Nursing of the spinal patient in general practice by Philippa Elphee

ABSTRACT: Spinal cases can be among the most daunting to nurse. Whilst the veterinary surgeon is in charge of diagnosis and devising the treatment plan, the nursing team plays an integral role in patient management and is heavily involved in the day-to-day care and recovery of the patient. Treatment of many spinal disorders is beyond the remit of general practice, although first-opinion practices are the front line for these cases. This article aims to cover the requirements of nursing the patient that either does not need referral, or requires care prior to referral.

Spinal cases can be among the most satisfying to nurse. Although the veterinary surgeon is in charge of diagnosis and devising the treatment plan, the nurses are heavily involved in the day-to- day care and recovery of the patients. In some cases, nursing of a spinal patient may end unsatisfactorily, yet it can still generate a great deal of job-satisfaction. Regardless of the outcome, the amount of care given really engages the skills that we have all been trained to use.

Surgical treatment of many disorders of the spine is beyond the remit of general practice, although first-opinion practices are the front line for these cases. Few first-opinion practices are able to offer any sort of spinal surgery or more specialised diagnostics, such as MRI scans, myelography or CSF analysis.

This means that most cases we see are for medical nursing or prior to referral.

Clinical signs

Usually within general practice, spinal disorders are diagnosed using the clinical history, clinical signs, radiographs and a neurological examination (Table 1).

Spinal patients can exhibit one or more of the following signs, to varying degrees, depending on the area of the spine affected and the severity of spinal cord damage:

• ataxia – incoordination

• paresis – weakness of one or more limbs

• paralysis – loss of function of one or more limbs

• paraplegia – both front or both hind limbs

• tetra- or quadriplegia – all four limbs

• hemiplegia – one side of the body

• urinary and/or faecal incontinence, which must not to be confused with urinary overflow

• urinary and/or faecal retention

• overflow can result in leaking of urine – this is not incontinence

• Lack of panniculus reflex

• a quick twitch of the subcutaneous muscles along the back in response to stimulation. Absence of this reflex is important in localisation of the lesion in the spinal cord

• Lack of tail function – paresis or paralysis.

Prior to diagnosis, if spinal instability is suspected, great care must be taken to ensure the patient is restrained correctly to limit movement of the spinal column. Sedation/anaesthesia and restraint on a board may be required. Several members of staff may be needed when manoeuvring larger patients to ensure the safety of the patient and those doing the lifting.

The extent of nursing is dependent on the severity of the spinal disorder, the amount of spinal cord damage and loss of function. AU aspects of the patients functionality need regular monitoring for both improvement and deterioration and the nursing plan adjusted accordingly.

Nursing considerations

The primary nursing considerations of the spinal patient are to ensure comfort, expulsion of waste products, nutrition, physiotherapy and owner education (Figure 1).

Figure 1: The primary nursing considerations of the spinal patient are to ensure comfort, expulsion of waste products, nutrition, physiotherapy and owner education

Appropriate bedding

Padded/orthopaedic beds should be used to relieve pressure and thus to prevent ulceration. Plastic covers should be fitted over padded beds to maintain hygiene, and clinical bedding, such as Vetbed, may be used. It is important to make sure that any bedding does not ‘wick’ urine and blankets must, therefore, be used with caution.

Monitoring

Regular monitoring of vital signs, as with any intensive care patient, is critical to the outcome of the nursing programme. So any improvement/deterioration in the patients condition should be reported to the duty vet.

Regular temperature monitoring is of particular importance because:

• some spinal disorders can compromise the animals thermoregulation

• recumbent patients are more prone to hypothermia as they are not creating heat through movement recumbent patients are unable to move away from undesirable temperatures – heat pads or draughts, for example.

Urination/defecation

If bowel movement is compromised in these patients, an enema may be needed. This will be decided by the vet. Where possible, the patient should be assisted outside for normal elimination, using a gathered' towel or proprietary sling for support.

Palpate the bladder every four hours and gently express it, if necessary. Be careful not to confuse urine overflow with incontinence. Palpate the bladder after urination; if its still full, it is urine overflow not incontinence.

A urinary catheter may be needed to facilitate urination or to prevent soiling – an in-dwelling catheter with a closed collection bag is the preferred method. This limits the potential for ascending infection, avoids trauma of repeated catheter placement, and allows urine output to be monitored.

Turning the patient

The patient must be turned every four hours to prevent ulcers and hypostatic pneumonia. Hypostatic pneumonia is caused by a restriction of blood flow to the lung tissues owing to the pressure of the animals weight. This reduced tissue perfusion and torpid blood flow can cause a shift of fluid from the circulation into the pulmonary spaces, which compromises respiration and can be a focus for secondary infection.

Decubitus ulcers, or pressure sores, are caused in a similar way to hypostatic pneumonia. The pressure of the animal’s body weight on the skin restricts blood flow. This causes the tissue to become devitalised and vulnerable to skin breakdown and secondary infection.

It is more common over bony areas because the added pressure is on the skin compressed between the hard surface and bone.

The risks associated with a recumbent patient must be weighed up against those associated with moving a spinal patient. Careful movement may be required using a spinal board under the supervision of the vet in charge of the case:

• ensure enough members of staff are available to maintain safety of both workers and the patient

• the time and position must be noted to ensure patients are not left in the same position for too long.

Keeping patients clean and dry

Nurses looking after spinal patients should constantly be mindful that urinary and faecal contamination can cause scalding and ulceration of the skin. Therefore, urinary catheterisation can help prevent urine scalding, as will regular bathing and thorough drying followed by the application of a barrier cream to protect the skin.

Clipping the fur on longer haired patients can be helpful, if owners will consent to it.

Hydration and nutrition

Hydration may be maintained, if necessary, by intravenous fluid therapy under the direction of the vet.

Nutrition may be facilitated by either hand or syringe feeding. Alternatively, the duty vet may decide that a feeding tube should be placed. Most commonly, a nasoesphageal tube is used, owing to its relative ease of placement – it is a tube inserted into the nose and the tip rests in the oesophagus, thus by-passing the mouth.

Other, more specialised, feeding tubes can be used, but details are not within the remit of this article.

If the patient is able to eat and drink from a bowl, it may need to be raised. Ideally, in these instances, use non-slip/non¬tipping bowls, which should be placed close to the patient for easy access. Constant observation, however, should be maintained to ensure that the bowls are not disturbed by the patient’s movement.

Diets specifically designed for convalescing patients should be considered for spinal patient nutrition because they are:

• usually suitable for syringe/tube feeding

• highly palatable

• highly digestible, so smaller amounts need to be consumed for adequate nutrition.

Enrichment

There is a whole series of factors affecting the enrichment and well-being of hospitalised patients. Some of these are simple things that can easily be overlooked:

• when possible, the patient should be assisted outside for normal elimination

• playing music or the radio can be beneficial

• pheromone spays/diffusers can be effective

• regular visits from the owner, as long as this does not cause over excitement or further depression when they leave

• ask the owner to bring in familiar items from home (toys may not be suitable)

• some patients may benefit from being positioned in a kennel where they can see what is going on

• veterinary nurses should include regular grooming and simple physiotherapy techniques as part of the patients care plan.

Physiotherapy

The use of in-depth physiotherapy can be beneficial, but its implementation must be decided by the vet and a qualified animal physiotherapist. However, once the decision has been taken to go ahead, the nurses can carry out some of the therapy, under supervision. Besides assisting patients outside, this activity may include passive manipulation of limbs and gentle massage of limbs and areas prone to pressure sores using the techniques of eftleurage, petrissage, friction and TTouch.

Some general practices have access to hydrotherapy, in which nurses may play a key role in assisting qualified staff.

Owner education

It is often the nursing staffs responsibility to educate owners in how to look after their pet after it has been discharged. Medications need to be discussed – passing on the vet’s instructions – and the signs of improvement/deterioration need to be highlighted.

Specific advice may be given on how to assist the pet outside correctly, cage rest, exercise and physiotherapy.

Summary

Within first-opinion practices, nursing spinal patients is rare owing to the complexity and large financial outlay. Unfortunately, many have to be euthanased because of financial constraints. The greater prevalence of pet insurance has improved this situation, but this then enables the patient to be referred to a specialist.

However, when a spinal patient is nursed within general practice, it can give the staff great satisfaction. The nursing team is integral in giving a spinal patient its best chance of recovery. Although not all cases have a positive outcome, the nurses involved can feel they have played an important part.

Author

Philippa Elphee RVN BSc(Hons) BVNA MIACE

Pippa Elphee [nee Greetham) obtained her nursing degree and NVQ qualifications from the University of Bristol in 2005. Since then, she has worked at Cedar Veterinary Group in Hampshire at both a small animal branch practice and at the flagship branch that is a mixed practice. Pippa also runs her own dog behaviour/training business in her spare time.

To cite this article use either

DOI: 10.1111/j.2045-0648.2011.00084.x or Veterinary Nursing Journal Vol 26 pp 305-307

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