A team was assigned to the patient to allow him to become familiar with the staff and to reduce his stress. It also enabled effective communication about his treatment plan among the team members.
As this case was an emergency, a cold spray, which acts for approximately 30 seconds, was used on the patient ' s neck before blood sampling. The usual hospital protocol is to apply EMLA( eutectic mixture of local anaesthetics), a numbing cream, 45 minutes before venepuncture, to minimise patient stress.
IVFT of Hartmann ' s solution was started immediately after the results of epoc blood analysis were obtained. Two 10 ml / kg fluid boluses were given to support the patient ' s hydration status and in view of the patient ' s degree of dehydration being assessed at 6 – 8 % [ 4 ]. Fluid volumes were calculated using the University of Bristol ' s calculation for fluid deficit [ 11 ].
Holden [ 4 ] suggests that mild hypovolaemia can usually be corrected with a rapid infusion of a crystalloid at 20 – 30 ml / kg; however, due to the patient not showing signs of hypotension, the VS chose to address the physical signs of dehydration with two fluid boluses to support the patient, followed by an ongoing infusion of crystalloid at 4 ml / kg / hour. Within an hour of IVFT beginning, the patient seemed brighter, his mucous membranes were slightly less tacky and the heart murmur was no longer present on auscultation. The fluids were stopped once the patient had been eating, drinking and regularly passing urine [ 4 ].
Before stopping fluid therapy, ideally the patient ' s urine production should have been measured via free catch to check that he was producing urine at a rate of 0.5 – 1.5 ml / kg / hour [ 4 ], as well as checking the USG to ensure his hydration levels were adequately improved.
The hospital ' s protocol during surgery is to administer antibiotics to reduce the risk of surgical site infections, especially during surgery that involves opening the gastrointestinal tract, where there is a greater risk of infection. Antibiotics are usually continued overnight and then the patient is reassessed during the next morning ' s rounds. In this case, cefuroxime was given every 8 hours at a dose of 22 mg / kg following the surgery until the patient was reassessed the next morning. The morning after surgery, following reassessment, the patient received oral amoxicillin / clavulanate( 12.5 – 20 mg / kg PO BID for 5 days).
Full observations were carried out every 6 hours, to monitor changes / trends and guide alterations to the patient ' s care plan, if required, depending on the findings. The specific parameters monitored were the heart rate, mucous membrane colour / moisture and temperature. The patient ' s temperature was stable throughout his stay in the hospital; he did not become pyrexic or hyperthermic, and his mucous membranes were no longer tacky.
Once the fentanyl CRI had finished, 0.2 mg / kg methadone was administered IV and continued every 4 hours, alongside the application of an eye lubricant( Viscotears, Novartis) to both eyes every 4 hours to reduce the risk of eye ulcers / dry eye, which are known to be caused by opioids.
The patient ' s requirement for opioids should have been monitored by carrying out pain scoring. Acute pain can be defined as a normal but noticeable response to an undesirable stimulus or tissue injury, such as surgical incisions, wounds or bruising. Responses can include twisting or turning in response to palpation of the affected area. Acute pain tends to improve within the first 3 days following the injury / event; however, pain can last up to 3 months during the healing process [ 14 ].
Ideally, a pain score should be given before administering the methadone, to assess the efficacy of the analgesia. This should be reported to the VS during morning rounds to allow adjustment of the care plan based on the quantitative data obtained from pain scoring as opposed to subjective data from handovers [ 15 ]. During morning rounds 12 hours after surgery, methadone administration was discontinued as the patient seemed comfortable; pain scoring was then started every 4 hours to monitor his pain levels and a top-up of methadone( 0.1 mg / kg IV) was prescribed in the event of breakthrough pain found on pain scoring. This top-up was given as needed, with a maximum total dose of 0.3 mg / kg IV methadone within a 4-hour period.
It is important not to rely solely on the use of pain scales when monitoring a patient ' s pain levels. Physical signs such as increased heart rate, changes in breathing, increased body temperature and changes in behaviour that could indicate pain( such as reduced appetite, reluctance to move or a change in temperament) should be taken into account [ 14 ]. Physical changes and behaviour were monitored throughout the patient ' s stay and recorded on the hospital sheets, and extra notes were added to the nursing section.
Any changes seen in the patient during his stay were also verbally reported to the clinicians / VNs caring for him to enable his care plan to be adapted as needed. Appropriate analgesia postoperatively allows the patient time to rest; however, analgesia must not be used unethically, for example, to restrain a patient with the intention of preventing patient interference with a surgical wound [ 14 ].
Conclusions
An obstruction within the patient ' s jejunum caused vomiting in an effort to dislodge the obstruction. The liquid loss due to vomiting resulted in dehydration, causing weakness and a heart murmur. Prior to this
40 Veterinary Nursing Journal