Aspergillosis treatment in kākāpō Feline urethral obstruction Helping our Australian animal whānau - VOLUME 26 No. 95 SEPTEMBER 2020 - New Zealand ...
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VOLUME 26 No. 95 SEPTEMBER 2020 Aspergillosis treatment in kākāpō Feline urethral obstruction Helping our Australian animal whānau
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CONTENTS
VO LUME 2 6 No. 95 SEPT EMB E R 2020
04 President’s report by Julie Hutt
05 Letter from the Editor
by Antoinette Ratcliffe
EXECUTIVE COMMITTEE OFFICERS 05 Membership Secretary’s report
President Julie Hutt by Kathy Waugh
PO Box 35831
Browns Bay
06 Feline urethral obstruction
by Kate Robinson
Auckland 0753
021 599 059
president@nzvna.org.nz
18 Helping our Australian animal
whānau by Mark Anderson
Vice-President Amy Ross
021 852 664 21 Aspergillosis treatment in
vicepresident@nzvna.org.nz kākāpō by Breeze Buchanan
Treasurer & Membership Secretary
Kathy Waugh
021 843 277
treasurer@nzvna.org.nz
National Secretary Luanne Corles
027 472 1072
secretary@nzvna.org.nz
JOURNAL EDITOR
Antoinette Ratcliffe
19
journal@nzvna.org.nz
The New Zealand
Assistant Editor: Catherine Taylor Veterinary Nursing
catherine.ellen.taylor@gmail.com Association would like
to thank Hill’s™ Pet
EDITORIAL BOARD
Nutrition NZ, our gold
Exotics: Kylie Martin sponsors, for their
23
Equine: Lyn Hobbs continued support of the NZVNA and the
OSH: Libby Leader veterinary nursing profession.
CPD: Patricia Gleason
COVER:
OUR VISION
Kākāpō chick “Toiora”
Photograph by Lydia Uddstrom Caring for our community
by promoting excellence
in animal healthcare.
DISCLAIMER The New Zealand Veterinary Nursing
Association Journal is published by the New Zealand
Veterinary Nursing Association Incorporated (NZVNA).
The views expressed in the articles and letters do
not necessarily represent those of the NZVNA or the
editor, and neither the NZVNA nor the editor endorse
any products or services advertised. The NZVNA is
not the source of the information reproduced in
this publication and has not independently verified
the truth of the information. It does not accept any
legal responsibility for the truth or accuracy of the
information contained herein. Neither the NZVNA nor
the editor accepts any liability whatsoever for the
NZVNA FORMS contents of this publication or for any consequences
The registration or list badge order which may result from the use of the information
contained herein or advice given herein. The provision
forms, merchandise order forms and new
29
is intended to exclude the NZVNA, the editor and its
membership forms can now all be found on staff from all liability whatsoever, including liability for
the website www.nzvna.org.nz or by emailing negligence in the publication or reproduction of the
materials set out herein.
membership@nzvna.org.nz.
NZVNA
President’s report
We have all faced some major challenges over the last few A mentoring relationship should be a two-way exercise
months, both personally and the veterinary industry as of trust, respect, and open communication. You can share
a profession. We all did our bit here in New Zealand with your veterinary nursing skills and clinical experiences
the restrictions in place to keep people and their pets safe. to help develop and achieve that successful mentoring
The safety of the staff has been paramount, and it has relationship. Mentoring is taking the time to help ensure
been enlightening to hear the stories of both veterinary that you guide your mentee to achieve their goals.
nurses and veterinarians on how they coped during the
Time available during busy clinic days is often a reason for
lockdown period. The challenges, the ingenuity of the team
not wanting to mentor others. Committing to mentoring
to problem solve difficult situations, the low times, but
relationships does not require excessive time but you
also the fun times have forged some special bonds within
do need to plan with the mentee and set goals for what
veterinary teams.
the expectations are to make the work experience more
If you need more information regarding Coronavirus manageable for all.
(COVID-19) and the workplace, Employment New
It is important to be able to listen to the goals of your
Zealand has guidance for employees, employers, and
mentee and remember to ask them questions and give
business. Just follow the link https://www.employment.
constructive and timely feedback. Know that mentees
govt.nz/leave-and-holidays/other-types-of-leave/
will need to practice skills to improve, and this includes
coronavirus-workplace/.
practising their communication skills with other team
As an NZVNA member, you have free access to Vitae, our members and even clients if appropriate. Providing
counselling service for veterinary nurses in times of stress, encouragement, demonstrating skills, being available
and the NZVNA website also has Mental Health Resources when required, and listening with an open mind will
available. Technology is a wonderful mechanism that we create an atmosphere of trust and respect. A great
can use to help our wellbeing, and there is an assortment resource for mentors published by the American Animal
of apps and websites designed for this. Wellness apps Hospital Association can be found at https://www.
are available for both iPhone and Android, and include aaha.org/aaha-guidelines/mentoring-configuration/
Calm, Happify: for Stress and Worry, and Take a Break: mentoring-guidelines/.
Meditations for Stress Relief.
Over the years I have had mentors, and they have helped
During these uncertain times and moving between Alert and guided me through my career as a veterinary nurse
Levels, veterinary clinics have had to place restrictions on and educator. I would not have stepped out of my comfort
student placements and customer interface. During Alert zone and taken those steps to lifelong learning if it were
Level 1, we hope student placements for veterinary nurses not for them. When you do have someone, a mentor that
can be offered, as the experience gained in placement has made a difference in your career, take the time to say
is invaluable and so important for their professional thank you.
development.
Remember, being a mentor can increase job satisfaction
Now is the perfect opportunity to become a mentor to and help new nurses stay in the field.
veterinary nursing students, veterinary nurse assistants
You never know when someone is observing and learning
and new employees in your clinic. What is mentoring?
from your actions.
Mentoring is an ongoing relationship between two
individuals who are committed to improving their Julie
professional environment. The mentee is often a team
member or junior colleague and the mentor is the more
experienced.
4 September 2020
NZVNA
Letter from the Editor
Welcome to our first digital format New Zealand Veterinary nursing plan in her case study, explaining how to best
Nurse journal! While it’s a little sad to see the end of the make these patients feel less stressed.
print era (at least for now), our hand was forced by the
We are currently looking for more articles for the next
marketing budgets of our advertisers. The upside of going
editions, so if you have any ideas, please feel free to get in
completely digital is that we can publish longer articles and
contact with me at journal@nzvna.org.
the links are active! If you are interested in reading more
about a topic, check out the reference links at the end of Antoinette
the article. If you want to know more about our advertisers’
products, click on their advert, they’re also linked to their
website.
I have been looking forward to publishing an article
about kākāpō for some time now after speaking with a
veterinary nurse working at the Auckland Zoo. Thankfully
Breeze Buchanan found some time to describe the nursing
aspects of Aspergillosis treatment, and we get to read
about the speciality knowledge and techniques used in the
rehabilitation of one of our beautiful native parrot species.
Even though it’s now looking like our trans-Tasman bubble
is further off than it was a few months ago, we can still
make time to prepare for the opportunity to travel in the
future. Mark Anderson is a volunteer with Animal Evac NZ
and shares his experience helping during the Australian
bushfires in New South Wales. If you are interested in
animal rescue programs, now is a great time to do some
research and find out how you can upskill.
Feline urethral obstruction is a common condition which
brings patients into our hospitals, and as veterinary nurses
we can always look at making them more comfortable
during their stay. Kate Robinson has detailed a thorough | Above: Cece enjoying some early spring sunshine
Membership Secretary’s report
First, let me apologise to anyone who was unaware that go online and update your details at https://www.nzvna.
their membership had expired. We had a number of issues org.nz/Membership/Manage+my+account.html.
with the website and realised that the renewal emails were
Otherwise, I am happy for you to email at
not being sent out. This has now been sorted and we are
membership@nzvna.org.nz or phone me on 0800 868773
just about ready to launch our new look website.
and I will update them for you.
Please ensure that we have your current email address on
file – we love to keep in touch with our members. You can Kathy
September 2020 5
FELINE URETHRAL OBSTRUCTION
Feline urethral obstruction
By Kate Robinson RVN, Vet Marlborough The veterinarian diagnosed the patient with a urethral
obstruction. Written consent was gained to perform blood
testing and administer intravenous fluid therapy, as well
An 8-year-old male neutered domestic long-haired feline as to provide analgesia and anaesthesia to place a urinary
presented to the clinic with dysuria and abdominal pain catheter. Due to the urgency of the medical condition,
that had been present for one day. the patient was immediately admitted to the hospital.
Pre-admission The dynamics of this situation meant that it was not
When the patient’s owner phoned the clinic and spoke to appropriate to speak to the owner further about their cat’s
the receptionist, they reported noticing the cat spotting normal routine, as would be routine for a non-urgent case.
small amounts of urine around the house. The receptionist However, the owner provided information by phone the
recommended he should be seen by a veterinarian next morning regarding behaviour, diet, and toileting of
urgently. the patient. The owner specified the patient normally ate
a mixture of wet and dry supermarket brand Whiskas® cat
Admission
food, and was given two meals a day. Behaviourally, he
Clinical examination revealed that the patient’s bladder
slept a lot inside on the owner’s bed and usually toileted
was extremely full and unable to be manually expressed.
outdoors. He did not have any behavioural issues that
His temperature was elevated at 39°C (normal reference
the owner was aware of. In hindsight, this assessment
range 38.2 - 38.6°C), and his heart rate (HR) was
could have been improved by having a more in-depth
tachycardic at 220 beats per minute (normal reference
conversation with the owner or providing them with a
range 100 - 200). Respiratory rate (RR) was also elevated
written questionnaire to gain more information on the
at 60 breaths per minute (normal reference range 20 - 30).
patient’s normal routine. According to the BSAVA (2011), it
He had a normal capillary refill time (CRT) of one second
“is important to know what is ‘normal’ for each patient”,
(normal reference range 1-2 seconds) and healthy pink
as this “could make a significant difference to the care
mucous membranes (MM) (normal reference range pink).
delivered”.
The patient’s demeanour was quiet, alert, and responsive,
with a pain score of 1/4 assessed using the Colorado Initial treatment
State University’s Feline Acute Pain Scale (Hellyer, Uhrig, The patient was given 0.39mL of buprenorphine (0.3mg/
Robinson, 2006). The patient was obese at 5.9kgs, with mL) at the rate of 20mcg/kg for analgesia by subcutaneous
a body condition score of 8/9. There was no evidence of (SQ) injection on admission. Buprenorphine is a partial
dehydration, and the owner indicated there had been no opiate agonist suited for analgesia in small animals
recent change in appetite, weight, or activity. experiencing mild to moderate pain (Plumb, 2011).
The disadvantage of using buprenorphine was that the
onset of action is slow when compared with other opioids.
Kate Robinson works as a veterinary nurse at Vet Marlborough. When given subcutaneously, buprenorphine takes 45
She has worked at this fast-paced mixed practice clinic for minutes to reach full effect (Flaherty, 2009). Giving the
three years since gaining her Certificate in Veterinary Nursing patient buprenorphine subcutaneously was not ideal,
from Otago Polytechnic. She recently gained her Diploma in due to its limited effect and reduced bioavailability
Veterinary Nursing whilst working full-time, and was awarded
when administered by this route. It would have been
the Boehringer Animal Health Award for Excellence in Veterinary
Nursing, as well as Otago Polytechnic’s award for outstanding better to have administered the drug intravenously or
achievement. Kate has a particular interest in dentistry, nutrition, intramuscularly (Plumb, 2011).
and surgical nursing. She loves the challenges and variety of
The benefit of using buprenorphine is that the duration
work that veterinary nursing brings, and the opportunity to work
with like-minded, animal-loving people.
of action is prolonged, lasting approximately six to eight
hours (Flaherty, 2009). Another is that buprenorphine has
6 September 2020
FELINE URETHRAL OBSTRUCTION
less adverse effects than other opioids, with respiratory Another improvement to the diagnostics performed for
depression being the main side effect, though this is a rare this patient would be taking radiographs of the bladder
occurrence (Plumb, 2011). and urethra to check for calculi (Beiter, 2016). Calculi in
the bladder or urethra could be a possible cause of the
Diagnostics
patient’s urethral obstruction, and if calculi had been
A blood sample was collected for biochemistry and
identified from radiographs, the treatment plan may have
electrolyte analysis. As the patient was unable to urinate,
been modified. Beiter (2016) states that “the presence of
waste products and excess electrolytes can accumulate in
calculi can make it much more difficult to use a urinary
the bloodstream. For this reason, it was important to check
catheter to remove the obstruction and can result in
blood biochemistry and electrolyte parameters, especially
additional urethral trauma”.
for elevations of potassium, urea, and creatinine, which
are common findings in feline urethral obstruction cases A urine sample was collected for urinalysis (including
(Beiter, 2016). sediment) once the urinary catheter had been placed to
check for possible causes of the obstruction. No crystals or
The veterinarian collected 1.3mL of blood from the left
bacteria were present, but there were many erythrocytes
cephalic vein for biochemistry analysis. Beiter (2016) also and epithelial cells. The sediment findings of no bacteria
recommends testing haematology, though unfortunately or crystals ruled out urinary tract infection or crystalluria
in this instance, we were unable to collect enough blood being the cause of the urethral obstruction. The finding of
as our IDEXX ProCyte Dx™ Hematology Analyzer requires many erythrocytes on the sediment exam reveals cystitis
1mL of blood. In hindsight, we could have run a PCV (Sabino, Boudreau, & Matthews, 2016). The patient’s urine
which requires very little blood. This would have given specific gravity was normal at 1.045. A reading over 1.060
information on the patient’s hydration status which in cats could indicate dehydration, acute renal failure, or
would have been useful when formulating the patient’s shock (Irwin-Porter, 2011).
fluid therapy plan. Patients with an elevated PCV may be
Ideally, an electrocardiogram should also be performed in
dehydrated or be suffering from other conditions such
feline urethral obstruction cases. A common complication
as endotoxic shock. Patients with decreased PCV may be
of urethral obstruction is hyperkalaemia, which can result
anaemic or have suffered blood loss (Irwin-Porter, 2011).
in heart rate disturbances such as bradyarrhythmia and
The biochemistry and electrolyte results were normal, ventricular tachycardia (Sabino, Boudreau, & Matthews,
apart from slightly low potassium levels at 3.4mmol/L 2016).
(range 3.5-5.8mmol/L). The hypokalaemia was a surprising
Intravenous fluid therapy
result, as blood results indicating hyperkalaemia were
The veterinarian opted to use 0.9% sodium chloride for
expected due to the patient’s inability to excrete waste
intravenous fluid therapy. The clinic’s policy for feline
products (especially potassium) in their urine.
urethral obstruction cases is to use this type of fluid due
Total plasma protein was normal, indicating a normal to the lack of potassium, as ‘blocked bladder’ cats quite
hydration status, but it would have been helpful to commonly have hyperkalaemia, though the patient’s blood
interpret this alongside a packed cell volume (PCV) reading, potassium levels were slightly low. Beiter (2016) suggests
as an elevated result could still indicate dehydration (Irwin- that a solution with balanced electrolytes, such as Lactated
Porter, 2011). Ringers Solution, Normosol-R, or PlasmaLyte 148, would
The pathological findings were considered valid as still be suitable for hyperkalaemic cases, as the amount of
the sample was collected correctly with good hygiene potassium in these solutions is very low at 5 mEq/L or less.
practices; the correct amount of blood was collected; the Beiter (2016) recommends determining the fluid rate
blood was deposited into a 2mL heparin tube without for feline urinary obstruction patients by assessing the
compromising the sample; and the sample was processed patient’s clinical signs and examination findings. The
correctly in-house using the IDEXX Catalyst Dx™ Chemistry patient was alert and responsive, did not appear to be
Analyzer. All of these aspects can affect the validity of the dehydrated on examination, and had normal total plasma
blood tests if performed incorrectly (Irwin-Porter, 2011). protein levels. For stable urinary obstruction patients such
September 2020 7
FELINE URETHRAL OBSTRUCTION
as this, Beiter (2016) recommends calculating fluid rates was relatively stable, he was experiencing a urethral
using the percentage of dehydration to correct hydration obstruction, and was a geriatric patient. Geriatric
status, along with a maintenance rate of 60mL/kg/day and patients have an increased anaesthetic risk due to the
factoring in ongoing urine output losses of 10mL/hr. compromising effects aging has on organ function (Bryant,
For this patient, the clinic’s recommended maintenance rate 2010). Geriatric patients may also have decreased renal
for cats was used, which was 40mL/kg/24hr, or 10mL/hr. If perfusion (Welsh, 2009), so administering fluid therapy and
Beiter’s (2016) suggested maintenance rate had been used, monitoring blood pressure is important during anesthesia.
the patient would have been administered 15mL/hr, so by The pre-anaesthetic evaluation given to the patient was
comparison, the actual fluid rate administered (10mL/hr) satisfactory. Welsh’s (2009) recommendations were
appears to be too low. An improvement would be to include followed, with information gathered from the patient’s
ongoing losses in this fluid rate, as suggested. history, age, breed, physical examination, blood work, and
Fluid therapy was administered via a calibrated fluid present complaint to assess his category on the ASA scale.
therapy pump, which was ideal as they are more accurate The patient could possibly have also been placed as a class
for the administration of fluids than a free-flow giving set 4 (high risk) on the ASA scale, as the urethral obstruction
(Taylor, Holmes, & Jasani, 2011). could lead to decreased renal blood flow, hyperkalaemia,
cardiac failure, and ultimately, death (Sabino, Boudreau &
Pre-anaesthetic evaluation and planning
Matthews, 2016).
The patient was scored as class 3 (moderate risk)
on the American Society of Anesthesiologists (ASA) Surgery set-up
Physical Status Scale (AVTAA, n.d.). Although his physical Preparation for surgery included checking the anaesthetic
examination and blood chemistry results indicated he machines and circuits. Three endotracheal tube sizes
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8 September 2020
FELINE URETHRAL OBSTRUCTION
(3mm, 3.5mm and 4mm) were selected by estimation, silicone catheter, and sterile giving set was set up. A sterile
then checked for proper inflation of the cuff and visually disposable gown, sterile gloves, a cap, and mask for the
inspected for damage. The selection of endotracheal tube veterinarian and the scrubbed assistant was also prepared,
size could have been improved by palpating the patient’s as well as a cap and mask for the attending nurse. An
trachea gently, measuring the length of the tube from the empty intravenous fluid bag was prepared to use as a
incisors to the tip of the shoulders (thoracic inlet), then closed collection system.
comparing the tube gauge against the area between the Anaesthesia
patient’s nostrils (Murrell & Ford-Fennah, 2011). Other
Preoxygenation was performed by delivering 100%
intubation equipment selected included 2% lidocaine spray,
oxygen to the patient via a face mask for five minutes.
a stylet and syringe to inflate the cuff.
Preoxygenation helps to prevent hypoxemia during the
The Ayres T-Piece circuit with 500mL rebreathing bag used high-risk induction phase of anaesthesia by increasing the
for patients under 10kg was connected to the anaesthetic amount of oxygen in the lungs and bloodstream (Baetge &
machines, and the AP Alert monitor was attached. Matthews, 2009). The patient was intubated with a 3.5mm
The patient’s oxygen flow rate was calculated using the endotracheal tube, connected to oxygen at the rate of 2.3L/
clinic’s suggested formula of 500mL/kg/min for patients on min, and isoflurane was administered at 0.5%.
a non-rebreathing circuit. This equated to 2.9L of oxygen The patient was induced using 0.35mL of ketamine
per minute for the 5.9kg patient. However, Murrell and 100mg/mL (6mg/kg) intravenously for anaesthesia, with
Ford-Fennah (2011) recommend calculating fresh gas flow 0.6mL of diazepam 5mg/mL (0.5mg/kg). The ketamine and
rates by multiplying the patient’s tidal volume (10-15mL/kg) diazepam were administered slowly and titrated to effect
by the respiratory rate per minute to get minute volume, as recommended by Plumb (2011) however, the patient
then multiplying by the circuit factor for the particular required the complete dose to enable intubation.
breathing system you are using.
Ketamine is a general anaesthetic drug which is rapid-
The calculation for this patient would be as follows: acting and has analgesic properties. The benefit of using
10 - 15mL x 5.9 kg = 59mL - 88.5mL tidal volume (volume of ketamine is that it does not depress cardiac function in
gas exhaled in one breath). healthy animals. Instead, it increases cardiac output, heart
59mL - 88.5mL tidal volume x respiratory rate 60bpm = rate, and blood pressure (Plumb, 2011).
3540 - 5310mL/min volume (volume of gas expired by the
The disadvantage to using ketamine is that it either
patient in one minute).
causes no changes to muscle tone, or actually increases
3540mL - 5310mL/min volume x circuit factor of (2.5) - 3 for
it. It is important for the patient to be monitored for
the T-piece breathing system = 8850mL/min-13275mL/min
hypersalivation, vomiting, respiratory depression, and
fresh gas flow rate.
an erratic or prolonged recovery, as these are noted as
The gas flow rate from this calculation is vastly higher adverse effects of ketamine administration (Plumb, 2011).
(8.8L/min -13L/min) than the original calculation (2.9L/
Diazepam is a benzodiazepine drug used for premedication
min) which may be attributed to the patient’s high body
or sedation (Murrell & Ford-Fennah, 2011). Using diazepam
condition score and high respiratory rate. Murrell and
in combination with the buprenorphine given on admission
Ford-Fennah (2011) recommend using lean body weight in
was advantageous as benzodiazepines can cause
the calculations (what the patient’s weight would be at an
excitement when used as a premedication, and are best
ideal body score). This could have been improved by using
combined with an opioid (Welsh, 2009). The benefit of
a higher fresh gas flow rate for the patient.
using diazepam, in this case, is that it provides muscle
Thermoregulation was addressed by placing a covered relaxation and has a minimal effect on the cardiovascular
bean bag on the surgery table with a heating pad on top, system. The diazepam was administered slowly as rapid
followed by a clean dry bed and towel to prevent the intravenous admision can cause hypotension. Diazepam
patient from overheating. On the surgeon’s table, a sterile can also cause phlebitis, therefore the intravenous catheter
suture kit, disposable drape, sterile tomcat catheter (3.5Fr), was flushed with 0.9% sodium chloride to ensure patency
kidney dish, various sized syringes, sterile lubricant, sterile as recommended by Plumb (2011).
September 2020 9
FELINE URETHRAL OBSTRUCTION
The patient was maintained under anaesthesia using The level of monitoring performed was adequate, as the
the inhalational agent isoflurane. Isoflurane can cause parameters were checked, recorded, and reported every
respiratory and cardiovascular depression (Murrell & Ford- five minutes to follow the recommendations in the BSAVA
Fennah, 2011), hence it was important to regularly monitor Textbook of Veterinary Nursing (2011).
the patient’s heart and respiratory rate, blood pressure, An improvement would be the addition of ECG to monitor
and assess the depth of anaesthesia. for cardiac arrhythmias, especially given that patients with
Intravenous fluid therapy rates were increased during urethral obstruction could be at risk of hyperkalaemia and
anaesthesia to counteract the negative effects that cardiac arrhythmias (Sabino, Boudreau & Matthews, 2016).
anaesthesia can have on vital organs (e.g. vasodilation and Blood gas analysis and capnography monitoring would
hypotension). Sodium chloride 0.9% was delivered at a also have been helpful to assess effective ventilation more
surgical fluid rate of 18mL/hr which falls in line with AAHA/ precisely (Bryant, 2010), however, this equipment was not
AAFP’s Fluid therapy guidelines for cats and dogs (2013), available.
in which it is recommended to deliver less than 10mL/hr Catheterisation
to avoid hypervolaemia with the author suggesting The patient was positioned in dorsal recumbency for
3mL/kg/hr for cats. catheterisation. The area around the prepuce was clipped
Anaesthetic monitoring and prepared aseptically with a 4% chlorhexidine scrub
The Bionet BM7 multiparameter monitor was used to solution, followed by a 70% isopropyl solution. The final
monitor blood pressure, oxygen saturation, heart/pulse step of skin prep was a tincture of 5% chlorhexidine
rate, respiration rate, and temperature. and methylated spirits (ratio of 1:9 creating a 0.5%
chlorhexidine concentrate). The veterinarian used a
An AP Alert breathing monitor was attached to the
sterile tomcat catheter (3.5Fr) coated in sterile lubricant
anaesthetic circuit to monitor respiration. At least every
to ‘unblock’ the urethral obstruction, and then placed an
five minutes, manual monitoring of the patient’s HR, RR,
indwelling silicone urinary catheter (3.5Fr), which was
tidal volume (by watching the reservoir bag and chest
sutured in place.
movement), MM, and CRT was performed. To determine
the depth of anaesthesia, jaw tone, eye position, and A urine sample was collected from the urinary catheter for
palpebral or pedal-withdrawal reflex were checked. The urinalysis (including sediment). A sterile giving set was
oxygen flow rate, vaporiser setting, fluid rate, and catheter attached to the urinary catheter, along with an empty fluid
site were also checked around every five minutes, and his bag to form a closed urinary collection system.
temperature every 15 minutes. The positioning of the patient was satisfactory, as this
The patient’s anaesthetic period was relatively smooth. The provided the veterinarian with the best access to place the
patient’s blood pressure remained on average 110mmHg urinary catheter without compromising patient comfort.
systolic, and the veterinarian would have been alerted Dorsal recumbency positioning can impair ventilation
if the patient’s systolic blood pressure dropped below (Murrell, & Ford-Fennah, 2011), but there were no other
90mmHg, as this is classed as hypotensive (Welsh, 2009). practical options for this particular procedure.
The patient’s HR remained at an average of 100 beats per Anaesthetic recovery and monitoring
minute at the beginning of anaesthesia, and increased Isoflurane was stopped and 100% oxygen administered
to 140 beats per minute at the end of anaesthesia. The until extubation. Extubation was performed when the
patient’s RR varied from 10 to 30 breaths per minute, and patient’s normal jaw tone and palpebral reflex returned.
oxygen saturation, measured by pulse oximetry as the Feline patients are at risk of developing laryngeal spasm
oxygen saturation of haemoglobin in the blood, varied so it is important to extubate before the patient regains
between 95%-99%. An ideal reading is 100% (Welsh, their ability to swallow (Murrel & Ford-Fennah, 2011).
2009). When oxygen saturation levels dropped to 95% the Monitoring was constant and recorded every five minutes
first step taken was assessing gum colour which was still until the patient was able to lift his head and move around.
a healthy pink and then moving the probe to a different An Elizabethan collar was applied to prevent premature
position on the patient’s tongue. removal of the urinary catheter. Once alert, the patient
10 September 2020FELINE URETHRAL OBSTRUCTION
was set up in a cage in the cat ward. The urine collection than drawing on details from his owner, which might have
bag was placed on a shelf below the patient’s cage, so that provided a clearer picture in some aspects. For example, no
gravity allowed the urine to flow freely. Intravenous fluid history of mobility issues were noted on his record, or signs
therapy was continued at the maintenance rate discussed of this on clinical examination, but this does not rule out
earlier of 10mL/hour (40mL/kg/24 hours). The patient that he may have had some mobility issues at home. If the
was left overnight to recover without regular monitoring, owner had informed the veterinarian of mobility issues at
though this was not ideal, as “all patients should be home due to spondylosis the nursing care plan would have
monitored closely until they have fully recovered, even if been altered to include an orthopaedic bed in the patient’s
this takes several hours” (Welsh, 2009). cage and more gentle handling.
Hospitalisation The Orpet & Jeffrey Ability Model (Jeffrey, 2011) specifies
The patient was hospitalised for two days following the ten abilities that should be able to be performed normally
urinary catheter placement. Monitoring included checking by the animal for them to be considered to be in ‘good
and recording heart and pulse rate once daily. His pain health’. This model was used to assess how the patient
scale, CRT, MM, RR, and depth was checked and recorded at normally functions for each ability, as well as to identify
least three times daily. Urine output, water intake, faecal the problems they were having with certain abilities.
output, and nutritional intake were all monitored regularly From the nursing assessment, the following problems were
and recorded on the hospital chart. identified:
In recovery, 0.35mL of meloxicam (5mg/mL) was Day One
administered SQ for analgesia at a dose rate of 0.3mg/kg. · Possible anorexia
Meloxicam is a non-steroidal anti-inflammatory drug · IV fluid therapy: potential for fluid overload and catheter
that, when given subcutaneously, has an onset of action site complications
of one and a half hours (Plumb, 2011). Adverse effects of · Urinary catheter: potential for introducing infection and
meloxicam are gastrointestinal disturbances, behavioural potential problems with patency
changes, elevated creatinine levels, and renal failure · Unable to groom with Elizabethan collar on: the potential
(Plumb, 2011). The patient was monitored for signs of to become soiled
gastrointestinal distress, such as vomiting, diarrhoea, and · Unable to express normal behaviour: potential for him to
blood in the stools, however, none of these symptoms were experience stress and depression whilst hospitalised
observed. An improvement would have been repeating · Pain
blood chemistry tests each day during hospitalisation to
Day Two
check renal function.
· Possibly not drinking enough: potential for dehydration
All drugs administered were also recorded, including dose- · Urinary catheter removed: potential for dysuria
volume, time administered, and route of administration. reoccurring
An improvement would have been to also include the drug · Unable to groom: potential for the coat to become soiled
strength and dose rate on the written record. · Unable to express normal behaviour: the potential to
Fluid therapy details were recorded, including the fluid rate, experience stress and depression whilst hospitalised
fluid type, total given, and IV catheter site. The IV, bandage, · Pain
skin turgor, mucous membrane moistness, and lung sounds From these problems and potential problems, the following
were checked every three hours and recorded. goals were developed:
Nursing assessment and care plan Day One
Having more information on the patient’s usual behaviour, · For the patient to consume his resting energy
mobility, and grooming habits would have given a more requirements of the prescribed diet
accurate picture of what he is like at home and may have · To identify signs of fluid overload and catheter
affected the nursing care plan. For some areas of the complications, with abnormalities reported to the
nursing assessment, the information gained from his veterinarian
history and clinical examination was relied on solely, rather · To check the urinary catheter site twice daily, and the
September 2020 11FELINE URETHRAL OBSTRUCTION
patency of the urinary catheter every two to three hours patient’s nursing care plan to allow the identification of
by monitoring urine output, with abnormalities reported difficulties the patient was having in maintaining normal
to the veterinarian functions and behaviours. In turn, it was possible to set
· To keep the patient’s coat clean goals to manage these and record nursing interventions
· To prevent depression and stress performed in order to evaluate how these interventions
· To keep as comfortable as possible and monitor pain were working. Jeffrey (2011) believes that “care plans
levels promote a more holistic approach to patient care”, which is
what was achieved by creating a care plan for the patient.
Day Two
· To monitor water intake to ensure it is adequate Improvements could be made to his care plan by stating
· To monitor urine output and alert the veterinarian if more specific goals and choosing ones that can be measured.
it is abnormal; normal urine output should be around As one example, a goal could be ‘Complete fluid monitoring
1 - 2mL/kg/hr. A volume of less than 0.5mL/kg/hr would sheet every two hours’ instead of simply ‘Monitor for signs
be considered abnormal and would need investigation of fluid overload’. Jeffrey (2011) explains that having goals
(Goddard.L and Phillips.C 2011) set that can be observed and measured is important “so that
· To keep the patient’s coat clean effective evaluation can then be carried out”.
· To prevent depression and stress Ability 1. ‘Eat’
· To keep as comfortable as possible and monitor pain
The veterinarian prescribed Royal Canin® wet feline
levels
prescription diet Urinary S/O due to the diagnosis of feline
These potential problems, planned goals, nursing lower urinary tract disease (FLUTD). The diet selected
interventions, and evaluations were written on the has a high moisture content, ideal for FLUTD. Kerr (2013)
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12 September 2020FELINE URETHRAL OBSTRUCTION
recommends feeding FLUTD patients a diet with high whilst in the hospital setting has the potential to create a
moisture concentrations to promote large volumes of food aversion. A food aversion is when a patient refuses to
dilute urine. Kerr (2013) also states that protein levels eat a certain diet as they associate it with an unpleasant
should be moderate to high at 30-40% of dry matter, as experience e.g. stress or pain (WSAVA 2011). WSAVA’s 2011
this increased protein can increase water intake. This Nutritional Guidelines recommends feeding the patient’s
urinary diet had 35.7% protein, which is ideal. Urinary usual diet or ‘comfort foods’ to encourage eating.
S/O also is also proven to dissolve struvite crystals and
Ability 2. ‘Drink’
prevent calcium oxalate crystals from forming by creating
The patient had access to fresh water at all times. This was
an unfavourable environment for urolith formation
provided in a 200mL stainless steel bowl, with graduations
(undersaturated urine). Although no crystals or uroliths
were identified in this case, feeding this particular diet for the easy measuring of water intake. Normal water
was chosen as it may reduce formation in the future. intake for cats is 50mL/kg/24 hours (Goddard & Phillips,
Whilst this diet was a suitable choice, the ‘moderate 2011), which equated to 295mL per day for the patient. The
calorie’ version would have been a better choice long- patient’s water intake was lower than normal (110mL) in
term, as well as implementing a weight-loss plan, due to the first 24 hours of hospitalisation, however, this wasn’t of
the patient being grossly overweight with a body score concern as he was having maintenance fluid requirements
of 8/9. The lower fat content of the ‘moderate calorie’ were provided by intravenous fluid therapy. Intravenous
version (7.2% lower than original formula) is more likely fluid therapy was removed on day two of hospitalisation,
to promote weight loss. so water intake was monitored closely. The patient’s water
intake increased to a total of 145mL consumed over 20
The patient’s resting energy requirement (RER) was
hours after the IV fluid therapy was discontinued.
calculated to be 247 kcals per day (see appendix for
nutritional calculations). To fulfil the patient’s RER, 252 Fluid therapy monitoring
grams of Urinary S/O, split into two meals of 126 grams Fluid therapy monitoring included checking parameters for
each per day, was required. signs of dehydration, such as tacky mucous membranes
and prolonged skin turgor, or for signs that indicate fluid
The nutrient profile of the urinary diet was compared to
AAFCO’s (AAFCO, 2014) nutrient requirements for cats. It overload, such as ‘wet’ respiratory noises (crackles, rattling
was found that the diet met or exceeded AAFCO’s protein or bubbling) or an increased respiratory rate (Lee, 2004).
and fat requirements. Most of AAFCO’s vitamin and mineral The colour and moistness of MM, CRT, lung sounds, RR and
requirements were also met or exceeded, but a few, such depth, and scapula skin turgor were checked at least every
as iodine and vitamin K, were not specified on the urinary three hours and recorded on the patient’s chart. Lee (2004)
diet’s nutrient profile information. recommends monitoring RR and character, HR, MM, and CRT
two or three times daily. Improvements could be checking
The patient’s RER, the volume and type of food he
HR at the same intervals as the other parameters, and
required, feeding times, and volume consumed on his
weighing the patient daily as sudden body weight changes
daily hospital chart were recorded so all staff were
can indicate fluid loss or gain (Lee, 2004). Hydration
aware of his nutritional status. Goddard & Irving’s (2011)
status could also have been confirmed more accurately by
recommendations were followed, as “knowing the volume
obtaining a PCV reading (Lee, 2004).
of food a patient needs to consume daily to meet its
nutritional requirement makes it easier to monitor whether Fluid therapy was administered via an infusion pump,
it is consuming the vital nutrition required”. The patient which is more accurate and reliable compared to a free-
readily ate all the food offered, and the goal of providing flowing giving set (Taylor, Holmes, & Jasani, 2011). This
nutrition to fulfil the patient’s resting energy requirement meant the fluid rate did not need checking as often.
was fulfilled. Bandaging was removed once daily to fully visualise
The veterinarian requested the patient start on Royal Canin the catheter site and inspect for signs of inflammation,
Urinary S/O sachets whilst in hospital due to the benefits of infection, swelling, or thrombosis, as well as to check
promoting large volumes of dilute urine. However, feeding patency. Orpet & Welsh (2002) recommend palpating
the patient a new diet that is intended for the long term lymph nodes above the catheter site and checking
September 2020 13FELINE URETHRAL OBSTRUCTION
temperature twice daily to detect possible infection of Ability 4. ‘Defecate’
the catheter site, which was not done. Asepsis could also The patient had no issues defecating. He defecated once
have been improved by wiping injection ports with 70% a day during his hospital stay, and the faeces appeared
isopropyl alcohol and applying a topical antibiotic cream normal. The time he defecated was recorded on his hospital
near the catheter entry site (Orpet & Welsh, 2002). chart. An improvement would be noting the amount and
Ability 3. ‘Urinate’ consistency (Goddard & Phillips, 2011).
Care of the urinary catheter Ability 5. ‘Breathe normally’
Care of the urinary catheter involved monitoring urine Respiration rate and depth was monitored and
output to ensure the catheter was patent, monitoring for recorded approximately every two hours during daily
signs of a urinary tract infection (patient discomfort or hospitalisation. The patient’s RR sat around 40 breaths per
elevated temperature), checking the catheter site twice minute during most checks.
daily for abnormalities, and ensuring the Elizabethan collar
stayed on to prevent self-trauma. Hygiene and asepsis
Ability 6. ‘Maintain body temperature’
could be improved by wearing gloves when checking the The temperature of the cat ward was maintained at 22°C
urinary catheter and applying antibacterial cream on the via a heat pump. This was ideal, as Goddard & Irving (2011)
skin around the catheter (Orpet & Welsh, 2002). recommend keeping the ward temperature between
18-22°C.
Urine output gives a good indication of kidney function
and hydration status. This was measured by checking The patient’s temperature was checked twice daily during
and recording how many mL of urine was in the collection hospitalisation. Welsh (2009) discusses the importance
bag at least every four hours, as recommended by of monitoring for pyrexia in patients with an indwelling
Bashear (2014). Normal urine output for the patient catheter, due to the increased risk of developing a urinary
was 6-12mL per hour (1-2mL/kg/hour). The patient tract infection.
produced approximately 200mL in the first 24 hours, or Ability 7. ‘Groom and clean themselves’
approximately 8mL/hour (a normal level of urine output The patient was unable to groom himself on day one of
for the patient’s weight, without concurrent intravenous hospitalisation, due to having an Elizabethan collar on.
fluid therapy). Ideally, he should have been producing
Maintaining the cleanliness of a patient is important for
approximately 10mL per hour, similar to the intravenous
hygiene reasons, as well as for wellbeing, as it provides
fluid therapy rate he was receiving. The patient produced
mental stimulation, decreases stress, and encourages a
another 80mL over the following 14 hours, and at which
bond between the nurse and patient (Goddard & Phillips,
point his urinary catheter was removed. Urine output
2011). A warm, damp cloth was used to mimic the self-
was then monitored by providing non-absorbent litter in
grooming the patient would normally perform to keep
the patient’s tray, and regularly measuring it by drawing
his coat clean. This was performed twice daily, as well as
urine up with a syringe and recording this on his hospital
brushing his coat. He responded well to this and his coat
chart. He produced approximately 80mL over the eight
stayed clean. On the second day of hospitalisation, the
hours following urinary catheter removal, which was
patient’s Elizabethan collar was removed, and he was able
within the normal urine output range for cats (1-2mL/kg/
to groom himself, so intervention was no longer required to
hr). This almost matched his water intake of 85mL over
help with grooming.
the same eight hours. An improvement would be noting
the colour, smell, and appearance of the urine when Ability 8. ‘Sleep and rest adequately’
monitoring his urine output (Goddard & Phillips, 2011), as Goddard & Phillips (2011) state that “it is important that
this can also give indications of disease - for example, patients are given the chance to rest and have undisturbed
haematuria could indicate trauma to the urinary tract. sleep”. As there are no staff covering night shifts at
It would have also been helpful to check the specific the clinic, this allowed the patient to have 14 hours of
gravity of the urine prior to discharge, as this can give undisturbed sleep, which was ideal to allow rest. However,
an indication of hydration status and kidney function this did mean that the patient was not monitored for a
(Brashear, 2014). substantial period of time.
14 September 2020FELINE URETHRAL OBSTRUCTION
Ability 9. ‘Express normal behaviour’ was provided. The patient spent a lot of time resting,
Stress management so the padded layer was ideal as it prevented pressure
Cats are easily stressed animals, and changes to their sores (Goddard & Irving, 2011). The vet bed layer was
surroundings and new people or animals can be some of good for comfort as it was soft, as well as they also
the most distressing events a cat can experience (Pageat, wick moisture away for fluid such as spilt water or
2007). According to Pageat, cats mark their territory small droplets of urine, which kept the patient dry
with the pheromone F3, and the loss of this territory (Goddard & Irving 2011).
can be very distressing. To reduce the patient’s stress, Pain management
a Feliway® diffuser, which emits a chemical copy of the The patient was pain scored at least three hourly using
F3 pheromone, was plugged into the cat ward. Following the Colorado State University Feline Acute Pain Scale.
Pageat’s recommendation of preparing the patient’s cage Assessing pain levels and ensuring analgesia is adequate
by spraying F3 in different corners of their cage would is important, as pain can have a huge effect on physiology
have been further improved. Feliway was also sprayed on (Goddard & Irving, 2011).
the hands of nursing staff before handling the patient, and
gentle handling techniques were used to reduce the stress On day one of hospitalisation, the patient’s pain score
that can be experienced by being handled by a new person. was 1/4 at 8 am. A subcutaneous injection of 0.39mL
buprenorphine 0.3mg/mL (20mcg/kg) was given for
To alleviate stress in the patient, he was placed in a cat- analgesia. The patient was pain scored at 0/4 two
only ward. Having other feline patients directly facing him hours later at 10 am, showing a positive response to the
was also avoided to minimise stress (Goddard & Phillips, buprenorphine administration. Two hours later (12 pm),
2011). The patient’s cage had two areas, with an opening in his pain score was 0/4. Three hours after this (3 pm),
the partition between areas to enable a separate toileting the patient was pain scored at 1/4, and the veterinarian
area with a litter box, from his sleeping and eating/drinking was advised of this change in pain. Nursing staff were
area. This was ideal, as having food and water bowls near instructed to administer the same dose of buprenorphine
the litter box can cause stress in cats (Pageat, 2007). An again. An hour later, the patient’s pain score had lowered
improvement would be having an elevated area to climb to 0/4, showing that the buprenorphine was successful in
upon in the cage, as a lack of access to the third dimension lowering his pain levels.
(something to climb up on) is an additional cause of stress
(Pageat, 2007). Another improvement would be providing On examination with the veterinarian, it was decided that
a box or igloo bed for the patient to hide in (Goddard & buprenorphine was no longer required on day two, as the
Phillips, 2011). patient had a pain score of 0/4. Metacam® (0.5mg/mL)
was prescribed at a dose rate of 0.05mg/kg, to start in the
To promote normal behaviour, the patient’s owner was evening after the patient was discharged, for analgesia and
encouraged to visit him in hospital, though they were anti-inflammatory effects. Side effects of Metacam oral
unable to. Nursing staff also interacted with him regularly are vomiting, diarrhoea, loss of appetite, and renal failure
by talking to him and grooming him. (Boehringer, 2014).
An improvement to promote normal behaviour would be On the morning of day two of hospitalisation, the
allowing the patient time out of his cage (Goddard & Irving,
veterinarian removed the urinary catheter and IV catheter
2011), however, this was not possible in this case due to the
(as it had blocked overnight). Urine output and water
urinary catheter and attached closed collection system.
intake were normal following catheter removal and
Efforts to reduce stress and promote normal behaviour in cessation of IV fluid therapy. There were no signs of
the patient appeared to be effective, as he seemed to be dysuria. The veterinarian recommended that the patient
relaxed after settling into the hospital, as evidenced by his be discharged with the Metacam prescribed earlier, and
great appetite and ability to rest easily during his stay. prescription diet to continue with at home.
Comfort Discharge
The patient’s cage was lined with newspaper, then one On discharge, the owner was provided with written
layer of padded bedding topped with a thick vet bed information on FLUTD and feeding plan, as well as shown
September 2020 15FELINE URETHRAL OBSTRUCTION
how to administer Metacam. The importance of monitoring CO2 in the anesthetized patient. In Anesthesia for
water intake and urine output was discussed. A revisit Veterinary Technicians (pp 217 -220 ). Chicester, Wiley
appointment was booked with the veterinarian for the Blackwell.
following week. An improvement would be discussing and Bryant, S. (2010). Anesthesia for Geriatric Patients. In
giving written information on the possible side effects of Anesthesia for Veterinary Technicians (pp. 504). Arnes,
Metacam and symptoms to look out for. Advice on how Iowa State University Press.
to promote weight loss in the patient and decrease his Chandler, S. & Middlecote, L. (2011). Complications
stress could have been given, which may have lowered his associated with urinary catheterization in principles of
chances of having a repeat obstruction. general nursing. In Cooper, B., Mullineaux, E., & Turner,
L. (Eds.), BSAVA Textbook of Veterinary Nursing (5th ed.,
Follow-up
pp. 428). Chicester, Wiley Blackwell.
A follow-up phone call was made one day after discharge Goddard, L., & Phillips, C. (2011). Observation and
revealed the patient was eating well and there no issues assessment of the patient. In Cooper, B., Mullineaux, E.,
with urination. & Turner, L. (Eds.), BSAVA Textbook of Veterinary Nursing
An improvement would be asking about his behaviour, (5th ed., pp. 373-374). Chicester, Wiley Blackwell.
water consumption, and how frequently he was urinating. Goddard, L., & Irving, L. (2011). Essential patient care. In
It would have also been helpful to have multiple follow Cooper, B., Mullineaux, E., & Turner, L. (Eds.), BSAVA
up phone calls over the next week to check the patient’s Textbook of Veterinary Nursing. Chapter 16.(pp. 390-
health status. Unfortunately, he was hospitalised again 14 396). Chicester, Wiley Blackwell.
days after discharge with dysuria. Hellyer, P., Uhrig, S., & Robinson N. (2006). Feline acute pain
scale. Retrieved from: http://csu-cvmbs.colostate.edu/
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