All feline monitoring and management techniques are unique. There are several reasons for this. One is they are a unique species; another is each cat should be treated differently. By this I mean tailoring the treatments to compliment the needs of the patient; physically emotionally and with our safety in mind. Like dogs their personalities differ from the friendly to the aggressive as well as the terrified and the stoic. In the past they have all been classified as cats, nothing else was taken into consideration. We now find ourselves doing increasingly advanced treatments to more cats and this parable is no longer a valid way of practicing medicine. With these advanced treatments we also have an obligation to the patient and the owner to provide them with analgesia and our unique ability to end pain and suffering with euthanasia.
Monitoring the feline patient is a delicate balancing act. Balance between collecting information in order to treat and the stress inflicted on the patient in gathering this data. Pain must be managed appropriate for this balance to exist. Cats have an easier time hiding pain, no walks and usually no vocalization. As a nurse this means it is our responsibility to recognize and treat pain, if you are doubtful always err on the side of analgesia. Pain is not only detrimental to healing it causes anorexia and additional stress.
The renal system must be watched closely as well. Monitoring urine output is essential for cats. In trauma the bladder/urethra may potentially be damaged or ruptured, therefore expressing a bladder can lead to more damage. Measuring urine output also ensures the kidneys are able to handle the fluids being delivered. The gold standard is to place a urinary catheter. Urinary catheters are also imperative to removing blockages, exact measurement of UOP, as well as cleanliness. If this is not possible (and the patient is mobile) placing material that will not absorb urine in the litterpan will aid in obtaining and measuring urine. The creatine, BUN, and electrolytes should be carefully monitored.
Oxygenation is very hard to monitor in the cat. Pulse oximeters may not read because of hypothermia/poor perfusion. Arterial blood gasses are very stressful for the feline patient and difficult to obtain. This leaves radiographs, auscultation, and observing MM color, RR & RE frequently. Keep in mind the cat must be stable before any radiographs are obtained, restraint causes stress. One way to assess oxygenation in a cat is to supply them with oxygen in a stress free environment and observe their respiratory pattern. Two very important aspects to providing cats with oxygen; do not stress, and allow for carbon dioxide to escape. Usually cyanosis will not be observed until the SPo2 is well below 80%, at this point mechanical ventilation needs to be considered.
Cardiovascular monitoring is difficult in the cat as well. Most MAP machines are not sensitive enough to obtain values from cats in shock or in a hypovolemic state, doppler blood pressure is the best option. Keep in mind when blood pressure drops below 60mmHg the kidneys can not be perfused. Heat must be supplied and TPR closely monitored as well as MM, CRT and pulse quality. EKG should be monitored, especially if electrolyte abnormalities are present. PCV/TS, BG and electrolytes should be monitored closely and glucose and KCL supplemented if needed. Blood/plasma transfusions should be administered if values are low (remember fluids will bring them both down), however every cat must be blood typed or crossmatched before any blood product is given, the reaction can be fatal.
Nutrition tends to be the hardest thing to address in the feline patient. Head trauma or any type of oral trauma a feeding tube must be placed. Appetite stimulants, a quiet box, catnip, and sometimes sitting and talking to them when you offer food can all be helpful for getting these patients eating. Make sure pain is being adequately managed; this tends to be a frequent cause of anorexia. Force feeding is highly discouraged, this often leads to increased stress and food aversion, neither helpful when treating the feline patient. Aside from the fact that they tend to be finicky eaters, hepatic lipidosis is a very real secondary problem to feline trauma and must be addressed. The recommended time is 3-5 days before placing a feeding tube.
What type of tube depends on the disease process and the clinician. This procedure is done to administer short-term nutritional support to a patient when they are not eating enough nutrition to meet its daily caloric needs. There are two forms of feeding tubes that can be placed which allow the patient to continue to eat and drink. The types are; nasoesophageal (NE) tube and nasogastric (NG) tube. These tubes can be kept in place from several days to weeks, however they are contradicted in patients predisposed to aspiration, esophageal dysfunction and patients that are actively vomiting. They are also contradicted in patients that have injuries to the head and neck or surgical procedures of the nasal cavity, pharynx or esophagus. Surgery is required for all other enteral support routes. These procedures include; pharyngostomy tubes, esophagostomy tubes, gastrostomy tubes and enterostomy tubes.
Esophagostomy tubes are placed when head trauma is present. They bypass the head and usually don't require the patient to wear an e-collar. The tube is inserted directly into the cranial esophagus and advanced to the end of the esophagus and capped. Sutures are then placed and the neck is wrapped with a bandage. Gastrotomy tubes are inserted directly into the stomach and are indicated when esophageal injury or disease is present. A French Pezzar mushroom-tip catheter should be used, which keeps the tube in the stomach and helps to create a seal. These tubes can be placed two ways; via laparotomy or percutaneous placement using an endoscope. These too need to be capped, sutured and wrapped.
Feedings may be done as a constant rate infusion (CRI) or as bolus feedings. It is all dependent on the patient's condition and the doctor's recommendations. For bolus feeding, Always offer the patient food or water first, unless instructed otherwise by the doctor. Complete any other treatments the patient may need before giving anything through the feeding tube. The patient should not be stressed or excited after the feeding, because that may cause them to vomit. Flush the feeding tube with 5 mls of water, wait to make sure the cat does not gag, cough or vomit. If you are administering a feeding make sure that you have measured out the amount you are giving, and let it warm to room temperature and refrigerate unused portions. Administer prescribed medication or feeding (only liquefied medications should be administered through these tubes, otherwise they can become clogged). If the tube becomes clogged, try pushing a very small amount of a carbonated beverage through it. Flush the tube with 10 mls of water and place cap on the end. If the patient vomits after its' treatment, skip the next feeding and then resume feedings at a slower rate of administration.
Feeding via CRI is helpful for cats that have not eaten for two or more days, it allows the stomach to slowly return to normal function. Using either a liquid diet or electrolyte solution the gastrointestinal tract slowly begins to move again. As this is tolerated the feeding is increased to meet the caloric requirements of the patient.
The ethical triangle between the patient, owner and veterinary care team is unique as well. As nurses we tend to have the most contact with the patient, conversely with the least control over the situation. This can lead to burnout of the staff which negatively affects patient care; there are ways to prevent this from occurring. Effective communication between all aspects of the triangle helps all involved. As nurses we need to take advantage of the ability to build a relationship with the client to help express the needs of the patient. Communication is the key.
1. Rollin BE. JFMS 2007; 9: 326