The patient ' s RER was recalculated after surgery to support his recovery and maintain normal homeostasis. He was weighed daily to monitor for any weight loss or gain during his hospital stay. Failure to meet his daily RER could have compromised healing, as the body would prioritise essential functions over repairing the fracture in the humerus.
In cases where a patient is not eating adequately, enteral nutrition should be considered. Enteral feeding not only provides essential nutrients but also stimulates the gastrointestinal tract by placing food directly into the gut. This helps to maintain normal gastrointestinal motility and so prevents ileus after surgery, and encourages the patient to begin eating voluntarily [ 17 ].
Pain management
When this patient was initially pain scored using the Glasgow Composite Measure Pain Scale [ 18 ], he scored high( over 7 / 20), so the VS chose to continue treating him with methadone. Pain scores were completed immediately before the opioid administrations as well as between administrations.
The pain scores were completed before administering the opioid to see whether there was a need to increase or reduce the dose, or whether a less potent form of analgesia could be considered to avoid dependence on the opioid. They were also completed a few hours after each administration to determine the effectiveness of the patient ' s analgesia plan.
The patient ' s pain scores decreased throughout his initial night in hospital, to < 5 / 24. Throughout the day following his surgery, his pain scores continued to be < 5 / 24, indicating that the analgesia plan was effective. Although the patient showed mild restlessness, his pain scores generally remained low, so the restlessness was considered in the context of the patient ' s breed-specific temperament and stress response.
On recovery after surgery, the patient was placed onto a constant-rate infusion( CRI) of ketamine, offering multimodal analgesia that could be adjusted by the VS in response to the patient ' s pain levels. Postoperative pain scores were carried out routinely every 4 hours, in line with the methadone administration. Ketamine was stopped 2 days after the road traffic accident, as the patient ' s pain scores were consistently low( 2 – 3 / 24) and to allow the VS to assess the patient ' s pain levels. Methadone was stopped the same afternoon, following pain scores of 2 / 24.
The patient was then administered buprenorphine. Following this change in medication, the patient ' s pain scores were < 5 / 24, so administration of buprenorphine continued to be the analgesia plan, with the dose reduced for the patient ' s discharge.
Discharge from hospital
On discharge of the patient, the owners were advised to monitor him over the next few weeks for signs such as lethargy, vomiting and anorexia. These signs could be indicative of peritonitis or septic peritonitis, which can take a few days to a few weeks to become apparent [ 5 ].
Had there been any signs of deterioration or a change in mentation, the patient would have been re-evaluated to ensure there were no complications, and further imaging and blood work may have been considered to ensure there was no free fluid, infection or inflammation.
Evaluation
It would have been useful to have had a client questionnaire available, which could have been completed by the owner while the patient was being stabilised, to gain information such as the patient ' s feeding, exercise and resting routine at home, their response to different stimuli, their normal behaviour, and whether they were used to being crated.
Further to this, a more in-depth nursing care plan for the patient could have been devised between the VS and the nursing team, which could have enabled treatments to be grouped together to allow the patient longer periods of rest between treatments / checks. For example, the patient ' s eyes were being lubricated regularly to prevent the development of dry eye and / or an eye ulcer due to the patient receiving a CRI of ketamine, which can reduce tear production [ 19 ]. Where possible, this treatment could have been given alongside other checks and treatments.
Similarly, it was necessary to disturb the patient to carry out regular pain scoring. However, using different analgesic drugs could have provided longer-lasting effects to help prolong the resting periods.
Conclusions
A key responsibility of a VN managing a patient following a road traffic accident is to recognise clinical deterioration and signs of discomfort or complications, alongside close monitoring of the PCV.
In this case, the patient was appropriately monitored and maintained in optimal comfort throughout his hospitalisation. Pain scoring was undertaken at suitable intervals to ensure the accurate assessment of pain before and between the administration of medications.
The patient demonstrated a favourable prognosis; he recovered well following the vehicular trauma and surgery, and was discharged with guidance provided to the owners regarding potential complications.
42 Veterinary Nursing Journal