Originally published in the December 2015 issue of Veterinary Practice News. Did you enjoy this article? Then subscribe today!
Recumbent patients are not all paralyzed or in a coma. They include patients with limited mobility: those recovering from surgery or anesthesia, suffering from trauma such as hit by car or dealing with metabolic imbalances, polytrauma, brain diseases or severe sickness.
Prolonged recumbency affects virtually every body system and organ. Here are 10 tips to manage your recumbent veterinary patients.
1. Pressure Sores
Decubital ulcers are probably the first complication that comes to mind when we manage “down” patients.
Bed sores are much easier to prevent than to treat. Patients should be kept on thick, dry, clean bedding at all times. The heavier the patient, the thicker the padding should be. The size of the cage should be proportional to the patient. If you don’t have a run, you may need to be creative and arrange an area on the floor.
Your treatment sheet should include:
- Rotating the patient every two to four hours.
- By convention, to avoid confusion, specifying the side down after you have rotated the patient.
- Inspecting the skin regularly, especially around bony prominences.
- Aggressively treating existing bed sores.
Ideally, down patients should be kept in sternal recumbency. Even then, the hind legs should be flipped over every few hours.
2. Urination and Defecation
Any time the bedding is soiled, it needs to be changed. Which means you need to specifically check it; the task should be written on your treatment sheet.
Similarly, soiled skin needs to be washed scrupulously, then dried thoroughly. Mild soap and water work better than dry shampoo.
Defecation usually occurs naturally as long as the patient eats enough. Occasionally, a laxative is necessary.
Urination can be trickier. If a patient is unable to urinate spontaneously, bladder infection, bladder wall damage (from overstretching) and even bladder rupture can occur. Manual expression can be performed four to six times daily. Various drugs may be used to help with spontaneous or manual expression.
An easier solution is an indwelling urinary catheter. However, it can be a source of bladder infection, so sterile catheter placement and sterile management of the urine collection system are critical. The collection system should be emptied and the amount of urine should be recorded every four to six hours. “Ins” should be compared to “outs.”
3. Eating and Drinking
Ensuring proper hydration is easy when patients don’t drink readily; IV fluids may be administered.
Maintaining caloric intake is more complex. Recumbent patients may not be interested in eating. They may not even have the energy to eat. Yet they must receive their minimum energy requirements, so you need to decide the best route to accomplish this.
The enteral route is typically preferred. If that is not possible, appetite stimulants, hand feeding, feeding tubes or parenteral nutrition should be considered.
To decrease the risk of aspiration, down patients should never be given food or water in lateral recumbency. They should always be positioned in sternal recumbency.
Additionally, preventing vomiting and regurgitation is critical in patients in lateral recumbency, again to decrease the risk of aspiration.
4. Body Temperature
Immobile patients may have trouble maintaining body temperature. Hypothermic patients can benefit from heating pads, forced-air devices, heating blankets or warming cages. Except for forced-air systems, warming devices should never be placed directly against the patient’s skin, even if you don’t think the device is too hot. Always use a thin blanket, towel or pillowcase to protect the skin.
Patients’ temperature should be checked frequently to discover hypothermia early and prevent hyperthermia. Skin burns and hyperthermia are two complications that can occur in a patient who cannot get away from the heat source.
Assisting to stand and walk — inside or outside — is good for the patient’s muscles, respiration, circulation and spirits. If you use a sling, don’t allow the back feet to drag on the ground.
6. Muscles and Joints
Unused muscles quickly atrophy and underused joints become stiff rapidly. This can be reduced using massage, passive range of motion, active range of motion and other rehabilitation modalities. Cold or heat therapy may be applied for five to 10 minutes every six to eight hours.
To ensure that perfusion of all organs is effective, measure blood pressure every four to six hours. Strive to get at least a systolic pressure of 100 mm Hg, a diastolic pressure of 40 and a mean arterial pressure (MAP) of 60.
PROM, active range of motion and simple walking improve circulation and lymphatic drainage. They in turn limit the risk of edema from prolonged recumbency.
Edematous limbs should be massaged by encircling the limb with your hands and “milking” the fluid. Rotating patients regularly also helps with pulmonary circulation.
Prolonged lateral recumbency can lead to atelectasis (i.e. collapse) of the down lung. This is another reason that rotating patients every four to six hours is recommended.
Even better, sternal recumbency is preferred as it significantly increases PaO2 (MW McMillan et al. J Vet Emerg Crit Care 2009). Coupage can be performed to help expel airway secretions and hopefully decrease the risk of pneumonia.
9. Pain Management
Managing pain in recumbent patients can be tricky. We need to combat pain in patients who may look naturally sedated. At the same time, we can’t overdose them and prolong the duration of recumbency.
10. Tender Loving Care
Being stuck in lateral recumbency is stressful for patients. Doing what we can to help their mental health in addition to their physical health is important.
There are countless little things we can do to help them feel relaxed. Speaking softly, repositioning them gently, fluffing up a pillow, facilitating owners’ visits, petting patients are all small gestures that should be part of excellent nursing care.
TLC is what we do after every box on the treatment sheet has been checked off.