This extended patient care report will focus on the key nursing interventions carried out on a feline patient that underwent a forelimb amputation. While all nursing interventions are important, the interventions that were significant in this case include pain management, bandaging and wound care, assisting ambulation and recumbency post-surgery. The interventions will be critiqued and recommendations for future practice will be drawn.
Patient signalment
Species: Feline
Breed: Domestic Short Hair
Age: 6 months old
Sex: Female (neutered)
Weight: 2.10 kg
Reason for admission
The patient was presented to practice after sudden onset non-weight bearing on the left forelimb for 24 hours. The owner had not witnessed any trauma and was not sure of the cause. She was eating, drinking and toileting as normal, however, had difficulties in ambulating to do so. The owner had no other concerns. She presented bright yet painful on palpation of the left forelimb. A fracture was suspected of the left humerus. The patient had no pre-existing medical conditions.
Veterinary investigations
On assessment of the patient, heart rate and respiratory rate were elevated (heart rate of 240 beats per minute and respiratory rate of 36 breaths per minute—normal values; heart rate 100–200 beats per minute; respiratory rate 20–30 breaths per minute (Goddard and Phillips, 2011)), with good pulse quality and normal mucous membrane colour. Capillary refill time was under 2 seconds and no abnormalities were detected on auscultation of the chest. Temperature was within normal limits (38.5°C) and no external wounds were found.
The patient was admitted for radiographs and further examination of the left forelimb. Intravenous access was gained, and she was premedicated and anaesthetised for mediolateral and craniocaudal left humeral radiographs. These revealed a fracture of the humerus (Figure 1). As a result of client finances, amputation of the left forelimb, to include the scapula, was performed.
Nursing care
After surgery, a thoracic bandage was applied over the wound and the patient was returned to wards to recover. The patient was hypothermic postoperatively (37.2°C; normal range 38.2–38.6°C (Goddard and Phillips, 2011)) and required heating aids to prevent delay in recovery (Robertson et al, 2018). Passive and active heating aids were used and included blankets, bubble wrap and a heat pad (Bowers, 2012). This restored the patient's temperature to within normal ranges within an hour. A highly palatable, easily digestible recovery diet (Canine/Feline Recovery, Royal Canin) was then offered to encourage spontaneous food intake and aid recovery (Corbee and Kerkhoven, 2014). This was taken well by the patient.
The main concerns during recovery included pain management, protecting the wound and assisting with ambulation.
Analgesia
Pain management is a key part of surgical patient care because of the detrimental effects pain can have on patient welfare and recovery (Cambridge et al, 2000). Unmanaged pain can lead to hyperalgesia and allodynia, whereby the patient is hypersensitive to pain and non-painful stimuli are found painful (Epstein et al, 2015), leading to difficulties in nursing care. Pain is considered the ‘fourth vital sign’ after temperature, pulse and respiration (Epstein et al, 2015), therefore pain monitoring should be carried out on all patients. However, recognising pain in cats is difficult because of the subtle signs they present, and because they often hide signs of pain as a protective mechanism when stressed (Barratt, 2013). Behavioural signs of acute pain in cats can include a hunched posture, reaction to palpation of wounds, reluctance to being handled, squinted eyes and paying excessive attention to wounds (Robertson, 2008). Pain scoring systems, where available, are recommended as they reduce subjectivity in observations and lead to more standardised care (Epstein et al, 2015). The Colorado State University Feline Acute Pain Scale (FAPS) is a commonly used, simple pain scale in cats (Epstein et al, 2015) and was the scale used in this case. The patient was monitored for pain throughout the day, using regular pain scores (every 30 minutes), with all those involved using the same scale. On admission the patient was very painful, displaying a hunched posture, reluctance to move or be handled, and was highly reactive in response to the left forelimb being palpated. Additional signs of pain in felines have been identified and include absence of grooming, reduction in appetite and lower head carriage (Merola and Mills, 2016), all of which could have been used alongside the Colorado State University FAPS to further help identify pain in this patient. Furthermore, the use of the Glasgow composite measure pain scale for acute pain in cats could have been a better choice of pain scale in this case as it is validated (Calvo et al, 2014), whereas, the Colorado State University FAPS is still undergoing refinement to improve its performance and achieve validity (Shipley et al, 2019).
Perry and Woods (2017) state that before fracture repair, patients with humeral fractures must receive analgesia. An-algesia was, therefore, started on admission with 0.3 mg/kg of methadone (ComfortanTM, Dechra). This considerably improved the patient's pain score from a score of three to a score of one. The patient was then, later, premedicated with a combination of 0.3 mg/kg of methadone (ComfortanTM, Dechra), 3 mg/kg of ketamine (NarketanTM, Vetoquinol), 0.15 mg/kg of midazolam (HypnovelTM, Roche), 0.1 mg/kg of medetomidine (SedatorTM, Dechra) and 0.05 mg/kg of meloxicam (MetacamTM, Boehringer Ingelheim). A brachial plexus block was also performed (Mosing et al, 2010) with 2 ml (dose unknown) of 1% lidocaine hydrochloride (hameln pharma Ltd.). This resulted in a multi-modal analgesic, anaesthetic sparing effect (Robertson, 2008; Mosing et al, 2010) and aimed to provide the patient with a pain-free recovery post-amputation. Analgesia was continued at home with 0.05 mg/kg of meloxicam (MetacamTM, Boehringer Ingelheim) orally for 5 days and 0.03 mg/kg of buprenorphine (BuprecareTM, Animalcare) via oral transmucosal administration every 8 hours for 3 days. However, the efficacy of oral transmucosal administration of buprenorphine is still in debate, and its effectiveness is relatively unknown (Robertson et al, 2005; Giordano et al, 2010). Therefore, had the owner's financial situation been different, keeping the patient hospitalised for longer may have been beneficial with respect to analgesia, where administration of analgesics via more recognised routes could have been continued.
Wound care
Stabilising humerus fractures and immobilising the scapulohumeral joint can be very difficult because of bandage slippage, resulting in discomfort (Perry and Woods, 2017). Therefore, it is not recommended to bandage a humeral fracture unless the fracture is open; in which case a tie-over dressing is advised to protect the wound (Tobias and Tobias, 2012; Perry and Woods, 2017). In this case, the patient's humerus fracture was a closed fracture, so it was left unstabilised before surgery to prevent further discomfort. This worked well as, after analgesia was given, the patient was comfortable, settled down well and displayed no adverse signs to the unstablised fracture. Therefore, bandaging to immobilise the joint and stabilise the fracture may have reduced comfort.
Postoperatively it is important that wounds are treated aseptically to help prevent infection (O'Dwyer and Tat-ton, 2007). Bacon (2007) stated that wound takes around 6–12 hours to form a seal after surgery. It is, therefore, recommended the surgical site is covered with an appropriate dressing, for the first 24 hours, to allow the wound to form this seal (O'Dwyer and Tatton, 2007). Dressings that are commonly used to cover wounds post-surgery are non-adherent, perforated polyurethane membranes (for example MelolinTM, Smith & Nephew) (Anderson, 2003). These dressings are suitable for covering surgical wounds because they can absorb a small amount of exudate, protect sutures and prevent contamination (Anderson, 2003). Despite this, bacterial-binding dressings, such as SobractTM (ABIGO Medical AB), may be more beneficial. These dressings have been shown to be effective postoperatively in preventing surgical site infection, absorbing exudate and encouraging healing (Cutting and McGuire, 2015; Chadwick and Ousey, 2019).
Postoperatively, the wound was dressed with Melolin (Smith & Nephew) and then covered with a thoracic bandage. On recovery from a forelimb amputation, the patient was going to be unsteady when ambulating and potentially fall over, knock the wound and cause trauma. The bandage protected the wound from contamination and, primarily, from harm and interference from the patient (Anderson, 2017). The conforming and cohesive bandage layers were applied with caution with respect to tension to prevent excess pressure on the chest and difficulties breathing (Swaim et al, 2011). The bandage was checked frequently during recovery for tightness and rubbing points (Chandler and Middlecote, 2011; Murrell and Ford-Fennah, 2011). An important rule of bandage management is to ensure the bandage is kept dry (Harper, 2017). A wet bandage can cause skin maceration and ulceration (Nguyen et al, 2016). It also provides the perfect environment for bacterial growth and, therefore, can result in development of a surgical site infection (McDowell et al, 2014; Nguyen et al, 2016). For this patient, the main potential causes of a wet bandage were urine and drinking water. Consequently, to manage this risk, the patient was never left alone with a water bowl and was, instead, offered drinking water regularly and fed a wet diet to assist with hydration (Cornell University, 2017). With regards to urine, the patient was unable to use a litter tray because of difficulties with ambulating and regularly falling and rolling; the litter tray was therefore removed to prevent injury. As a result urine was managed using incontinence pads and a VetbedTM (Petlife) (Elphee, 2011; McDonald, 2017), and was checked, cleaned and changed as necessary when soiled. This method worked well, and the bandage remained dry and clean.
Recumbency and ambulation
On recovery from surgery, the patient was ataxic and had difficulties in ambulating properly. This resulted in the patient falling over and rolling frequently. Although amputee patients struggle initially, it is noted that patients can begin to ambulate within hours of surgery (Blackwood, 1999), and generally cope well with limb amputation (Forster et al, 2010; Dickerson et al, 2015) provided the remaining three limbs are free from disease (Fahie, 2016). The patient's kennel was padded with VetbedsTM (Petlife), blankets and foam padding to prevent trauma when attempting to ambulate and to ensure patient comfort when recumbent (Figure 2) (Goddard and Irving, 2011). If the patient was recumbent for 2 hours, they were turned onto a different recumbency to aid patient comfort, prevent decubitus ulcers and hypostatic pneumonia (Murrell and Ford-Fennah, 2011). The patient was aided in attempts to ambulate by encouraging standing and providing support while walking to allow the patient to learn the new weight distribution (Anderson and Smith, 2011; Daniels, 2011; Drum, et al, 2015). This was also incorporated into the discharge instructions for the owner while explaining postoperative care, surgical goals and expectations (For-ster et al, 2010; Fahie, 2016).
Recommendations for future practice
An area of nursing care which was overlooked in this case was physiotherapy and rehabilitation. Cats are often neglected with regards to rehabilitation because of the lack of knowledge of orthopaedic problems in cats, in comparison to dogs, and because of their intolerance of staying still and being handled (Drum et al, 2015). Physiotherapy is also difficult to carry out in practice where the extra time needed with patients is lacking and where no dedicated physiotherapy clinician/nurse exists (Thomas, 2012). However, physiotherapy and rehabilitation after orthopaedic surgery can aid recovery by increasing muscle strength and reducing pain, swelling and inflammation (Connell and Monk, 2010).
Therapeutic exercises could have been used to help increase muscle strength, improve quality of gait movements and enhance proprioceptive re-education in the remaining legs (Drum et al, 2015). These therapeutic exercises could include assisted standing with slings or support rolls (Drum, et al, 2015). Slings are frequently used in canine amputation patients when walking post-surgery (Daniels, 2011). Although cats do not need to be taken out for walks, using slings to assist with standing and learning to ambulate would be useful. The patient did struggle with ambulating initially, and since slings were available in the practice, structured therapeutic exercises may have proved beneficial. Where slings are not available in practice, rolled up towels are sometimes used, with the same success.
Cryotherapy could have also been useful in the recovery period. Cryotherapy has been discussed as a useful technique for reducing pain, inflammation and swelling (Shum-way, 2007; Rexing et al, 2010) by reducing the blood flow and the release of inflammatory factors to an area (Connell and Monk, 2010). Ice packs are wrapped in a towel to prevent damage to the skin, and then placed on the area for 10–20 minutes (Connell and Monk, 2010; Drum et al, 2015) repeatedly throughout the day. The use of ice packs on cats can be difficult because of their reluctance to lie still for long periods of time (Drum et al, 2015), and can be painful on application. However, this may be easier during the recovery period when the patient is drowsy.
Patient outcome
The patient was discharged the same day and returned 2 and 10 days later for postoperative follow-up appointments. The patient had no post-discharge complications and quickly adjusted to ambulating on three legs.
Conclusion
Orthopaedic patients benefit greatly from well monitored, multi-modal pain management and require additional time and nursing care for their rehabilitation and recovery. This time should be made available for nurses to spend with all orthopaedic patients in recovery, to begin their physiotherapy and accelerate their return to normal ambulation. Nurses should be aware of the different types of physiotherapy from which their patients can benefit and ensure cats are not neglected with regards to rehabilitation. Knowledge of effective wound management and recumbency care is also essential for these patients.
On writing this patient care report, it is clear there is limited literature on the nursing of veterinary amputation patients, in particular, feline amputee patients. More must be done to outline which nursing interventions benefit these patients most in order to improve amputation patient outcomes. This would also assist in improving nurse's knowledge of amputation patient rehabilitation.
KEY POINTS
- Well-monitored, multi-modal pain management is essential for orthopaedic patients.
- Amputee patients benefit from a well-padded and protected surgical site.
- Care of dressings and bandages are an important part of wound management.
- Amputee patients require additional one-on-one care when beginning to ambulate.
- Veterinary nurses must be aware of and able to perform all types of physiotherapy.