​​Optimising nurse-led inpatient care

In the field of veterinary nursing, the principles of inpatient care serve as a foundation for providing patients with proper care. This critical stage requires a careful balance between providing a pleasant environment, close observation, and team decision-making among veterinary specialists. 

The principles of inpatient care are [1]:

• Patient Assessment
• Individualised care plan
• Effective communication
• Administration of medication
• Patient monitoring and record-keeping
• Pain assessment and management
• Client Education
  

Determining the Care for a Veterinary Inpatient: A Collaborative Approach

The onset of a patient’s hospitalisation marks a collaborative consultation between the care team and the patient’s owner. The process of determining the care plan involves several key steps [4]:

1. Initial consultation/assessment: Typically, the owner and the veterinary professional engage in an initial discussion to address the patient’s concerns.
2. Shared decision-making: Following the initial consultation, a joint decision is reached between the veterinary team and the client regarding whether to admit the patient to the hospital.
3. Making individualised care plans: The veterinary team develops a tailored care plan for the patient based on their specific needs and conditions.
4. Continuous communication: Ongoing communication between the client and the veterinary team ensures that the patient is settling well in the hospital and that treatment can commence smoothly.
5. Patient monitoring and evaluation: The patient receives constant monitoring by the veterinary team, with their progress diligently recorded.
6. Client education and involvement: The client is provided with information about the patient’s ailment and the proposed care plan. Additionally, the client is encouraged to actively participate in the care process, as they possess valuable insights into the patient’s behaviour.
7. Regular reassessments and care plan adjustments: The patient’s condition is regularly reassessed, and the care plan is adjusted accordingly to ensure optimal care and treatment effectiveness.

Monitoring Patient Vitals

When looking after hospitalized animals, it is important to ensure that they are carefully monitored to prevent the escalation or development of disease.

Important vitals that need to be checked at least once a day include [1];

• Blood tests (including serum albumin, glucose levels, RBC concentration, etc.)
• Oxygenation and ventilation levels
• Neurological status
• Heart vitals (including rate, rhythm, and blood pressure)
• Temperature
• Immune status
• Drug dose and metabolism
• Weight and nutritional status

Assessing Demeanour

Monitoring and keeping records of patients' general behaviour as well as behavioural responses to treatment, feeding and environment [1]. It is important to note signs of pain, discomfort, aggression, and fear as these not only impact the well-being of the patient but could potentially affect other patients and the care team. Early identification of behavioural conditions is important as treatment and appropriate changes can be made on time especially when the behaviour progresses. Some signs include panting, increased respiration and heart rate, trembling, shaking, excessive licking, and hypersalivation. 

Nutrition

Daily Caloric Requirement [1]:

• For animals weighing above 2kg, the daily calorie intake is calculated using the formula 30(body weight in kilograms)+70.

Assisted Feeding [1]:

• Hospitalised animals may face difficulties eating independently due to issues such as trauma or physical limitations, necessitating assisted feeding.
• Various modes of assisted feeding include oral feeding, naso-oesophageal tubes, nesophagostomy and gastrostomy.

Guidelines for record-keeping.  

Maintaining accurate records is crucial for inpatient care. The purpose of these guidelines, established by the Veterinary Surgeons' Board of Western Australia, is to ensure meticulous documentation of all aspects of a patient's care journey, encompassing consultations, examinations, surgical procedures, and treatments [2][5].

Patients' records should adhere to the following criteria [2][5]:

• Precise and comprehensive.
• Documented promptly at the time of, or as soon as feasible after, the veterinary service is provided. This includes but is not limited to, consultations, advice-giving, examinations, surgical operations, diagnostic tests, etc.
• Sufficient to depict the veterinary surgeon's evaluation and management of a patient.
• Contain adequate information to enable another veterinary surgeon within the practice to continue the clinical evaluation and treatment of a patient, or if the animal is referred.
• Compliance with applicable laws.
• Indicate the originator, the animals involved, the timing of observations or procedures, the practices conducted, or issues encountered, and the rationale behind actions taken. 

Client communication and support

The interaction between clients and veterinary nurses typically involves discussing patient history, conducting physical examinations, and explaining possible diagnoses, prognoses, and treatment options. Trust between both parties is essential for effective communication [3]. Veterinary patients cannot verbalise how they feel, necessitating reliance on information provided by clients and clinical examinations [3]. Spending additional time with clients, when possible, reduces misunderstandings by allowing them to ask more questions [3]. Body language and facial expressions play a vital role in communication with clients [3]. Showing empathy during conversations reassures clients that their pet's well-being is a priority [3]. Using open-ended questions encourages clients to express themselves more freely [3].

Patient Transfer

When working with inpatients, smooth transitions to specialist or emergency facilities are vital. Consider the following steps when transferring a patient [3]:

• Communication and handover protocols: Ensure thorough communication between current and receiving hospitals, adhering to handover protocols.
• Proper documentation: Document patient details accurately and transfer them to the new care team.
• Permission from the pet owner: Obtain consent to transfer patient records for continuity of care.
• Collaboration with veterinary professionals: Coordinate with other professionals to ensure safe transfer.
• Client communication: Keep owners informed about transfer details and introduce them to the new care team.
• Patient safety and comfort: Ensure patient and client comfort during transfer and check on the patient until arrival.
• Patient follow-up: After arrival at the new facility, follow up with the new care team to facilitate continuity of care.

Patient Discharge

When discharging a patient from the hospital, careful preparation is essential. Veterinary nurses must ensure that all necessary procedures, including final examinations, diagnostic tests, and treatments, are completed before discharge [1]. Creating comprehensive discharge instructions is a crucial responsibility for veterinary nurses. These instructions should be clear, concise, and tailored to the patient's specific needs [3]. They should include information such as prescribed medications, dietary requirements, exercise limitations, and any signs or symptoms requiring immediate attention [3]. Communication with the patient owner is also integral to the discharge process [3]. This involves giving discharge instructions, providing a hard copy (or soft copy when appropriate) for reference, demonstrating instructions for tasks requiring physical assistance, and addressing any questions or concerns the client may have about the aftercare process.

Summary

In veterinary inpatient care, principles such as patient assessment, individualised care plans, and effective communication are crucial. Monitoring vital signs and assessing demeanour are key components, alongside nutrition management and record-keeping guidelines. Smooth patient transfers and thorough discharge planning, including clear instructions and client support, ensure optimal care continuity.

Further reading 

Cooper, B. (2020). BSAVA Textbook of Veterinary Nursing. John Wiley & Sons. [1]

Committee on a Review of the Smithsonian Institution’s National Zoological Park. (2004). Animal Care and Management at the National Zoo: Interim Report. National Academic Press. https://ebookcentral.proquest.com/lib/monash/detail.action?docID=3375965&pq-origsite=primo [2]

Pun, J. K. H. (2020). An integrated review on the role of communication in veterinary clinical practice. BMC Veterinary Research, 16(1), 394. https://doi.org/10.1186/s12917-020-02558-2 [3]

Ryan, S., Bacon, H., Endenburg, N., Hazel, S., Jouppi, R., Lee, N., Seksel, K., & Takashima, G. 2018. WSAVA Animal Welfare Guidelines. Journal of small animal practice, 60(5), 1-46. https://doi.org/10.1111/jsap.12998 [4]

Veterinary Practice Board of Western Australia. (2021, July) Veterinary Clinical Record keeping Guidelines. https://www.vsbwa.org.au/common/Uploaded%20files/vet%20Guidelines/Guidelines-Veterinary-Clinical-Record-Keeping.pdf [5]