A NEW APPROACH to VETERINARY NURSING: THE NURSING PROCESS

A NEW APPROACH to VETERINARY NURSING: THE NURSING PROCESS Harold Davis, BA, RVT, VTS (Emergency & Critical Care) William R. Pritchard Veterinary Medical Teaching Hospital University of California, Davis CA THE NURSING PROCESS In human nursing, the nursing process is the framework for nursing practice in that it provides the mechanism by which nurses use their beliefs, knowledge, and skills to diagnose and treat the client s response to actual or potential health problems 1. In addition, the nurse must use critical thinking skills, creativity and flexibility. It is a method of making clinical decisions or a way of thinking and acting to a clinical event of concern to the nurse, or in our case the veterinary technician. The nursing process provides an organized, systematic approach to solving clinical problems. Traditionally, the nursing process comprised five phases or components: assessment, nursing diagnosis, planning, implementation, and evaluation. While each step of the nursing process is addressed separately, they may occur simultaneously, overlap, or occur out of sequence. WHY THE NURSING PROCESS? The nursing process has several implications for the individual veterinary technician, the patient and the profession of veterinary technology. The nursing process requires the veterinary technician to be a critical thinker. Critical thinking involves questioning, assumptions, determining conclusions, and identifying the justification to support them. Critical thinkers can enhance their role as a member of the veterinary health care team, ultimately enhancing professional growth. Utilization of the nursing process may help to further define the scope of nursing practice for the veterinary technician profession. Using the nursing process to develop veterinary nursing standards of care will enhance patient care. Standards of care can be developed for particular disease processes encompassing each phase of the nursing process. Finally it is a great tool for developing nursing care plans. PREREQUISITES TO THE NURSING PROCESS The veterinary technician must have a sufficient knowledge and skill base and the ability to think critically. The knowledge base must encompass basic concepts of anatomy and physiology as well as a basic understanding of common disease processes, diagnostic, and therapeutic procedures. Technicians should also be familiar with potential complications or risk factors associated with these diseases, and procedures. A variety of technical and interpersonal skills are needed to implement the nursing process. Some technical skills include working with specialized diagnostic or monitoring equipment; others involve performance of procedures such as placing catheters, administering medications, or administering physical therapy. Because you interact with clients, technicians, veterinarians and other members of the veterinary health care team, you must possess excellent verbal and non-verbal communication skills. Critical thinking is not innate, but rather a learned skill. Critical thinking skills are necessary for you as an individual and professional - you must be able to make informed personal decisions as well as those necessary to provide safe, competent and skilled nursing care. 1 The five modes of thinking that collectively represent critical thinking in nursing are: 1. Total recall, 2. Habits, 3. Inquiry, 4. New ideas and creativity, and 5. Knowing how you think 2. The first letter from each word forms the mnemonic T.H.I.N.K. Total recall is your ability to access knowledge that you have acquired or the ability to remember how and where to find information when needed. Habits are things you do repeatedly so that they become second nature, such as intubating a patient. Inquiry means not taking anything at face value, examining issues in depth, and questioning those that seem immediately obvious. A superficial thoracic chest wound that a little dog received from a big dog requires investigation; often the wound is more serious than it appears. New ideas and creativity is a mode of thinking that allows one to step outside the box rather than say this is the way it has always been done the creative thinker will find new ways of doing things. The final mode is knowing how you think. Thinking about how you think is easier said than done. When you think,

do you find that you are easily biased, jump to conclusion, look at the negatives, require detailed information in order to form a conclusion. Knowing how you think can help you to expand your thinking process. Having met the prerequisites of knowledge, skill, and critical thinking you are in a better position to assess, arrive at conclusions, plan, intervene and evaluate your patient. COMPONENTS OF THE NURSING PROCESS Assessment Assessment is the data collection and analysis portion of the nursing process. The basic categories of techniques used in the assessment include interaction, observation and measurement. Data may come from a variety of sources. Owners provide a history; members of the health care team share information concerning the patient; the technician or veterinarian performs a physical examination; review of previous medical history and laboratory data for pertinent information; and collection of physiologic parameters (blood pressure, ECG, central venous pressure etc.). The veterinary technician may obtain some history from the client by phone, or in person, which, can be useful in preparing a treatment plan. For example, a client calls the clinic and tells the technician that their 5-year-old German Shepherd is retching and the stomach is swollen like a balloon. The dog had eaten a full meal a couple of hours earlier and went on a 5 mile run with the owner. Based on this information, and one s knowledge base, the technician should begin thinking about likely causes for the patient s problem, and potential diagnostics and therapeutic interventions the veterinarian may want to undertake. The technician should anticipate the patient s needs. It can be challenging at times trying to obtain useful, accurate, chronological information form a client. Three techniques are useful in obtaining a history: questioning, reflection and supplementary statements. Questions may be either open or closed. Open questions tend to elicit the client s perception of an event or description of an event. You are more likely to get honest replies. For example What prompted you to bring your pet into the clinic today. Closed questions usually require one or two word responses and are useful for obtaining specific facts or focusing the data collection. Clients tend to answer leading questions with what they perceive to be desirable responses. Reflection allows you to repeat or rephrase your perception of what the client said. This allows you and the client to expand, clarify, or correct your perception of the information. Supplementary statements like yes, go on, what happened next encourages the client to continue verbalization. In addition, it lets the client know that you are interested. Using the previous example, the patient arrives at the hospital as the owner described on the telephone. The veterinary technician may ask a few additional questions to further understand what is going on. How long has the animal had this problem? or when did you last see your pet normal? Does your pet have any other medical problems? or is your pet taking any medication? Is there any history of trauma? The technician should become skilled at performing physical examinations; it defines the patient s responses to the disease process. The physical exam helps establish a baseline for comparison in evaluating ongoing nursing or medical interventions. In our example, the technician rapidly assesses the patient s airway, breathing and circulation. It is determined that the patient s airway is patent, rapid shallow breathing, mucous membranes are pale with a capillary refill of 3 seconds, the patient is tachycardic, has poor pulse quality, cool extremities, and decreased mentation. The abdomen percussed with a tympanic sound. The veterinary team may need to proceed to the intervention step following a brief assessment. As soon as the patient s condition permits, the veterinary team should finish the assessment. Technician Conclusion or Judgment (Analysis) In human nursing the next step in the nursing process is arriving at the nursing diagnosis. The nursing diagnosis is based upon the patient assessment. A nursing diagnosis is a label that conveniently describes in a few words what the problem is. The North American Nursing Diagnosis Association (NANDA) developed a list of approved nursing diagnosis. A similar approved list does not formally exist for veterinary technicians. However, in the text Patient Assessment, Intervention and Documentation for

the Veterinary Technician the authors include a list of technician evaluations 3 (Figure 1) that might be considered analogues to the NANDA nursing diagnosis. The technician evaluations is the veterinary technician s conclusion about the animal s or owner s response to physical and psychological challenges and is based on the data collected during the assessment. In the text, each technician evaluations is defined/characterized, a desired resolution, suggested or common interventions and rationales are given. Following the assessment the veterinary technician will analyze the data obtained in the assessment phase. He or she will try and cluster or group those abnormalities that fit together and help identify a problem. Clustering the signs help to organize information in a systematic manner and facilitate the formation of the technician s conclusion(s). Ultimately, the technician s conclusion(s) will serve as an aid in determining proper nursing interventions. In our example the technician considers abdominal fluid, abdominal organomegaly and concludes that the patient may have a gastric dilatation with or without volvulus (abdomen percussed with a tympanic sound), resulting in circulatory (mucous membranes are pale with a capillary refill of 3 seconds, the patient is tachycardic, has poor pulse quality, cool extremities, and decreased mentation) and ventilatory (rapid shallow breathing) impairment. At this point the technician should anticipate what diagnostic and therapeutic modalities the patient will require. The technician should also consider what if any nursing interventions would be required. Planning The planning phase involves developing plans to meet the needs identified in the assessment phase. Planning helps the technician become organized, set priorities, and contemplate actual and potential problems or risk factors. The doctor provides the medical orders and it is one of the technician s responsibilities to implement the orders. Prioritizing It is not uncommon for the human or animal patient to present with more than one problem; as a result it will be necessary to prioritize the order in which each problem will be addressed. The human nursing profession has used Maslow s Hierarchy of Needs as a tool to help in prioritizing care. The thought is that certain critical (oxygenation, perfusion) physiological needs must be addressed before less critical (nutrition, chronic pain) physiological and psychological needs are addressed. While Maslow s Hierarchy of needs don t quite fit the needs of the veterinary patient it is still felt that there are certain physiological needs that must be met before others. The authors of the text Patient Assessment, Intervention and Documentation for the Veterinary Technician included a veterinary version of the Hierarchy of Needs in their text; they call it the Needs Ladder. There are nine rungs on the ladder with the most critical need being the bottom rung of the ladder. The idea is that this ladder will help the veterinary technician prioritize patient care; the veterinary technician just has to remember to go up the ladder (most critical to the least critical need). In the previously mentioned veterinary technician patient assessment text, the authors have taken the technician evaluations and grouped them according to the Needs ladder (Figure 1). Planning Care When patient problems are identified, the technician, in collaboration with the veterinarian should be thinking about the disease processes and potential risk factors associated with them. The technician should be capable of recognizing those risk and have a plan for dealing with them. Following the nursing process should enable the veterinary technician to anticipate the needs of the patient and veterinarian. The ability to select appropriate interventions should follow naturally from the identification of the technician conclusions (evaluations). The veterinary technician should be knowledgeable in the most common interventions associated with each of the technician evaluations. The following questions may be helpful to the veterinary technician in developing nursing care plans: 1. What are the goals of therapy? 2. What adverse effects could the disease have on the patient and how you would recognize it? 3. What action would be taken if the patient developed the problem? 4. What drugs are being administered to the patient; what adverse effects can the drugs cause; and how would you recognize the drug reaction? 5. What type of monitoring is generally utilized for the given disease process? 6. What type of general nursing care is required i.e. IV catheter care, urinary catheter care, and / or

recumbent patient care etc.? Needs Ladder Oxygenation Critical Safety / Acute Pain (severe) Hydration Elimination Nutrition Noncritical Safety Chronic Pain / Acute Pain (mild to moderate) Activity Utility Technician Evaluation 1. Altered gas diffusion 2. Altered ventilation 3. Cardiac insufficiency 4. Decreased perfusion 5. Obstructed airway 6. Risk of aspiration 1. Acute pain 2. Electrolyte imbalance 3. Hyperthermia (severe) 4. Hypothermia (severe) 5. Postoperative compliance 6. Preoperative compliance 1. Hypervolemia 2. Hypovolemia 1. Altered urinary production 2. Bowel incontinence 3. Constipation 4. Diarrhea 5. Inappropriate elimination 6. Self-care deficit 7. Urinary incontinence 1. Altered oral health 2. Abnormal eating behavior 3. Ineffective nursing 4. Overweight 5. Self-care deficit 6. Underweight 7. Vomiting / diarrhea 1. Altered mentation 2. Altered sensory perception 3. Noncompliant owner 4. Hyperthermia 5. Hypothermia 6. Impaired tissue integrity 7. Owner knowledge deficit 8. Risk of infection 9. Risk of infection transmission 10. Self-inflicted injury 11. Status within appropriate limits 1. Acute pain 2. Chronic pain 1. Exercise intolerance 2. Reduced mobility 3. Sleep disturbance 1. Aggression 2. Anxiety 3. Client coping deficit 4. Client knowledge deficit 5. Fear 6. Inappropriate elimination 7. Reproduction dysfunction Figure 1Combined Needs Ladder (From most critical to least critical) and the associated Technician Evaluations (Technician conclusion). In. Patient Assessment, Intervention and Documentation for the Veterinary Technician

Part of the planning process includes consideration of general nursing care procedures. It is helpful to have a checklist of daily nursing care tasks (Figure 2). Perhaps standing orders could be made for certain nursing care task; in other words, these tasks are always performed on a patient unless told otherwise by the veterinarian. Ideally when the clinician provides you with the medical orders you have anticipated his or her needs for the patient and ready to implement the plan. You should review the orders to make sure you understand what needs to be accomplished and ask questions if you don t. The experienced technician, knows how to set priorities and how to implement the orders efficiently. Daily Patient Care Checklist Beginning of shift checklist Review case(s) (Record and Orders) [ ] Conduct rounds [ ] Check all catheters and monitoring devices [ ] Check emergency equipment [ ] Organize the "to do list" [ ] Patient care check list Evaluate patient status (mentation, TPR, auscultation) [ ] Weigh and record (acute or gradual change?) [ ] Is the patient urinating? (Palpate bladder if not) [ ] Is the patient eating and drinking? [ ] a) Is it consuming enough calories? [ ] b) Is it consuming enough water? [ ] Are the psychological needs being met? (Walks, TLC) [ ] Wound and or bandage care as ordered [ ] Is the patient clean and comfortable? [ ] Are steps being taken to prevent nosocomial infection? [ ] Are steps being taken to control pain? [ ] Non-ambulatory patient care Turn the patient q 2-4 hrs [ ] Is the cage / run well-padded [ ] Check for decubital ulcer formation [ ] Are there any contraindications to physical therapy? [ ] Catheters Perform IV cath care q 48 hrs or prn [ ] If IV cath has been in > 96 hrs consider changing [ ] Flush capped IV cath with heparinized saline q 4 hrs or perform heparin lock q 12 hrs [ ] Urinary cath care q 8 hrs [ ] Chest drain / feeding tube care q 24 hrs [ ] Change IV administration sets q 48 hrs [ ] Artificial airway management / care q 4 hr or prn [ ] Figure 2 A daily Patient Nursing Care Check List

In our GDV example, the doctor has ordered oxygen administration, placement of two IV catheters, fluid administration along with decompression and gastric lavage. Radiographs are to be taken when the patient is stable. The technician would have developed a nursing care plan (Figure3) having anticipated that these procedures would be performed. In addition, the technician should have the treatment area and the supplies ready. Immediate potential risks for this patient include aspiration and gastric perforation related to gastric decompression / lavage; arrhythmias; non-responsive shock ; electrolyte imbalance; disseminated intravascular coagulation; and sepsis. Implementation Implementation or intervention is the initiation of the doctor s orders and nursing care plans. This may include performing diagnostic procedures, administering medications, performing therapeutic procedures or initiating monitoring procedures. In our example, the technician should have the skill and knowledge level to provide oxygen therapy, administer fluids, assist or decompress the patient, take diagnostic radiographs and recognize when the patient is stable. Technician Evaluations (conclusion) Nursing Care Plan 1. Administer oxygen 2. Monitor Altered ventilation or gas exchange a. SPO2 / Arterial blood gas b. Respiratory rate, effort, breath sounds c. Mucous membrane color 1. Place IV catheter(s) 2. Have appropriate fluids and IV set available per clinician orders 3. Monitor a. Perfusion parameters (Hr, pulse quality, mucous membrane color, CRT, mentation and extremity temperature) b. Temperature Decreased perfusion c. Blood pressure d. ECG (Arrhythmias) e. Note ins and outs 4. Risk factors no improvement in perfusion parameters a. Consider other factors b. Have other fluid options available (Crystalloids to Colloids?) c. Have dopamine available, be prepared to make infusion. 1. Protect the airway if intubated Risk of aspiration 2. Head elevation if extubated 1. Observe for: a. continued bleeding from venipuncture sites b. ecchymosis Risk of coagulopathy c. petichea d. epistaxis, hematoma formation, and/or gastrointestinal, e. urinary, or intracavitary hemorrhage 1. Repeated physical exam as condition dictates 2. Repeated lab test (CBC, Chem, Lytes) as condition dictates 3. Keep warm, clean and dry General nursing care (When stable) 4. Recumbant patient care (if non ambulatory) 5. Weigh daily 6. IV catheter care 7. Incision check 8. Pain management? Figure 3 An example of a nursing care plan for a GDV patient

Evaluation Evaluation is the final phase of the nursing process although it should occur throughout the nursing process. During the evaluation phase we are looking to see if therapy is improving the patient s condition. The technician will repeat physical exams and utilize a variety of monitoring techniques as the patient s condition dictate (table 1). If the patient is not meeting the desired goals, we should ask why not?. There are several issues to consider: 1. maybe it is too soon to evaluate; 2. perhaps the intervention should be intensified; 3. there may be some other factor that has not been considered; 4. the nursing evaluation could be incorrect. If the patient s condition does not improve or it worsens a new plan will need to be developed. In our example, the patient has undergone surgery and is 24 hours post-op, and has a sinus tachycardia (160 bpm). The tachycardia is documented, the clinician is alerted and, the technician should develop a list of possible causes: hypoxia, hypotension, hypovolemia, excitement, fever, pain and recent drug administration. When notifying the doctor of the tachycardia, also tell him or her that you were able to rule in or out potential causes (include your supportive information). This process should not cause any delay in the delivery of necessary medical treatment by the veterinarian. The ultimate goal is to try to enhance the care that you give to your patient and be a strong contributor to the health care team. Body System Monitored Parameters Nursing Priorities Mucous membrane color Respiratory rate and effort Maintain or enhance oxygenation Character of breath sounds Maintain or enhance ventilation Respiratory Breathing pattern Arterial blood gases Pulse oximetry End-tidal CO 2 Circulatory Neurological Renal Gastrointestinal Heart rate & rhythm Pulse rate & character Mucous membrane color Capillary refill time Electrocardiogram Blood pressure Central venous pressure Skin turgor & mucous membrane moisture Packd cell volume Mentation Posture Heart rate Blood pressure Breathing pattern Deep pain sensation Pupil size and response Daily ins and outs Bladder size and urine output Body weight Skin turgor & mucous membrane moisture Urinary specific gravity Appetite Body weight / Body condition score GI losses (vomitus / diarrhea / gastric suction) Abdominal girth (distention) Recognize the signs of shock Place and maintain IV catheter Maintain or enhance circulating blood volume and tissue perfusion Recognize arrhythmias Detect and arrest hemorrhage Recognize and initiate CPR. Recognize changes in neurological status Recumbent patient care Minimize risk of increased ICP Pain management Assess and maintain hydration status Assess renal function Place and maintain urinary catheter Maintain adequate nutrition Assess and maintain hydration status Correct Electrolyte abnormalities Musculoskeletal Ability to ambulate Skin integrity Bandage /dressing Table 1 Patient evaluation parameters and nursing priorities Patient comfort Physical therapy Prevent decubital ulcer formation Bandage / dressing care

Summary The nursing process is a valuable clinical tool in human nursing and many of the principles can be applied to veterinary nursing. Veterinary technicians may or may not use some or all components of the nursing process. The Academy of Veterinary Emergency and Critical Care Technicians (AVECCT) conducted a role delineation study in 1996 and determined that technicians spent some portion of their time utilizing the nursing process Utilization of the nursing process in its entirety will enhance the delivery of patient care and help to enhance the role of the veterinary technician as a member of the health care team. Are you using the nursing process in your practice? References 1. Iyer, P.W., Taptich B.J., Bernocchi-Losey, D (1995). Nursing Process and Nursing Diagnosis. Philadelphia: Saunders 2. Rubenfeld, M.G., Scheffer, B.K. (1999). Critical Thinking in Nursing: An Interactive Approach. Philadelphia: Lippincott 3. Rockett J, Lattanzio C, Anderson K. Technician evaluations with suggested interventions. Patient Assessment, Intervention and Documentation for the Veterinary Technician. New York: Delmar Cengage Learning, 2009; 53-121