Plus-Hex REFERRAL NURSING and Pierre , 2010 ). On reflection , this resulted in minimal improvement in the patient ’ s ventilation parameters , despite an initial improvement in pulmonary auscultation . Therefore , due to the limited evidence of its use in noncardiogenic oedema , the use of furosemide could have been avoided in this case .
Pulmonary oedema within bronchi results in increased turbulence , which can induce bronchoconstriction of the airways ( Krodel et al ., 2010 ). Bronchodilators such as terbutaline and salbutamol are both beta-agonists and can be considered for use in patients with lower airway disease ( Tong and Gonzalez , 2020 ). In this patient , terbutaline was started at dose of 0.01 mg / kg subcutaneously BID for 4 days during hospitalisation . Salbutamol is another bronchodilator and is available as an aerosolised drug . The use of beta-agonists in pulmonary oedema is controversial , with previous studies indicating the use of aerosolised salbutamol . However , more recent studies have found beta-agonists to be detrimental ( Smith et al ., 2012 ). Due to the severity of the patient ’ s clinical signs , a single dose was trialled but discontinued as the patient did not tolerate administration .
Prior to arrival at the clinic , the patient was administered a single dose of dexamethasone . Glucocorticoid use is also controversial and although there are studies showing dexamethasone use in humans is associated with a significant reduction in mortality , a recent meta-analysis of the data indicates further studies are required to confirm the safety of its use in ARDS patients ( Zayed et al ., 2020 ).
Nursing care
The patient was monitored closely in the ICU , which was always staffed by an RVN or veterinary surgeon . The patient received one-to-one care from an RVN or intern at all times . Kirby ’ s Rule of 20 ( Figure 1 ) was utilised to ensure that all the patient ’ s requirements were addressed ( Haskey , 2015 ). By considering all items , the team could assess the patient holistically while also implementing critical thinking skills ( Waxman , 2020 ).
Due to the dynamic nature of the disease , close monitoring was vital to recognising changes that were indicative of deterioration and allow rapid intervention . Potential complications for the patient were identified and recorded , in order to tailor observations accurately . All treatments , procedures and observations were written accurately , to monitor ongoing trends .
Buddy was a demanding case that required a team effort with frequent reassessment . It was helpful to refer to the nursing process using the cyclical model of Evaluation > Assessment > Planning > Implementation ( Haskey , 2015 ). This allowed the team to move through the stages continuously initially , then prolonging to every 30 minutes , then 60 minutes as the patient stabilised .
KIRBY ’ S RULE OF 20 CHECKLIST
1 . Fluid balance 2 . Albumin and oncotic pull 3 . Electrolyte and acid-base 4 . Mentation 5 . Heart rate , rhythm and contractility 6 . Blood pressure 7 . Body temperature 8 . Oxygenation and ventilation 9 . Red blood cells and haemoglobin 10 . Coagulation cascade 11 . Renal function 12 . Gastrointestinal motility and integrity 13 . Nutrition 14 . Glucose 15 . Immune status and antibiotics 16 . Wound healing and bandages 17 . Drug doses and metabolism 18 . Pain control 19 . Nursing care 20 . Tender loving care
Figure 1 . Kirby ’ s Rule of 20 checklist ( Waxman , 2020 ).
Over the period of hospitalisation , serial oscillometric blood pressure monitoring helped to quickly identify hypertension or hypotension . Simultaneously , the cardiovascular system was further assessed by checking the heart rate and pulse quality , as critical illness often places significant demands on the cardiovascular system ( Waxman , 2020 ). Hypotension can indicate circulatory compromise and is common in patients pre-arrest ( Latimer-Jones , 2020 ). It is reflective of the cardiac output and the perfusion to tissues ( Latimer-Jones , 2020 ). A mean blood pressure of > 60 mmHg is essential for maintaining organ perfusion ( Latimer-Jones , 2020 ). The patient ’ s blood pressure remained within normal limits throughout hospitalisation . While this method of monitoring blood pressure gave indications of trends , using direct blood pressure measurements may have given more accurate results .
When recovered from anaesthesia , the patient ’ s level of consciousness was assessed by observing demeanour and responsiveness to stimuli in the environment . The patient always remained alert .
Fluctuations in fluid balance can be responsible for weight alterations ( Latimer-Jones , 2020 ). The patient
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