Medical Nursing For Veterinary Technician

Part of the role of a veterinary technician is administration of medications. There are multiple routes for the administration of medications; which route is used will depend on many factors. Some of these factors are: the type of medication, the type of effect desired (local or systemic), the ease of administration, and the patient’s condition. Depending on these factors a doctor might instruct a technician to administer medication orally, intravenous, subcutaneously, transdermal, intranasal, and/or through an orogastric tube. For this research paper, I will be focusing on one method of administration; orogastric intubation. Orogastric intubation is when a tube is passed from the mouth of a patient directly into the stomach.

There are many instances when an orogastric tube is needed, it can be used to administer food, and it can also be used for serious medical conditions. For example; if an animal has ingested toxins and their stomach must be lavaged, the orogastric tube is used to administer activated charcoal as part of this process. Also, if an animal needs their stomach decompress because of gastric dilation, the orogastric tube aids in the process. Canine patients in particular, permit the placement of orogastric tubes with moderate resistance (Davis, et al. , 2014), which means they do not usually have to be sedated, and the process has one less step the technician should be concerned about. Inserting an orogastric tube, is a complex process. In an article published on dvm360. com, by Catrional MacPhail, DVM, PhD, BA, DACVS (2008), she points out the steps of orogastric intubation for a gastric dilation canine patient.

The first thing mentioned in the article is measuring the gastric tube, the tube should go from the dog’s nose to it’s last rib (MacPhail, 2008). She proceeds to mention that a roll of 2" tape can be placed in the dog's mouth, followed by gently passing the tube through the patients esophagus (MacPhail, 2008). The tube should have a small amount of lubricant at the end, to facilitate the route (MacPhail, 2008). Usually, the animal is restrained in sternal recumbency, changing the position of the dog (from sternal to sitting to vertical with feet elevated) while passing the tube, can often help get the tube into the stomach (MacPhail, 2008). Once in the stomach, the other end of the tube should be put in a bucket underwater to assess successful gas decompression (MacPhail, 2008). The stomach is then washed with warm water until the fluid returns clear (MacPhail, 2008). One important note she mentions in her article, is the possibility of coming across large amounts of blood or necrotic tissue (MacPhail, 2008). This could indicate gastric necrosis and could lead to more serious complications (MacPhail, 2008).

Finally, she also mentions that if the tube is unable to be passed, gastric trocharization might be performed (MacPhail, 2008). The steps are similar if the tube is used to treat animals for toxin ingestion, or just used as a feeding tube. The only difference would be that for administering activated charcoal or food, you would not have one end of the tube in a bucket of water, but rather you would be administering the food or charcoal through this end with a syringe, a metal drench pump or a funnel. Also, once the food or charcoal have been administered, the tube should be bent to occlude, and removed in a downward direction to avoid aspiration (Davis, et al. ,2014). Knowing how to properly use an orogastric tube and the process of the intubation is important, if not done correctly, the tube can enter the trachea and this could lead to aspiration of materials into the lungs (Davis, et al. , 2014).

The tube should be measured before insertion. The length of the tube can be estimated by placing the tube from the nasal planum along the side of the patient to the 7th or 8th intercostal space (Lee, 2013). It’s also recommended that the tube does not pass through the lower esophageal sphincter as it can result in esophagitis (Wortinger, 2010). It’s also important for the tip of the tube to be lubricated, this way the esophagus is not irritated. The dog’s mouth should be held open so that the patient doesn’t bite into the tube before it is inserted properly, and the tube should be passed through a mouth speculum slowly, this way swallowing can be observed. Once the tube has made its way into the esophagus, the technician should be paying attention to any coughing. If the patient does cough the tube may be in the trachea, and should be removed to avoid aspiration. Potential complications of orogastric tube placement vary depending on the reason the tube is being placed. If the tube is being used for gastric dilation, it is possible that the tube might not even get into the stomach because of the torsion of the stomach (Harkin & Simpson). In the article, “Feeding tube management and complications” (2010), Ann Wortinger points out the main complications of a feeding tube.

One main concern is that the tube can get obstructed depending on what material is being fed. Also, patients that are tube fed can have gastric discomforts, like diarrhea, constipation, nausea. Aspiration pneumonia is also a potential complication of a feeding tube. Overall, the general complications of orogastric tube placement include insertion into the trachea, and the fact that it might involve mild sedation if the patient resist placement of the tube. This procedure can provide relief for many medical situations, but if not done properly, it can be highly stressful for the canine patient.

Part 2: Fluid Administration

Fluid therapy is a common aspect of hospitalized patient care. Fluids are administered to replace nutrients and water that the patient has lost. Fluids will be administered to a patient if the patient is dehydrated, if the patient has an electrolyte disorder, if the patient needs to improve urine production, or if intravenous access wants to be maintained to deliver other medications (Davis, et al. , 2013). Once a patient is presented for a physical exam, as part of the exam the technician can assess the hydration status. Animals start showing signs of dehydration when they are at least 5% dehydrated, before that the signs of dehydration would be undetectable (Beiter, et al. , 2014).

Although there are no precise quantifiable ways in which dehydration can be measured, there are physical signs that can help estimate the percentage of dehydration. When looking at the oral cavity of the patient, if the patient is dehydrated the mucous membranes will be dry or tacky. The tenting of the skin or the skin turgor will also be a good indicator of how dehydrated a patient is. If the patient is severely dehydrated, the capillary refill time may be affected and the eyes might look sunken. These signs can estimate the percentage of dehydration the following way; if the patient is 5% dehydrated: the mucous membranes will be mildly dry, if the patient is 7% dehydrated: mild loss of skin turgor, dry mucous membranes, and possible mild tachycardia, if the patient is 10% dehydrated: pronounced loss of skin turgor, dry mucous membranes, tachycardia, weak pulses, and sunken eyes, and if the patient is more than 10% dehydrated: severe loss of skin turgor, sunken eyes, shock, and the patient can go into coma or die (Beiter, et al. , 2014). Fluid therapy can be divided into three phases; resuscitation, replacement, and maintenance.

Resuscitation fluid therapy is used to restore vascular volume, reverse hypovolemia or shock. Replacement fluid therapy is used to correct dehydration, and replace ongoing loss of liquids. Maintenance fluid therapy is used once dehydration has been corrected and the patient is not suffering any ongoing loss of liquid. For this research paper, we will assume that we are treating a female cat that weighs 8lbs, is 10% dehydrated and has no vomit or diarrhea with fluid therapy. Because this patient has no blood loss, we would not start fluid therapy in the resuscitation phase. This patient is dehydrated, and we would have to start fluid therapy in the replacement phase. In replacement phase, the goal is to provide the patient with the normal maintenance fluids that the body needs, but also replace all the fluids that they have lost. Because this cat weighs 8lbs and 10% dehydrated we first calculate the fluid deficit by multiplying the patient’s body weight in kg by the estimated percent of dehydration expressed as a decimal, 8lbs converted to kg is 3. 63kg multiplied by 0. 10 will give us. 363L or 363ml of fluid loss.

Now that the deficit has been calculated, the next step would be to decide length of time over which those fluids will be replaced. Ideally, the fluid that is being replaced should not be replaced in a quick manner, depending on the cat’s condition it could be anywhere between 4 and 24 hours. The doctor would be the one making that decision, in this case that number has been left to our discretion, for this exercise the length of time over which those fluids will be replaced will be 8 hours, which means we divide 363ml of fluid loss by 8, which gives us 45. 4 ml/hr. Replacement fluid therapy also considers maintenance fluids, which means that to get our total replacement rate we also must calculate the maintenance rate. For cats the standard formula for maintenance rate is (Beiter, et al. 2014), which can also be calculated by multiplying the body weight in kg by itself twice, calculating the square root of this number, calculating the square root of that result, multiplying that number by 80 and then dividing by 24. Using the data provided in this example the formula would look like this.

The square root of 47. 8 is 6. 9 and the square root of 6. 9 is 2. 6, which is then multiplied by 80, 80= 210. 4. That number is then divided by 24 to give us our maintenance rate, 210. 4/24 = 8. 7 ml/hr. Total replacement rate can be expressed as dehydration + ongoing losses + maintenance, because this cat has no vomit or diarrhea, the ongoing losses would be zero. Urine would also be considered an ongoing loss, but the formula for maintenance rate accounts for urinary losses. Our final replacement rate would be dehydration (45. 4ml/hr) + ongoing losses (0ml/hr) + maintenance (8. 77 ml/hr), which would give us a rate of 54. 2 ml/hr. The doctor would also be the one deciding what kind of fluids this patient would be on. Usually, the fluid chosen is isotonic, because isotonic fluids won’t have a severe negative impact on most electrolyte imbalances, and their use will begin to bring the body’s fluid composition closer toward normal (Davis, et al. , 2013).

Once an IV catheter has been inserted in this patient and fluid therapy has begun, the technician needs to keep monitoring this patient to make sure the patient doesn’t suffer from fluid overload. Since this patient has been diagnosed with 10% dehydration, it’s important to assess if this is improving as fluid therapy progresses. To asses’ hydration in this patient, we can conduct a physical exam on the patient every few hours, assessing skin turgor to see if it has decreased, looking at the mucous membranes to see if they are still tacky, and listening to the heart of the patient. Paying attention to how frequently the patient urinates can also be a good indicator of how the patient is doing hydration wise. Also, conducting a packed cell volume (PCV) or total protein (TP) test on their bloodwork can give some useful information as to how they are improving (Beiter, et al. , 2014). It’s important to monitor the patient’s hydration status, because fluid overload can have severe consequences on a patient, especially sick cats. Cats require very close monitoring due to their smaller blood volume, lower metabolic rate, and higher incidence of acute cardiac disease which make them less tolerant of high fluid rates (Davis, et al. , 2013). If at any point of the monitoring, the patient is deemed to have recovered the fluids loss, the doctor might decide to turn fluids down to maintenance rate or stop them all together. Fluid overload can cause pulmonary edema, peripheral edema, it can worsen bleeding, and it can cause electrolyte imbalances. Another aspect of fluid therapy that must be closely monitored is the IV catheter site and the fluid line. IV catheters should be monitored to avoid phlebitis, thrombosis, perivascular fluid administration, infection, and constriction of blood flow (Davis, et al. , 2013). Done correctly and monitored closely, fluid therapy can have great results in patients.

Part 3: Dental Prophylaxis

Most animal practices today, offer dentistry’s for their animal patients. Dental disease and the consequences of this disease on the animal are of concern not just in house pets, but also with horses and exotic species. Technicians should become familiar with the differences in the dental structures of a variety of species, performing assessments on these animals, educating clients on the importance of clean teeth, and know how to perform periodontal debridement. Two animals in which dental prophylaxis is performed commonly is dogs and horses. Dogs have brachyodont teeth, which means they have small crowns and well developed roots. The apices of these roots, are only open for a short time and the teeth do not continually grow. Horses, on the other hand have hypsodont teeth, which means they have large crowns that allow for continued growth of the teeth during most of the horses’ life. The horses’ teeth are radicular hypsodont, which means the apices are open for a large part of the horses’ life, but eventually close. Dogs have four kinds of teeth: incisors, canines, premolars and molars. The kinds of teeth a horse has will vary: they have incisors, premolars, molars, and some horses will also have canine teeth and wolf teeth. Wolf teeth are considered vestigial premolars and commonly occur in the upper jaw. Both dogs and horses are diphyodont, which means they have two sets of teeth: their deciduous or baby teeth, and their permanent teeth. Horses teeth are also different from dogs because their occlusal surfaces are covered in cementum, while in dogs’ teeth cementum only covers the roots. Finally, the number of teeth that each species has is different too, dogs have 42, while the number of teeth a horse ranges from 36 to 44 (Lewis & Miller, 2014). Dental prophylaxis is performed in both species to prevent dental disease.

Dental disease is a condition that progresses if not treated on time. For dogs, a dental cleaning should be performed if the dog has gingivitis, which if left untreated can lead to periodontitis. Yearly cleanings might not be necessary or recommended for every dog. Diet, chewing behavior and preventative care are among the important factors affecting the potential of a dog getting dental disease and how fast the disease will progress. Depending on the dogs age and size, there will be different dental concerns. Following the 2013 AHAA Dental Guidelines, dental prophylaxis is recommended in younger dogs, if the dog has problems with their deciduous teeth, occlusions, or oral development. 2013 AHAA Dental guidelines also suggest that dogs up to 2 years of age may get dental prophylaxis when they show problems related to developmental anomalies, and start to show the accumulation of plaque and calculus. Periodontal diseases may begin during that age too. It’s important to mention that smaller dogs are disposed to periodontal diseases and can start to show signs as early as 9 months old (Holmstrom, et al. , 2013). In horses, the main concern of dental prophylaxis is the odontoplasty of the sharp enamel edges of a horse’s teeth.

In Merck’s Veterinary Manual, (n. d. ), Jack Easley mentions that enamel edges should be removed twice yearly during the establishment of the permanent dentition, dependent on the management of the horse. The lifestyle of the horse, what it is fed, will affect the frequency of dental prophylaxis. Easley (n. d), mentions that if they graze on free range or grass they usually require a yearly dental prophylaxis; while if they are stall confined and essentially fed hay and grain, they may require twice yearly oral examinations and dental prophylaxis. In a horse, dental prophylaxis will focus on eliminating the rough enamel edges of cheek teeth, these edges if permitted to get too sharp can cause painful sores in the horse’s cheek, this is known as “floating” the teeth (Easley, n. d. ). Horses may also need dental prophylaxis for the removal of their wolf teeth. The procedure of dental prophylaxis in dogs involves the patient been placed under general anesthesia. Before completing a dental cleaning, the dog will have a physical exam (Rosenbland, 2017). Before the dog has been put under anesthesia, it is a common procedure to have bloodwork done, this helps keep the procedure safe for the patient, and reduces the risk of the patient having complications from the anesthesia (Rosenbland, 2017).

Once the dog is under the effects of anesthesia, the veterinarian will inspect in more detail the teeth and gums (Rosenbland, 2017). Dental radiographs are usually used to asses’ the complete damage of the teeth (Lewis & Miller, 2014). However, many practices also have the capacity to perform CT Scans of the patient ahead of the dental prophylaxis, which provides more details as to the dental health of the patient. Once the imaging is complete, the veterinarian can decide the extent of the damage on the teeth of the patient, and decide if extractions need to happen. The veterinarian or technician, will remove the tartar from the teeth, first manually, and then using the ultrasonic instruments. The goal of the ultrasonic instruments is to clean the surface of the teeth as fast as possible, while providing minimal damage to the enamel. The final step of the dental prophylaxis is polishing the teeth (Rosenbland, 2017). In horses, the procedure of dental prophylaxis involves many of the similar steps as with dogs. To thoroughly examine the oral cavity of a horse, the horse needs to be sedated (Easley, n. d). Before the patient can be sedated it’s important to conduct a physical examination. Dental care of horses involves the use of files or rasps (called floats) and extractors (Easley, n. d. ). The floating or filing of the teeth is done with power tools, that help make the process faster while keeping the enamel of the teeth safe. Because the horse is a large animal, imaging of their skull and teeth can be more difficult. Depending on the equipment available, intraoral dental radiographs, might be limited to imaging of the incisor teeth (Lewis & Miller, 2014). However, there is always the option of a CT scan or an MRI (magnetic resonance imaging). The procedure of dental prophylaxis has similarities for both species. Physical examination before sedation is a must for both. Imaging of the teeth is also important in both species, and diet and lifestyle will play a role in how often a dental prophylaxis is needed for both dogs and horses. Certain differences do exist in the procedure for both animals.

While, a big focus of a horse’s dental prophylaxis is dedicated to floating their teeth, for dog’s tartar buildup is more important. This has to do with the fact that horses teeth are hypsodont, while dogs teeth are brachyodont. Another difference is the fact that a dog’s skull is smaller and dental radiographs can help image even the nasal area of their skull, while in horses their larger skull makes it harder to image.

Part 4: Emergency Care

Less than 6 percent of dogs and cats that experience cardiopulmonary arrest in the hospital survive to discharge (AVMA, 2018). Once a cardiopulmonary arrest occurs, it’s imperative that basic life support begin immediately. This means chest compressions and ventilation, it can also include medications, defibrillation, and open chest procedures. The most recent guides of performing cardiopulmonary resuscitation express the importance of chest compressions and restoring perfusion during the resuscitative effort (Fletcher & Boller, 2013). CPR or cardiopulmonary resuscitation is the act of sustaining life by maintaining blood flow and oxygenation once cardio pulmonary arrest has occurred. When CPR is initiated, the algorithm of CAB (circulation, airway, breathing) is followed instead of ABC (airway, breathing, circulation) as blood flow is most important and chest compressions provide ventilation even before intubation of the patient has occurred (Samuelson, n. d. ). The goal of CPR is to sustain the patient and force blood and oxygen to keep flowing through the body. The newest guidelines for giving CPR in dogs and cats were published in 2012. Using AAHA’s guidelines, it is recommended that once cardiopulmonary arrest has occurred, you begin with chest compressions. Ideally, the dog or cat should be positioned in either left or right lateral recumbency (AAHA, 2012). The chest compressions should be performed at a depth of 1/3 to 1/2 the width of the chest and at a rate of 100 to 120 compressions per minute, regardless of animal size or species (AAHA, 2012).

The person performing the chest compression should allow full recoil of the chest between compressions and should be rotated every 2-minute cycle of CPR (AAHA, 2012). If the patient is in the veterinary hospital, the patient would be intubated for ventilation and the person performing CPR would deliver 10 breaths/minute at the same time as compressions, with 1 second in between (Fletcher & Boller, 2013). If intubation is not possible, the patient’s mouth can be closed tightly, making a seal over both nostrils with mouth, in this method you want to deliver 30 chest compressions and 2 quick breaths, resuming compression after the breaths (Fletcher & Boller, 2013). In an animal clinic setting, as soon as a patient is identified to be in critical state, it should be taken immediately to the area designated for initial evaluation and stabilization (Samuelson, n. d. ). Signs that a patient is in a critical state and might be close to cardiopulmonary arrest include: decreased mentation, cyanotic membranes, and/or a labored, irregular breathing pattern (Samuelson, n. d. ).

When cardiac arrest occurs in a veterinary hospital, advanced life-support techniques are used. Advanced life support adds drugs, defibrillation, and the ECG, in addition to the basic chest compressions and ventilation (Samuelson, n. d. ). Usually, the area designated for stabilization has the crash cart near. The crash cart should be in a central location and should be stocked with all the materials needed for advanced life support. The crash cart should have all the supplies you need to deal with an emergency, this cart should be properly stocked with different sized endotracheal tubes, tube ties, a syringe for cuff inflation, different size IV catheters, and a laryngoscope (Yagi, 2017). The cart should also have tape, flushes, gloves, fluid bags and IV sets (Yagi, 2017). Finally, it is very important that this cart or area have different size needles and syringes, medications like Epinephrine, Atropine, and Reversal Agents. A defibrillator and ECG, should also be near (Yagi, 2017). Overall, performing CPR correctly and quickly has the potential to save the life of an animal in need. It’s important to be familiar with the signs of cardiopulmonary arrest, the steps of CPR, and where the correct materials for advanced life support are in the animal clinic.