Transcript File - Mr. Lavoie`s Science Webpage

Nursing Care and Procedures
Michael Lavoie
Veterinary Assisting Program
Middlesex Community College
March 2012
Record keeping
 Medical records provide documentary evidence
of the patient’s illness, hospital care, and
treatment
 Also serve as a basis for review, study and
evaluation of the care and treatment given by
the veterinarian
 Veterinary assistant may be responsible for
many office procedures and administrative
duties
Creation, maintenance and organization of medical
records
Medical records
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Records detailed information for each veterinary patient
Includes both client and patient information
Patient history
Surgical and medical records
Progress notes
Laboratory information
Medical record is a legal document
Keep private and confidential
Record is owned by the facility and is the property of
Medical records
Original record must remain in the facility
for at least 1-3 years from last visit
Check state regulations
Many keep records for 7 years
Copies of the original record can be made
and sent with owner to another facility
May not withhold the release of the
veterinary medical record contents
Medical records
 Should be updated on a regular basis
 Includes
 Client and patient information sheet
 Master problem list- vaccine history, surgeries, previous medical
problems
 Progress notes- allow for chronological logging each time a
patient is seen and treatment is completed (SOAP)
 Laboratory reports, veterinary test results
 Radiology reports
 Pharmacy reports
 Surgical and anesthesia reports
 Content forms and other forms that may be recorded and
documented
Medical records
 Each facility will have a preference for medical
forms used as well as their sequence within the
medical record
 Keep each record in the same format with
information in the same location
 Estimate, authorization forms, consent forms
 Discharge sheet- after treatments or procedures
are completed; instructions for the client on the
care of the animal; care for surgical sites;
prescribed medication instructions
Medical record
Invoice
Keeps a working list of itemized charges
Should be updated and reviewed often
Give to clients at discharge along with payment
history
All services rendered
Medical record rules
 All information must be recorded in blue or black
ink- no pencils or colored pens
 All information must be accurate and legible
 Never erase, use white out, or scribble
 If a mistake is made put one line through the
error and initial the error and then place the
corrected statement after the entry
Indicates an error in writing occurred rather than
suggesting the information has been changed
Medical records
 Record all communication and phone
conversations held with owners
 Detail the conversation including the date and
the initial of the team member involved
 Help others identify and communicate with the
patient’s caregiver
 Each patient record should contain one medical
record for that patient only
Exception laboratories, large farms, herds
The “SOAP”
 Subjective- based on the animal’s overall appearances
and the health care team’s description of the animal
 Objective- measured facts that can be recorded based
on the patient
 TPR, weight
 Assessment- what the veterinarian determines to be the
diagnosis or the patient’s problem
 Plan- treatment or procedures to be given to the patient
 Usually found in the progress notes and physical
examination section on the record
Sample SOAP
S: 6 month old intact male DSH cat,
friendly, well groomed
O: T=102, P=180 bpm, R=purr, 10lbs,
CV=NAF, EENT= NAF; bladder small,
feces palpated in colon
A: Healthy 6 mos old intact DSH
P: castration, TGH later today with
buprenorphine PO q 6 hrs x 3 doses,
meloxicam PO x 3 days
True or false?
 All errors in a medical record should be erased?
 FALSE
 The SOAP format is used as a system filing
medical records
 FALSE
 Each medical file should have a format or
sequence of where each form is place in the file
 TRUE
 You can use red ink to record patient information
in the medical record
 FALSE
QUESTIONS?
Hospital patients- observations
Essential for all staff members to learn to
observe patients
Necessary skill
Includes the moment a patient enters the
facility until it is discharged
observation
 Watch and note an animal’s:
behavior
Appearance
Mental status
Overall health
Some may be subtle and easily overlooked
Compare to what is normal for the species and breed of
the animal
Monitor and note any changes in the medical record
observation
Visual
Smell
Palpation
Auditory
Use all of your senses
Diarrhea, tense abdomen, ocular
discharge
Hospital patients- emergencies
 A situation that requires immediate life-saving
measures
 Important that all of the staff members work
together as a team
 Success relies on the staff working as a team
and staying calm under pressure
 Emergencies are common in all veterinary
facilities
 Vet assistants can help by locating supplies,
medication, and emergency equipment
Crash cart
Moveable table that holds emergency
equipment and supplies
Should be easily accessible
Contains items prepared ahead of time for
emergency situations
Tool chest
Set a moveable plastic drawers
Crash cart contents
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Emergency drugs- epinepherine, atropine, lidocaine
Needles and syringes- all sizes
Endotracheal tubes
Ambu bags
Tape
IV catheters
Fluid bags
Administration sets, extension sets, t-sets
Suction hoses/catheters
EKG-defribulator
Heparinized saline
Be familiar with the contents and locations
What can you do?
 Be able to locate the crash cart or emergency kit
 Be able to locate the emergency equipment that may not
be located in or on the crash cart
 Be able to maintain emergency equipment, drugs, and
supplies
 Be able to update and stock the emergency equipment
 Be able to identify common emergency equipment
 Be able to locate common general supplies
 Be able to restrain and position patients properly
 Perform simple in-house lab procedures
 Provide skin preparation as necessary
Common emergency equipment
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Laryngoscope and blade
Pulse oximeter
EKG
IV catheter
Syringes and needles
Stethoscope
ET tubes of various sizes
Ambu bag
Emergency drugs
Bandage materials
Fluid bags and lines
Training
All staff members should be trained on
what to do during an emergency
Each member must understand the job
Knowledge is invaluable during an
emergency and is not the time to learn and
be trained
Mock events
Call a code
Model dog
Things to watch for…
 No signs of a heartbeat
 No signs of breathing
 An animal that is not alert
 An animal that is having difficulty breathing
 An animal that is hemorrhaging excessively
 An animal that has a low body temperature and
is pale in gum color
 An animal that has an excessively high body
temperature
What to do next?
 Notify the veterinarian or technician of your
concern
 Follow orders as indicated by vet or tech
 Set up emergency equipment as directed
 Call for help
 Record events and any medications
administered
 Be a runner
 Stay calm and focused
Hospital patients- monitoring
 Look for warning signs that warrant further
medical attention or the attention of a
veterinarian or technician
 Important to observe and record in the patient’s
medical record any pertinent observations
 Important to record changes in appetite,
urinations, defecations, attitude, changes in
body temperature
 Nutrition is often overlooked
 Maintain IVC and fluid pumps
Trust your Gut!
 If you feel that something is not quite right speak
up
 No questions are stupid
 Trust your gut
 Would you rather bring up your concerns, or
dismiss them?
 Remember the patients are counting on you
 You are their voice, be loud!
 You may catch something that nobody else does
 You are caring for the patients intimately and
often for days- you can get to know them!
QUESTIONS?
Flea life cycle
 Collectively, all of the
species of fleas are
categorized under the
order name of
Siphonaptera.
 The cat flea,
Ctenocephalides felix, is
the most commonly found
flea in the US and infests
cats, dogs, humans, and
other mammalian and
avian hosts.
Fleas thrive in warm, moist environments
and climates.
The main flea food is blood from the host
animal. Host animals are many species cats, dogs, humans, etc.
Fleas primarily utilize mammalian hosts
(about 95%).
Fleas can also infest avian species (about
5%).
Flea saliva, like other biting skin parasites,
contains an ingredient that softens, or
"digests" the host's skin for easier
penetration and feeding.
Fleas have four main stages in their life
cycle: egg, larva, pupa, and adult.
 The total flea life cycle can range from a
couple weeks to several months,
depending on environmental conditions.
Adult
 The adult flea is very flat
side to side.
 There are hair-like bristles
on the flea body and legs
to aid in their navigation
through pet hair.
 Fleas have 3 pairs of legs,
the hindmost pair designed
for jumping.
 Fleas are well known for
their jumping abilities.
Adult fleas prefer to live on the animal and
their diet consists of blood meals courtesy
of the host animal.
The female flea lays white, roundish eggs.
The adult female flea can lay up to 50
eggs per day, 500-600 eggs over several
months.
Egg
 The eggs are not sticky (like some parasites),
and they usually fall off of the animal into the
carpet, bedding, floorboards, and soil.
 When the flea egg hatches varies -- anywhere
from two days to a few weeks, depending on
environmental conditions.
 The larva emerges from the egg using a chitin
tooth, a hard spine on the top of the head that
disappears as the flea matures.
Larvae
 The larval stage actually has three
developmental stages within this stage.
 Larvae are about 1/4" long, and semitransparent white.
 They have small hairs along their body and
actively move.
 They eat the feces of adult fleas (which is mostly
dried blood) and other organic debris found in
the carpet, bedding, and soil.
 the larval stage lasts about 5 to 18 days
Pupa
 The pupa is the last stage before adult.
 The adult flea can emerge from the cocoon as
early as 3 to 5 days, or it can stay in the cocoon
for a year or more, waiting for the right time to
emerge.
 Stimuli such as warm ambient temperatures,
high humidity, even the vibrations and carbon
dioxide emitted from a passing animal will cause
the flea to emerge from the cocoon faster.
Flea Control: Shampoos
 A shampoo, or "flea bath" is a good first attack
on fleas for the pet that has large numbers of
fleas visible on its body.
 Cats can be difficult to bathe.
 It is important to realize that a flea shampoo is
not intended for lasting control.
 Shampoos are only effective for a day or less.
 They leave little residual chemical on the animal
when properly used.
Flea Control: Flea Dips
Flea dips are strong chemical rinses to rid
animals not only of fleas, but mites and
ticks as well.
 Dips last approximately 1-2 weeks.
That is a lot of chemical residue to leave
on an animal!
Flea shampoos and dips are effective for
adult fleas.
Flea Control: Flea Collars
 Flea collars work one of two ways - by emitting a
toxic gas, and by being absorbed into the
animal's subcutaneous fat layer.
 The toxic gas is usually only effective in the
immediate area of the head and neck.
 This type of collar is best used in the vacuum
cleaner bags to kill any fleas vacuumed up.
 The collars that absorb into the subcutaneous fat
are much more effective.
 Flea collars are effective for adult fleas.
Flea Control: Flea Powders
 Flea powders and sprays offer short term (2-3
day) protection from fleas, and with some
products, ticks and mites too.
 Powders and sprays have fallen out of favor
recently with the newer spot-on treatments that
are available.
 Most flea powders and sprays are only effective
for adult fleas, some offer additional flea
protection by inhibiting flea egg and larval
development.
Flea Control: Spot on Treatments
Common brand names include: Advantage (tm),
Frontline®, and Bio-Spot® just to name a few.
Please consult with your veterinarian for the best
choice for your pet(s).
These products are applied between the
shoulder blades of the pet, and typically last
about one month.
Spot-on treatments are effective for adult fleas.
Some include ingredients to inhibit the larva
from emerging from the flea egg and some are
active against larval development as well.
Flea Control: Oral Medications
Flea "pills", such as Sentinel® work by stopping
the larva from emerging from the flea egg.
Fleas ingest the blood of animals on these
medications, and the female fleas then lay eggs
that are unable to hatch.
They do NOT kill adult fleas.
These medications are essential to break the
flea life cycle and stop the flea problem when
used in conjunction with flea adulticide
treatments.
Flea Control for the House and Yard
Only about 10% of the flea population
(mainly the adults) are on your pet.
The flea eggs, larvae, pupa, and the few
adults that reside in the carpeting,
bedding, and living areas make up
approximately 90% of the flea population.
Neglecting this population of fleas will
ensure that the flea problem will continue
and worsen over time.
 Daily vacuuming - this is very important for
overall flea eradication.
 This will pick up (and get rid of) adults, eggs,
larvae and pupae before they develop.
 Putting a flea collar in the vacuum bag and
emptying the bag frequently are also important;
otherwise, the fleas will hatch, develop, and
leave the vacuum to re-infest the living quarters.
 Dispose of the vacuum bag properly and
frequently.
Wash all bedding, clothing, and removable
furniture covers.
Coccidia life cycle
 Coccidia are single celled organisms that infect
the intestine.
 They are microscopic parasites detectable on
routine fecal tests in the same way that worms
are, but coccidia are not worms and are not
susceptible to deworming medications.
 Coccidia infection causes a watery diarrhea that
is sometimes bloody and can be a lifethreatening problem to an especially young or
small pet.
Coccidia
Coccidia Life cycle
 Coccidia come from fecal-contaminated ground.
 They are swallowed when a pet grooms/licks the
dirt off itself.
 In some cases, sporulated oocysts are
swallowed by mice and the host is infected when
it eats the mouse. Coccidia infection is
especially common in young animals housed in
groups
 This is a common parasite and is not necessarily
a sign of poor husbandry.
How is it Found?
A routine fecal test is a good idea for any
new puppy or kitten whether there are
signs of diarrhea or not as youngsters are
commonly parasitized.
This sort of test is also a good idea for any
patient with diarrhea and is recommended
at least once a year for healthy dogs and
cats as a screening test.
How is it treated?
The most common medicines used
against coccidia are called coccidiostats.
They inhibit coccidial reproduction.
Once the numbers stop expanding, it is
easier for the patient’s immune system to
catch up and wipe the infection out.
The time it takes to clear the infection
depends on how many coccidia organisms
there are to start with and how strong the
patient’s immune system is.
A typical treatment course lasts about a
week or two, but it is important to realize
that the medication should be given until
the diarrhea resolves plus an extra couple
of days.
Medication should be given for at least 5
days total.
Sometimes courses as long as a month
are needed.
In dogs and cats, sulfa-based antibiotics
are the most commonly used
coccidiostats.
QUESTIONS?