ABSTRACT: Nursing assessment is currently under-utilised in many veterinary practices. One of the primary roles of the veterinary nurse is to ensure that patients receive the most appropriate care based on a structured and thorough nursing assessment. Much of the information regarding the normal routine of the animal may be obtained from the owner and this initial contact with the owner by the nurse can ultimately improve client relations with the practice. The nursing assessment then leads to the creation of an informed care plan which ensures the animal's welfare is not compromised during hospitalisation.

Anyone who has spent even the briefest period in hospital will understand how stressful this can be. Lack of privacy and home environment, family and decent food can lead, at best, to a distressing time, let alone the stress of the illness or dysfunction. For most pets, being taken from their normal environment and housed in unfamiliar surroundings can lead to post hospitalisation behavioural problems.1

So it is essential that as nurses we obtain as much information as we can with regards to the patient we are caring for.

This article will describe a process of nursing which is likely to be inherent in most practices but perhaps not so well structured or documented. It will, hopefully, encourage a more structured approach to the care of our patients and, at the very least, persuade nurses that we really need more information on our patients.

From a good nursing assessment, consistent nursing care may be carried out in the form of a care plan. Anecdotal evidence indicates enthusiasm for the use of a structured veterinary nursing model of care, but often the paperwork involved precludes consistency of use within the practice. This is echoed in papers in [human] nursing journals. However, recent information on the changes in the National Health System indicate that a lack of nursing care plans results in poor patient care.2

The nursing process

When a patient is admitted and hospitalised, the following process of nursing care will often take place:

•   assessment – identify the patient and the initial nursing requirements and veterinary interventions (size of kennel, bedding, blood tests, radiographs etc.)

•   plan – is the appropriate size kennel available? Should this species be housed separately? When do the bloods need to be taken? A hospitalisation chart is usually drawn up with times of medication or procedures identified

•   carry out the nursing interventions – provide appropriate bedding, food. Take the blood sample or administer the medication prescribed (is this always consistent amongst the staff?)

•   evaluate the progress of the patient – is he eating? Has he defecated recently? Is he in pain after the procedure?

Figure 1 shows the five-step model of the nursing process to which veterinary nurses will follow to a certain degree – the assessment part being the most important part.

Figure 1: The nursing process

Assessment of patient requirements

This stage of the process is the most important – if we do not have enough information we are in danger of neglecting our patients. The following standard questions are often used when a patient is admitted: “When did s/he last eat?” “Any vomiting or diarrhoea?” “Is s/he currently on any medication?”

Is this enough information? A recent cohort of Graduate Diploma in Professional and Clinical Nursing students at the Royal Veterinary College were asked to create a patient assessment questionnaire to use when admitting a patient as part of their Applied Clinical Nursing module. In the evaluation of the forms created and the online discussion, the nurses realised that they required much more information about the patients normal habits than initial practice paperwork allowed.3

One concern was that the veterinary surgeons usually admit the patients and do not always ask the type of questions to which we, as nurses, need answers. If the veterinary nurse admits the patient following the veterinary consultation, not only does the nurse obtain the information they need but the client also values that more personal contact with the person who will be caring for their pet.

The role of the veterinary nurse is to help the patient return to normal health, or at least be able to cope with the illness or dysfunction in order to maintain a good quality of life. If we do not know what is normal for our patient, how do we know when our nursing care is working? You would not bother to measure the temperature, pulse and respiratory rate of a patient if you could not decide if the measurements were higher or lower than normal.

Who else but the owner is going to know the behavioural habits and eating preferences of your patient? Owners are often contacted as a last resort to find out the food preferences of the anorexic cat which has been hospitalised for the last three days. As the minimum standard of care we should be looking towards the Five Freedoms (Figure 2) to ensure appropriate welfare4 and an understanding of the physiological and psychological needs of our patients.5

Figure 2: The Five Freedoms

In order to provide the most appropriate housing, nutrition and protection from fear and distress we need to understand not only the requirements for that individual species but also that patients individual needs.

What should we ask? What do we need to know?

Using a structured framework from a model of nursing care will help to ensure no aspect of the patient’s needs is missed. Based on the assessment process of the Orpet & Jeffery Ability Model,5 the questions in Table 1 could be asked.

These are just examples of the types of questions that should be asked of the client. From the clients point of view, he or she now feel much more at ease knowing that the practice is concerned for their pets welfare, and trust can be built between the nurse and client.

It is important to record if there are activities or abilities that the patient can not currently do as a result of the illness, or even ageing. For example, the elderly dog may be admitted for blood tests and radiographs to aid diagnosis of a gastric problem; however, unless we ask, we would not know about the arthritis in the hind limbs and the recent loss of hearing. Of course, not all animals have owners – and the initial assessment will be based on the physical findings and knowledge of the particular species needs.

Making a nursing diagnosis

The nursing diagnosis is where the nurse is ‘making a decisive statement concerning the patie
nts nursing needs’." This differs from the medical diagnosis made by the veterinary surgeon. As a nurse you are deciding on the most appropriate nursing interventions for that patient.

The North American Nursing Diagnosis Association (NANDA) has devised a set of pre-written nursing diagnoses.-1 The intention is to develop appropriate and standardised terminology which enables systematic patient care. NANDA’s [accessed at http://www.nanda.org/ Home.aspx] nursing diagnoses provide the name of the diagnosis along with a definition which incorporates the defining characteristics and related factors.

The European version of this is the Association for Common European Nursing Diagnoses, Interventions and Outcomes (ACIENDO) [accessed at http://www.acendio.net/AboutACENDIO.html and serves to promote the development of a professional language much in the same way as NANDA. Murray & Atkinson states a number of organised nursing diagnoses according to basic human need which are identified in relation to the patients symptoms or in the case of animals – the clinical signs exhibited.8 Essentially this stage of the nursing process is about deciding on what we need to do for our patient.

Planning the care

Once the nursing problems have been identified, the appropriate care is planned. Often these procedures are documented on the hospitalization chart for that patient. They can be quite concise but not particularly specific.The examples in Figure 3 indicate what needs to be carried out with this patient but are not explicit enough to ensure standardised care. What type of brush should be used? How often does the patient need grooming? Does the patient like being groomed? What should it be hand fed? How much? Is there a space for recording how much has been eaten, type of food given or is the box just ticked?

Figure 3: An example of a typical entry on traditional hospitalisation sheets

This part of the care plan can be invaluable as an aid to training student veterinary nurses, where they will learn from the expertise of the experienced veterinary nurse as long as the statements are explicit. When planning the nursing interventions, it is always important to consider what goals you are hoping to achieve by carrying out those specific nursing tasks. Goals should state the change in ability or behaviour of the patient and written as outcomes that can be measured.9 In this way you can see the progress the animal is making.

Implementing the care

During this phase, the nursing interventions and also veterinary interventions (or instructions from the veterinary surgeon) are carried out. Everything that is done to the patient should be documented. Unfortunately, some of the more basic nursing tasks – such as grooming, cleaning around the mouth – are not often recorded as well as detailing what the patient has eliminated and when.

A clearly stated care plan would ensure that everything is recorded. Our own RCVS Guide to Professional Conduct states ‘maintain clear, accurate and comprehensive case records and accounts’ as a professional requirement to account for our actions.

‘Care bundles’ were introduced into human medicine as a method of achieving consistency in care and best practice in nursing care (Health Protection Scotland).10 They consist of a set of practices for particular conditions or procedures which are evidence-based and have been reported to improve patient care. Standardising the procedures in the practice once again ensures consistency in the care given to each patient.

Evaluating the care

Evaluation is concerned with measuring how effective the nursing care has been.9 The goals set at the planning stage need to be revisited to see how far they have been met.7

Veterinary nurses generally evaluate what they do on a daily basis – it is just not always documented. During hand feeding a patient, you evaluate whether the procedures you have carried out have made any difference to the patient’s food intake. As the nursing process is a continuous cycle, the next stage would be to re-assess the patients needs and plan further care – which may include changing the type of food fed.

Summary

The purpose of this article is to try and improve the procedures in planning patient care by obtaining enough information on the patient’s normal routine. If the processes of admitting the patient are geared towards obtaining adequate information and improving client communication, then patient care will improve. The role of the veterinary nurse also becomes more explicit in the eyes of the client with the focus being the individual care of their pet. So not only does the client benefit from the personal care, the practice benefits from improved client relations and, most importantly, the role of the veterinary nurse is defined in the structured and consistent evidence based nursing care which is the essence of a professional. 

Author

Hilary Orpet BSc DipAVN(Surgical) FHEA CertEdDipCABT(COAPE) RVN 

Hilary is course director for the undergraduate nursing degrees at the Royal Veterinary College and is currently undertaking an MSc in Veterinary Education.

To cite this article use either

DOI: 10.1111/j.2045-0648.2011 00069.x or Veterinary Nursing Journal Vol 26 pp 242-245

References

1.   RICCOMINI. F. 120091 Avoiding behaviour problems following vet hospitalisation. Veterinary Nursing Times. January 2009.

2.   LOMAS. C. and SANTRV. C. 120101 Safety fears prompt calls for more nurse led care plans. Nursing Times Net. Available at http://www.nursingtimes.net/nursing-practice- clinical-research/clinical-subjects/patieni safety/safety-fears-prompt-calls-for-more- nurse-led-care-plans/5013058 article [accessed on 12th March 2011).

3.   Personal Communication with Graduate Diploma students – for further information regarding the course http://www.rvc.ac.uk/Undergraduate/ VNdiploma/lndex.cfm

4.   Farm Animal Welfare Council – Five Freedoms. Available at http://www.fawc.org.uk/ freedoms.htm (accessed on 15th March 2011]

5.   ORPET. H. and WELSH. P. 120111 2nd ed. Handbook of Veterinary Nursing. Wiley-Blackwell,

6.   Animal Welfare Act 2006 guidance from Direct.gov.uk Available at http://www.direct.gov.uk/ en/HomeAndCommunity/lnYourHome/AnimalsAn dPets/DG_l 0025980 [accessed on 15th March 20111.

7.   AGGLETON. P. and CHALMERS. H. 120001 Nursing Models and Nursing Practice. 2nd ed. Palgrave, Hampshire.

8.   Murray. M. E. & Atkinson. L. 0. [19941 Understanding the Nursing Process – The Next Generation. 5th revised ed McGraw-Hill Professional.

9.   Kratz, C. R, 119891 The Nursing Process. Bailliere Tindall, Oxford.

10.   Health Protection Scotland – care bundles. Available at http://www.hps.scol.nhs.uk/ haiic/ic/bundles.aspx also http://www.documents.hps.scot.nhs.uk/posters/ 2008/using-bundles-reliably-improve-care.pdf [accessed on 15th March 20111.

Additional reading

MASON. C. 11999) Guide to practice or load of old rubbish ? The influence of care plans on nursing practice in five clinical areas in Northern Ireland. Journal of Advanced Nursing. 29[2]: 380-387.

Veterinary Nursing Journal • VOL 26 • July 2011 •