1 Jul 2011
Linda Roberts
Job TitleLinda Roberts VTS(Oncology), DipAVN(Medicine), outlines common procedures for such cases in the second of her two-part article
IN the previous article (VN Times 11.06), the more commonly encountered presentations of canine gastrointestinal (GI) diseases, as well as diagnostics, were discussed. This part concludes by focusing on treatment options and nursing care specific to GI cases.
As discussed in part one, the aetiology of GI signs may be many and varied, and may not be due to primary GI disease, but systemic illness, toxic insult, etc.
Treatment options depend on a patient’s condition and its severity at the time of presentation, the chronicity of symptomatology and the underlying cause. Treatment may range from “watchful waiting” (such as in generally well patients) to intensive care management (for example, for dehydrated/ hypovolaemic patients, those in shock, severely debilitated or hypoproteinaemic). In all but the most transient of cases, treatment is aimed at symptomatic support while treating the underlying cause.
Resting the GI tract by withholding food for 12 to 24 hours is often sufficient to resolve the problem. Acute vomiting and/or diarrhoea is a common presentation in dogs, which is frequently self-limiting. When clinical signs have abated, bland food should be reintroduced little and often. The animal should be fed like this for up to a week before resuming a normal feeding regime. During the acute illness, small volumes of water may be offered frequently. Water should only be withheld with caution, and only in healthy patients.
Nutrition has an important role to play in GI disease, both in specific and symptomatic care. In patients with chronic signs, withholding food is not beneficial. Feeding these patients not only provides nutrition to the patient, but also to the intestinal mucosa, maintaining its health and helping prevent bacterial translocation.
Patients with chronic GI disease may be debilitated and often benefit from supportive dietary intervention – proprietary convalescence diets are aimed at reducing the workload of the GI tract by being easily digestible, low in fat and/or carbohydrate, and calorie-dense, to allow increased calorie intake. These diets may be supplemented with glutamine, an amino acid not required in healthy dogs, but which may become “essential” in catabolic, stressed or starved patients.
Dietary exclusion trials, glutenfree or low-allergen diets, or those with hydrolysed proteins, may be indicated if food intolerance or allergy/immune response is a suspected cause. If patients deteriorate or do not respond to dietary trials, further diagnostics/ therapeutics should be embarked on.
Higher-fibre diets may help maintain intestinal health, as they are beneficial in certain small intestinal diarrhoeas, and in colitis and constipation.
Fluid therapy is a mainstay of supportive and specific treatment. Patients may receive intravenous fluid therapy (IVFT) to prevent or treat dehydration and/or electrolyte derangements, which may result from acute or chronic vomiting and/or diarrhoea. The selection will depend on the patient’s condition. Compound sodium lactate solution is often successfully used in the first instance. However, in prolonged illness or systemically unwell patients, serum proteins, electrolyte parameters and acid-base balance should be monitored so that IVFT can be tailored to losses, supplements added (such as potassium), and/ or colloid/plasma prescribed (in patients with protein-losing disorders).
Pharmacological therapeutics may be aimed at anti-emesis, protection of the GI mucosa, motility modification, immune suppression, anti-inflammatory or anti-spasmodic effect.
The VN’s role in managing GI disorders is diverse and includes the following considerations.
Because of their obvious and unpleasant nature, GI signs are a common reason for owners to seek veterinary help, even if the dog isn’t unwell.
Nurses should record as much detail as possible about the nature, severity and duration of the problem, questioning owners on how much fluid the patient has taken in and lost in the preceding hours or days and/or if blood has been passed, as well as ascertaining whether the patient is bright. Information gleaned from the owner may indicate whether the patient needs veterinary attention urgently, if at all. For example, if it’s a healthy dog, which is bright, has no known concurrent illness or history suggestive of toxicity or foreign body ingestion, and has vomited once or had one episode of diarrhoea, it may be reasonable to wait a few hours before deciding if the animal should come to the clinic.
Conversely, if the patient is dull, passing blood or has lost a lot of fluid, has pre-existing medical problems, is known to have ingested a toxin/foreign body or if the problem has been present for some time, the owner should be advised to come to the clinic without delay.
Whatever the outcome following initial contact, the VN should ensure details are recorded on the patient’s permanent medical record and the attending veterinary surgeon is informed.
Nurses may be involved in ongoing owner communication in GI disease cases, providing information on the disorder and its treatments, dietary advice and feeding techniques, home nursing, and acting as a liaison between the clinician and owner.
Nurses should have a working knowledge of the tests routinely performed in canine GI disorders and be aware of sampling methods and requirements, as well as their laboratory processing techniques. The VN’s role during diagnosis of GI disease often begins by assisting with initial history-taking and clinical examinations, then preparing for and obtaining samples, such as blood, faeces and/or urine.
For further testing, such as radiography, ultrasonography and endoscopy, preparation will be necessary. For upper GI endoscopy, patients should have food withheld for only enough time to ensure passage of ingestia from the stomach and to allow safe induction of anaesthesia. Colonoscopy patients should have food withheld for up to 48 hours and have free access to water. Warm water enemas (approximately 10ml/kg) and/or oral cleansing preparations are often needed to ensure minimal residual colonic faecal material. VNs should check with the clinician what type of preparation is required and whether any patient-specific contraindications or concerns exist. Care should be taken when administrating oral cleansing preparations. Large volumes of these hypertonic solutions must be syringe or tube-fed, with patients often resenting and resisting administration, making aspiration a real risk. If in doubt, stop and liaise with the attending clinician.
Radiography and ultrasonography should be performed on an empty stomach and in advance of enema administration – gas may be introduced by the Higginson syringe, which could create artefacts or obscure pathology.
VNs may be involved in devising and implementing sedation with or without anaesthesia plans for diagnostic procedures. In addition to routine checks, there are specific considerations for GI patients.
While many are systemically well, some patients with GI disease may be at higher risk – for example, if patients are hypoproteinaemic, care is required to avoid overdose of protein-bound anaesthetic drugs. Systemically ill or emaciated patients may be less able to thermoregulate or tolerate the physiological stress of anaesthesia.
Vomiting or regurgitating patients, or those with oesophageal disease, are at higher risk of aspiration of gastric fluids when sedated or anaesthetised, therefore, care should be taken with patient positioning and airway protection to prevent oesophagitis and aspiration.
Some anaesthetists advocate avoiding use of nitrous oxide during GI endoscopy as it may diffuse into gas-filled spaces, potentially causing over-distension or diffusion hypoxia.
The nursing requirements for patients with GI disorders vary depending on the presenting problem and condition of the patient. Some patients may need minimal care, whereas those in shock, are hypovolaemic, hypoproteinaemic, recumbent or infectious, may require intensive care and barrier nursing.
General nursing of GI patients includes administration of prescribed treatments, managing patient comfort, monitoring for signs of uncontrolled pain or nausea and alerting the clinician to any patient concerns. It is important to keep the patient clean and dry, which is often a full-time job.
Clipping patients with long hair around the perineal region (or the ventral neck in regurgitating patients) helps to keep patients clean and prevent scalding (and thus secondary infection) of the skin and allows application of barrier cream.
Bandaging patients’ tails helps to prevent soiling and formation of sores (Figure 1).
Monitoring and record keeping are essential whatever the patient’s condition. Detailed notes should be made on the patient’s appetite/attitude to/ability to eat, as well as all episodes of regurgitation, vomiting, diarrhoea and any changes in the patient’s condition.
Notes should be made on the nature of vomit and faeces passed. Nurses should regularly monitor patients’ demeanour, vital signs, hydration status and weight in accordance with clinicians’ instructions. If patients are well, physiological parameters may need to be recorded every 12 to 24 hours, whereas in critically ill patients, monitoring may need to be one to two hourly or even constantly.
IVFT, often the cornerstone of treatment, may be crystalloid, colloid or both and should be delivered according to clinicians’ directions. In small and critically ill (but ideally all) patients, IVFT must be delivered via an infusion pump. Response to IVFT should be assessed in all patients – very frequently in sick patients, with vigilance for signs of over or under perfusion (see standard texts for further information on hydration assessment).
Careful maintenance of intravenous access points is essential to ensure patients receive their prescribed IVFT dose and to minimise the risk of phlebitis and catheter damage. Catheter surveillance should be performed at least every 12 hours (up to one to four hours in critical care patients, those that are myelo/ immunosuppressed or pyrexic).
Close attention should be paid to hygiene when handling intravenous catheters in patients with GI disease. Vomit and faeces may be present but not visible on the coat.
Implementation of nutrition plans is often the VN’s responsibility. Patients with GI disorders, unless in healthy acute cases, should be fed, despite vomiting and/or diarrhoea, and enterally whenever possible.
Some GI disorders may respond to dietary manipulation. Thought should be given as to how to feed patients. For example, should solids or slurry be fed?
Does the patient need to be fed from a height, such as in megaoesophagus? Does it need a specific diet? Is tube feeding necessary?
Usually feeding little and often is preferable to large meals. Patients fed parenterally should have 24-hour monitoring, with close attention paid to central IV catheter care, asepsis, perfusion status, vital signs and blood parameters (such as blood glucose, electrolytes and proteins).
Patients may have feeding tubes in place to ensure correct nutritional and calorific intake (Figure 2; see standard texts for further information on feeding tubes). Patients with indwelling tubes have increased nursing needs, which tend to intensify the further down the GI tract they are placed. Some require constant care.
In all cases, the tube site should be inspected at least every 12 hours and at each feed and checked for irritation or erythema of surrounding skin, pain or tenderness, discharge or oedema. Before each feed, tube positioning and suitability to feed should be established (see standard texts for further details). However, if there is any doubt over correct tube positioning, feeding should not proceed and radiography should be performed.
Only proprietary tube-feeding diets, or those that have been blended and sieved, should be used. They should be fed at body temperature.
Feeds should be administered slowly over 10 to 30 minutes, or as a continuous infusion, according to the nursing care plan (Figure 3Figure 3), with constant monitoring and close attention to patient tolerance. Always flush feeding tubes with water following each food or medication administration to prevent blockages occurring.
GI diseases may have primary or secondary aetiologies that may be zoonotic, such as Salmonella, Toxocara, Campylobacter or Giardia. When caring for patients with GI disease, regular and thorough hand washing between patients and after contact with contaminated material and surfaces, as well as effective environmental disinfection, is vital to prevent cross-contamination and self-infection.
Patients with suspected infectious or zoonotic diseases should be isolated and barrier nursed (see standard texts for further details on isolation and barrier nursing). Infectious patients are often critically ill and need a high level of nursing care – therefore, there should be a facility for good observation and instant access to the patient in an emergency.
The role of nursing staff in the management of canine GI diseases is diverse and challenging, but often very rewarding.
By understanding GI diseases, their diagnostics and treatments and being proactive in nursing care, VNs can help to provide compassionate care and have a real impact on the outcome of cases.
Article reviewed by Tony Ryan, MVB, CertSAS, DipECVS, MRCVS and Donna Gaylor, RVN
Linda Roberts
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