Advances in the Delivery of Practical Nursing Care--Practical Examples
World Small Animal Veterinary Association World Congress Proceedings, 2008
Hilary A. Orpet, BSc, DAVN (Surgical), Cert Ed, FHEA, DCABT, RVN
Royal Veterinary College
North Mymms, Hatfield, Herts, UK

The application of a nursing model is often explained best when worked examples are used, illustrating the process through which the nurse structures the care required by the individual patient. It is essential that nurses have a good understanding of the concept of holistic nursing and fortunately, the underlying principles form the basis of care already delivered by compassionate and conscientious nurses.

Central to the many nursing models is the initial assessment of the patient. This provides specific information about the needs of the individual. From the information gained by a thorough assessment, problems can be identified and nursing care can be planned.

Models of Nursing

There are many models of nursing that can be used or adapted to inform the practice of nursing. Unfortunately they are based on the nursing care of humans.

Roper, Logan & Tierney's

This model is based on the 12 activities of living--the essential requirements for being a healthy human. The patient is assessed against the 12 activities; the nurse decides through the assessment whether the patient is able to independently carry out the activity or whether nursing care is required. This model has been adapted to be used with animals as the assessment of the 12 activities mostly relates to assessment of veterinary patient needs.

Orem's Model of Self Care

This can also be adapted to a certain extent for veterinary patients (Figure 1). The model focuses on the assessment of the patient's ability to self care. Similar to RLT's activities of living, there are 8 'self care requisites'--what can the patient do for themselves and what do they need help with or care from the nurse. Often the ability of the patient is affected by the illness or health deficit. The self care deficits are identified and a care plan is drawn up.

The Orpet & Jeffery Ability Model

From working with, and adapting the current human nursing models, it became apparent that a model that focused on veterinary care was needed. The work of Roper, Logan, Tierney and Orem influenced the creation of this model. The assessment phase is structured around the 'abilities' of the animal. What is the animal able to do or not do by itself? Ten 'abilities' were selected as the basic requirements for a animal to function. Being able to eat, drink and eliminate but also to express normal behaviour.

Application of the Model

The care of a patient starts when the animal enters the practice, usually with its owner. If the animal is to be admitted, there are certain questions that are required to ensure the correct information is obtained. Most of these are covered during the completion of the consent form or from consultation with the veterinary surgeon, but is that enough information? We constantly take measurements of our patients; temperature, respiration rate, oxygen saturation, and evaluate organ function through measurements of electrolytes, enzymes etc. in the blood. These values are useless unless we know what normal values should be. This should also go for the nursing care for our patients--do you know what the animal's normal routine is?

In order to illustrate this model, a worked example is given below based on the following patient.

Kitty Kent is an 18 month old female (spayed) domestic short hair cat. She underwent surgery to repair a fractured jaw following a road traffic incident. Due the nature and extent of the injury she will be tube fed via a percutaneous endoscopic gastrostomy (PEG) tube. She is tolerating this well; however, she is a thin cat anyway and observation of weight is necessary. Kitty's owner wishes to be involved fully in all aspects of the cat's care and stays in a campervan in the practice car park!

Assessment

Initial assessment of the patient can take the form of a questionnaire that the owner completes before or during the admission of their animal (Figure 2). On occasions, however, the first time that information may be obtained from the owner may be after the initial stabilisation of the animal, as in the case above.

To guide the assessment the 10 'abilities' may be used as a checklist to ensure a complete assessment. The types of questions used are important, to elicit enough information and to encourage the owner to expand their answers in order to get as much information about the animal's normal routine as possible. For example: 'Does your pet eat adequately?' would probably result in a 'yes/no' answer. However 'What does your pet normally eat, how much and at what times' will hopefully give a better picture of the animal's normal eating habits. Of course finding out the animals 'favourite' food is important when tempting the inappetent animal.

The next stage is the nursing assessment of what the animal can or cannot do now it has been admitted. Again this is using the same 'checklist' of 10 'abilities' from the model. Transfer the information obtained to the nursing assessment form.

If the questionnaire can be given prior to the admission, this gives clients an opportunity to think clearly about their answers. It gives a good impression to the client and they often feel that the practice values their pet and the care given to them.

The Care Plan

From the information gained from the assessment, various problems have been identified. It is important to also consider potential problems that may occur so they can be prevented. This stage is useful in informing student or less experienced nurses. The nursing care required is then based on the problems identified from the assessment (Figure 3).

Implementing the Care

Detail in the care plan is important, everyone needs to know exactly what the nursing intervention is and how often, or how much is required. The decision on the nursing intervention is guided by the goal to be achieved. Setting goals is important to validate the nursing decision made and also to measure the outcomes of the nursing intervention.

Evaluation

In order to evaluate effectively, the assessment should be carried out again. From each of the 10 'abilities', assess what the animal can now do or still not do by itself. Hopefully the nursing interventions have worked and the animal is now more 'able' than when admitted. If not, it will be necessary to look again at the care given and adjust the plan as necessary.

Influencing Factors

The assessment and consequent nursing care that is carried out may be affected by other factors. The life stage of the animal is an important factor to consider--neonates are unable to feed, drink, keep warm, mobilise by themselves and this is when they are healthy. Geriatrics may have their senses affected purely by the fact they are old. Mobility may be decreased due to joint pain, muscle stiffness etc.

Cultural and Financial Influences

Cultural differences may affect the care given to the animal. What role does the pet play in the owner's life--working dog? Only companion? Breeding animal? Intensive palliative care may be required if the owner's beliefs prevent the animal from being euthanased.

There may be financial implications that prevent the care that the animal requires taking place. What alternatives are there? Working with the owner, the nurse may be able to teach basic care techniques or rehabilitation methods when perhaps full physiotherapy and hydrotherapy is prohibitively expensive for the client.

Summary

Nursing involves not only caring for your patient but liaising with the owner regarding the nursing care given. The nurse's role is invaluable in maintaining the communication between the client and the practice. Once the animal goes home, the care continues and the nurse needs to ensure the owner is able to administer, and is also compliant in administering the care required. Alternative solutions to a problem may be required and built into the care plan.

The influencing factors should always be considered when creating the care plan for the animal and adjustments made appropriately.

The templates can be adapted for use in the practice, the idea is to ensure the nursing care is structured and documented and useable for everyone involved in the care of the patient.

Figure 1. Orpet & Jeffery Ability Model 2007.
Figure 1. Orpet & Jeffery Ability Model 2007.

 

Figure 2. Patient assessment form.

Patient Assessment Form

Date of Admission: 19.08.08

Date of nursing assessment: 20.8.08

Case No. 123456

Patient Name: Kitty
Breed: DSH
Sex: FN

Owner: Kent
Address:
Contact No.:

Clinical summary: (reason for admission)
Fractured jaw following road traffic accident
PEG tube placed for assisted feeding

Owners perception of problem:
Injury to face and jaw--unable to eat

Previous history (surgery, disease, vaccination status, allergies)
Fully vacc. Booster due Oct 08
Neutered July 07

T 37 C

Current medication:
Analgesia prn (prescribed by VS)

P 150

R 20

MM pale pink

CRT <2secs

Wt. 4.7kg

Life stage:
Age: 18mths
neonate / adult / geriatric

Assessment of patients abilities

 

Usual routine

Actual Problem

Potential Problem

Long Term Goal

Eat adequate amount

Eats 1 sachet 2x daily

Unable to eat due to injury

Wt loss

Maintain weight

Drink adequate amounts

~200ml/day

Unable to drink

Dehydration

 

Urinate normally

Outside

Reduced

 

 

Defecate normally

Outside

Reduced

Constipation

 

Breathe normally

No problems

Dried blood around nose

 

 

Maintain body temp

No problems--sleeps on boiler

Normothermia maintained since recovery from GA

 

 

Groom itself

Owner grooms occasionally

Unable to groom due to injury

Matted coat. Poor coat condition

 

Mobilise adequately

No problems

None

 

 

Sleep/rest

No probs--indoors mostly

Should be normal if breathing clear

 

 

Express normal behaviour

Plays with toys

Buster collar and abdominal bandage may reduce movement & play

Pain
Boredom,

 

Figure 3. Care plan.

Patient Name: Kitty

Date:

Date

Problem

Short term Goal

Nursing intervention

Reassess/evaluation

Review time/date

20.8.08

Unable to eat

Maintain fluid status

Calculate fluid requirements and monitor IVFT administration

Monitor hydration status
Monitor weight

21.8.08

20.8.08

Unable to drink

Maintain fluid intake

Continue IVFT as above

Assess hydration

 

20.8.08

Unable to groom

Maintain coat condition

Groom with cat comb x2 daily
Wipe discharges from face

No matts develop and coat condition maintained

 

20.8.08

Normal behaviour affected by condition and Buster collar

Encourage as far as possible normal behaviour

Regular contact with nursing staff not just when feeding or medicating.
Assess pain relief requirements

Monitor temperament regularly

 

21.8.08

Unable to eat / drink

Maintain weight & hydration status

Calculate 1/3 food requirements to feed by tube

Ensure no problems occur whilst tube feeding

 

References

1.  Orpet & Jeffery (2006) Moving towards a more holistic approach. VNJournal vol 26 no.5 May 2006

2.  Jeffery (2006) Moving Away from the medical model VN Journal vol.21 no.9 September 2006

3.  Joiner T.2000 An holistic approach to nursing. Veterinary Nursing Volume 15 No 4 July 2000

4.  Davis S (2006) Model Answer? Using nursing plans in veterinary practice. VNTimes p4 vol 6 no.7

5.  Peate I (2006) ed. The compendium of Clinical Skills for student nurses. Whurr.

6.  Aggleton & Chalmers (2000) 2nd ed Nursing Models & Nursing Practice. Palgrave

7.  Roper, Logan, Tierney (2000) The Roper, Logan and Tierney Model of Nursing. Churchill Livingstone.

8.  Holland (2003) Applying the Roper-Logan-Tierney Model in Practice: Elements of Nursing. Churchill Livingstone

9.  Pearson, Vaughan Fitzgerald (2004) Nursing Models for Practice. Butterworth-Heinmann

10. Walsh M (1997) Models and Critical Pathways in Clinical Nursing: Conceptual Frameworks for Care Planning. Balliere Tindall

11. Kratz C (1979) The Nursing Process. Balliere Tindall

Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Hilary A. Orpet, BSc, DAVN (Surgical), Cert Ed, FHEA, DCABT, RVN
Royal Veterinary College
North Mymms, Hatfield, Herts, UK


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