Monitoring (Conner)

Question 1

Why monitor?

Answer 1

• To identify problems and intervene early
• prevent complications
• avoid/catch mistakes
• adjust therapy

Question 2

No point in monitoring if….

Answer 2

result not associated with an action

Question 3

Kirby’s rule of 20

Answer 3

• Albumin concentration
• Blood pressure and perfusion
• Coagulation
• Drug dosages and metabolism
• Electrolyte and acid-base
• Fluid balance
• GI motility and integrity
• Heart rate, rhythm, and contractility
• Immune status, abx, leukogram
• Joint motility and nursing care
• Kidney function
• Love
• Mentation
• Nutrition
• Oxygenation and ventilation
• Pain control
• Protein/osmotic pull
• Red blood cell and hemoglobin concentration
• Sugar (glucose) concentration
• Wound care and bandage changes

Question 4

Hypoalbuminemia

Causes

COnsequences

Answer 4

• Causes
  
  • liver failure
  • protein-losing enteropathy/nephropathy
  • malnutrition
  • systemic inflammation
• Consequences
  
  • altered pharmacokinetics
  • delayed wound healing
  • reduced oncotic pressure

*hyperalbuminemia almost always dehydration

Question 5

Albumin drug binding

Answer 5

• Change in volume of distribution
• Short term inc in free drug, but
• higher volume distribution
• more rapid clearance

Question 6

Blood pressure and Perfusion

Answer 6

• BP = CO x VR
  
  • CO = HR x SV => preload + afterload + contractility
    
    • preload is dependant on blood volume (I believe)
  • VR = something weird => vasodilation/constriction

*VR: vascular resistance

Question 7

Cardiac output

Answer 7

• Half of the blood pressure equation
• Determined by heart rate and stroke volume
  
  • after dertain inc in HR, no more inc CO
    
    • from dec SV

Question 8

Vascular resistance

Answer 8

• Other half of BP equation
• Resistance to flow is directly proportional to viscosit of fluid and length of tube
• Resistance is inversely proportional to radius of tube to fourth power

Question 9

Pulse quality

Answer 9

• sense of blood perfusion and pressure

Question 10

Coagulation

Answer 10

• Always monitor patient
  
  • patechiae, ecchymoses
  • gums, pinnae, ventral abdomen
• Often monitor
  
  • plately count
  • clotting times
  • antithrombin
  • fibrin degradation products (D-dimers)
  • Thromboelastography

*Beware of thrombosis

Question 11

Drugs and Metabolism

Answer 11

• Double check dosage every day
• Have someone else double check
• Evaluate need for change
  
  • renal excretion
  • hepatic metabolism/excretion
  • degree protein-bound
• Assess if drugs still needed
• double check IV drug compatibility

Question 12

Electrolytes and acid-base

Answer 12

• Hypokalemia, hypocalcemia common
• refeeding syndrome
  
  • hypoglycemia
  • hypokalemia
  • hypophosphatemia
  • hypomagnesemia
• diabetic ketoacidosis
  
  • hypokalemia
  • hypophosphatemia
• renal failure
  
  • hyperphosphatemia
  • hyper/hypokalemia
• rapid Na changes

Question 13

Fluid balance

Answer 13

• One of the most difficult parameters to monitor accurately
• Encompasses both hydration and vascular volume
  
  • these are not the same thing
• Most accurately monitored via serial, consistent body weight measurements
  
  • often we don’t know patient’s ideal body weight

Question 14

GI Motility & Integrity

Answer 14

• Ileus is common
  
  • primary
  • secondary - opioids
• Compromised GI barrier
  
  • bacterial translocation
  • altered drug uptake (PO meds)
  • vomiting
  • diarrhea
• Enteral feeding whenever possible

Question 15

Heart rate, Rhythm, contractility

Answer 15

• Heart rate
• Check often
• feel pulses
• Auscult while feeling pulse
• tachycardia in a dog is bad => investigate
• bradycardia in a cat is bad => investigate

Question 16

Indirect Measures of hydration

Answer 16

• Elevated hematocrit and total solids
• Hyperalbuminemia
• Hypersthenuric urine
• azotemia
• hypernatremia

Question 17

True/False: Normal resting heart rate for a dog is dependent upon size of the dog

Answer 17

False

Question 18

Normal heart rates

Answer 18

• Dogs: 60-100
• Cats:
  
  • 180-220 (in hospital)
  • 140-160 (at home)

*cat in hospital < 180 in hospital probs not good!

Question 19

Arrhythmias

Answer 19

• Monitor progression
• Treat if Clinical Signs
  
  • weakness
  • collapse
  • hypotension

Question 20

Contractility

Decreased with

treated with

Answer 20

• Decreased with
  
  • Sepsis
  • SIRS
    
    • primary heart dz
• Treated with
  
  • positive inotropes
    
    • Dobutamine (sepsis, SIRS)
    • Pimobendan or digoxin (heart dz)

Question 21

Oxygenation

Answer 21

• Hypoxemia
  
  • dec partial pressure of oxygen/ saturation of oxygen in the blood
• Hypoxia
  
  • dec oxygen tension in tissues

*Hypoxemia leads to hypoxia but hypoxia can be present without hypoxemia

Question 22

Oxygen content

Answer 22

• 98% of blood oxygen carried by hemoglobin
• 1.5% of oxygen from dissolved oxygen

*Anemic animals don’t need oxygen, they need blood!

Question 23

Immune status

Answer 23

• Infectious dz common
• not all infections are bacterial
• not all sick patients need antibiotics

Question 24

Antimicrobial therapy

Answer 24

• evaluate on a daily basis
• empiric therapy should be based on
  
  • sources of infection
  • tissues infected
  • likely pathogen
• whenever possible obtain cultures

Question 25

Leukogram analysis

Answer 25

* monitor in patients with known/suspected infection * immature neutrophilia to mature * suggests patient is not overwhelmed * left shift neutrophilia to degenerative left shift * suggests patient may become overwhelmed \*inflammation DOES NOT EQUAL infection

Question 26

ELevated temperature Hyperthermia

Answer 26

* Hyperthermia * temp elevated from external heat source * imbalance heat production and heat loss * radiation * convection * evaporation * conduction * patient wants to be cooler

Question 27

ELevated temperature Fever

Answer 27

* Temp elevated from within * Stimulation of pyrogens * inc set point in hypothalamus

Question 28

TPLO patient coming out from blankets and temp is 97.9 and panting. What do you do?

Answer 28

Take off blankets -opioids mess up set point

Question 29

Joint and nursing care

Answer 29

* recumbent animals prone to complications * decubital ulcers (bed sores) * venous stasis =\> thrombosis * muscle atrophy and weakness (disuse atrophy) * urine and fecal soiling * promotes decubital ulcers

Question 30

Preventing recumbency complications

Answer 30

* Lots of soft, padded bedding * turn patient * keep sternal as much as possible * turn hips when sternal * check bedding frequently for soiling * passive range of motion for joints * tissue massage

Question 31

Kidney function

Answer 31

* Primary dz * complication of primary dz * complication of therapy * Frequent monitoring of creatinine * +/- urea concentrations * urine output necessary in some patients

Question 32

Love

Answer 32

* encourage visits from owners

Question 33

Mentation

Answer 33

* Investigate sudden changes * may not be primary neuro prob * oxygen * glucose

Question 34

Nutrition

Answer 34

* Often overlooked * causes mal/undernourishment * altered immune function * poor wound healing * increased risk of infection * weaknessness and recumbency

Question 35

Pain

Answer 35

* Look for it * Treat it \*pain is physiologically harmful

Question 36

Red blood cells and hemoglobin

Answer 36

* Hematocrit or PCV * should be measured frequently (once daily) if on fluid therapy * check more frequently in patients with anemia * measure total solids every time PCV is checked

Question 37

PCV and things that affect it

Answer 37

* Fluids =\> hemodilution =\> lowers PCV * Acute bleeding =\> lose whole blood =\> no change in PCV * Hemolysis =\> normal volume, loss of RBCs =\> lowers PCV * Dehydration =\> lowers volume =\> inc PCV

Question 38

Sugar (glucose)

Answer 38

* Sever hypoglyclemia can be immediately life threatening * anorexic kittens and puppies (esp small breeds) * patients with sepsis * patient w/ escessive insulin * insulinoma * diabetes mellitus * iatrogenic diabetes

Question 39

Wound Care

Answer 39

* Inspect all wounds/holes at least daily * inc cath sites * Eval bandages frequently and change if wet/soiled

Question 40

Writing treatment orders

Answer 40

* Consider which parameters most imp for THIS patient * Consider pros and cons of each monitoring parameter * Choose actions for parameters outside of range