran, 2016).
Pain control is primarily achieved through the use of analgesics, or drugs that provide the absence of pain or loss of sensitivity to pain (Gottlieb, 2019). Opioids are the most effective drug class in providing analgesia because they act centrally to limit nociception by exerting their effects on different receptors within the brain and spinal cord (Scalf, 2014). Other pharmacologic options for pain control include alpha-2 agonists, dissociative agents, gamma-aminobutyric acid (GABA)-inhibitors, non-steroidal anti-inflammatory drugs (NSAIDs), and local anaesthetics. The pain therapy plan should address a multimodal approach. Multimodal analgesia refers to the practice of using multiple drugs, each with a different mechanism of action, that are complementary or synergistic (Pigott, 2017).
To ensure adequate monitoring of pain, a variety of patient parameters are assessed as well as using pain scale systems. Being able recognise and evaluate pain is integral to the wellbeing of critically ill patients. Patient parameters to assess include heart rate (+/- heart rhythm), respiratory rate, blood pressure, mentation, patient posture, and general behaviour. Pain scales can be a useful tool in helping evaluate a patient's pain level because they provide a means of objective pain assessment (Shaffran, 2016; Pig-ott, 2017; Gottlieb, 2019). In the author's experience, the use of the Colorado State University's canine and feline acute pain scales has shown to be effective in veterinary pain assessments (Figures 3a, 3b). A pain score using a pain scale system is an ideal way to determine if pain is being addressed appropriately, and should be included as part of routine assessment of other patient parameters (Babyak and Backus, 2019).
Nursing care and tender loving care
Providing nursing care to the critically ill involves a skilled, knowledgeable, attentive, and trained nursing staff. Veterinary nurses need to practice the discipline of critical thinking, which is the process of conceptualising, analysing, synthesising, and applying critical care concepts to patient care (Darbo and Page, 2017). Kirby's Rule of 20 provides an organised approach to monitor vital patient parameters in the critical care setting and provide standardised, evidence-based holistic nursing care.
Part of nursing care also includes medical record keeping and patient handover (patient rounds). Medical record keeping (charting) is the meticulous documentation of the care a critical patient receives while under the care of the veterinary team. It is essential that medical record charting be done well because a patient's chart is considered a legal medical record. Medical records provide a means to record and communicate crucial patient information to all members of the team providing care. An accurate chart is essential to determine the patient's current and previous status and to assess the patient's future needs. When charting in the medical record, just the facts should be stated in an objective way (for example clinical signs/values, treatments, procedures). Entries should be legible, free from spelling or grammatical errors, and contain detailed and straight-forward statements of the medical facts related to the case (Darbo and Page, 2017).
Checkboxes are often used to record information (i.e. treatment orders, treatment sheets, discharge instructions). When using checkboxes, initials should be placed in the box, never checkmarks or an ‘X’. From a legal standpoint a checkmark does not allow tracking and accountability. While checkboxes can save time in the recording of patient orders, they lack the ability to accurately describe a patient's condition. Patient specifics of a veterinary nurse's assessment is an integral aspect of patient care and should be noted to add accuracy to the monitoring as a nursing note to better reflect the quality of care given.
Documentation in the chart should be done as soon as possible to prevent omission of crucial details that may be forgotten at the end of a shift. This is also important because a critical patient's status can change in a matter of moments and lack of prior documentation can be problematic.
Patient handover is an important aspect of the nursing care process and involves a structured and systematic approach to discussing a patient's condition and coordinate care. Approaching each case in a regular, repeatable fashion develops a routine that eliminates the chance that information is overlooked or omitted. Further systematisation of the rounding procedure includes adding written materials to a traditionally verbal process. Veterinary hospitals can do this by setting aside time in the schedule for nursing staff to address the oncoming shift and inform them about the cases that they will be handing over. It is ideal to have all nurses who are stationed in the intensive care unit to attend and learn about each patient (Darbo and Page, 2017; Kerrigan, 2020).
Items that should be included as part of standardised patient handover include patient signalment, presenting complaint, date of admission, general attitude, working/definitive diagnosis, physical examination and daily progress, pertinent diagnostics, current medications, information pertaining to catheters/ports/drains, appetite/food preferences, owner communications, and advanced directive status (Scalf, 2014; Babyak and Backus, 2019; Farry and Norkus, 2019). Effective patient handover will provide a foundation for the new shift to begin their care. Observing the patients together will also help to provide continuity of care.
Thorough medical charting and structured patient handover are both practices that lead to effective team communication when it comes to patient care.
The nurse-patient relationship is enhanced when patients are provided much-needed TLC (Darbo and Page, 2017). TLC involves the nursing care that goes above and beyond the written patient care. Examples include giving soft and plush cage bedding, providing massage and physical therapy for recumbent patients, warming up food and/or hand feeding, ensuring cleanliness, giving ‘privacy screens’ for timid patients, applying eye lubrication for patients in oxygen kennels, turning off the intensive care unit lights at night to allow rest, spending extra time (off-treatment time) providing one-on-one love and attention, facilitating owner visitations, and generally treating each patient as a pet.
Conclusion
Veterinary nurses are the patient's primary caregivers and are involved in monitoring critical patients. Utilising the Kirby's Rule of 20 patient checklist provides an organised method for veterinary nurses to thoroughly assess the critical patient parameters of wound healing and bandages, drug dosage and metabolism, pain control, nursing care, and TLC. Having a thorough understanding of each of these patient parameters enables veterinary nurses to prioritise patient needs by assessing the overall clinical picture to elevate the standards for quality patient care.
KEY POINTS
- Kirby's Rule of 20 is an established, evidence-based patient checklist that can be used by veterinary nurses in the emergency and critical care setting to assess the overall clinical picture of critically ill patients, implement critical thinking skills, and elevate the quality of patient care.
- Wound care involves preserving viable tissue, restoring damaged tissue, and promoting an environment to minimise infection. Bandage dressings should be applied to promote wound healing and should be monitored daily.
- Drug therapy protocols for the critically ill requires having knowledge of both pharmacokinetics and pharmacodynamics so as to closely monitor the patient's response.
- Pain control care involves understanding the pathophysiology of pain, the pharmacology of analgesics, behavioural and physiologic signs of pain, as well as use of pain scoring systems.
- Nursing care and tender loving care is the advanced level of care provided to critically ill patients by the veterinary nursing team. Important aspects of nursing care include medical record keeping, patient handover, and the nurse-patient relationship.