All nursing records, such as anaesthetic monitoring sheets, hospitalisation charts, etc. should be included in your case study as supporting documentation. These records should be as detailed and specific as possible and supplied as appendices or attachments. You will also need to summarise them in your case study.
The patient was TPR’d and the IV catheter was checked and flushed with heparinised saline. The patient was then disconnected from his fluids, and walked outside, where he urinated (‘3’). Sucralfate was administered, and one hour later ranitidine and clav/amoxicillin were administered orally (see above for dose and routes of administration).
The patient was walked outside several times through the day, and urinated each time (‘3’). He was offered food every 4 hours (see nutrition plan) and received 80% of his RER in the previous 24 hours.
Although the patient’s temperature was not raised anymore, the patient’s heart rate had increased. No observations by staff were noted that could explain the elevated heart rate. If this rate was taken just after exercise outside, pain from moving around may have caused the heart rate to spike. Analgesia was not administered.
Any details of specific nursing care should also be detailed, this may include bandage care, assisted walking, barrier nursing, patient rotation, monitoring of vital signs (at least twice daily), pain assessment, etc.
Examples:
Grade: Fail
The bladder should be palpated every four hours to ensure it is emptying and the catheter is still working. The urinary catheter collection bag also needs to be emptied every four hours in a sterile fashion. We also need to monitor the urinary output to ensure that is 2-3mL/kg/hr as this is what the vet wanted.
Grade: Pass
The bladder should be palpated every four hours to determine whether the bladder is fully emptying via the urinary catheter and collection system. A blockage or kink in the collection system can lead to urine retention. Urine retention can result in cystitis or sepsis.
It is also important that the urine output be monitored for assessment of hydration, blockages of the urinary collection system, and haematuria, which can predispose the patient to infection.
The urinary catchment bag was charted to be emptied and measured every 4 hours. Sterile technique is important when dealing with the indwelling catheter system to ensure that pathogens are not introduced to the urinary tract. See Appendix A for Urinary Catheter Management.
Normal urinary output in a dog is 1 to 2 mLs per kilogram of bodyweight per hour. The veterinarian asked for the urine output to be maintained at approximately 2 to 3 mLs/kg/hr.
Grade: Credit+
The bladder should be palpated every four hours to determine whether the bladder is fully emptying via the urinary catheter and collection system. A blockage or kink in the collection system can lead to urine retention. Urine retention can result in cystitis or sepsis. Furthermore, over distension of the urinary bladder can result in a “stretch” injury (disruption of the tight junctions within the bladder wall) and permanent bladder damage. It is essential to maintain a decompressed bladder until voluntary urination resumes.
It is also important that the urine output be monitored for assessment of hydration, blockages of the urinary collection system, and haematuria, which can predispose to infection.
The urinary catchment bag was charted to be emptied and measured every 4 hours. Sterile technique is important when dealing with the indwelling catheter system to ensure that pathogens are not introduced to the urinary tract. See Appendix A for Urinary Catheter Management.
Normal urinary output in a dog is 1 to 2 mLs per kilogram of bodyweight per hour. The veterinarian asked for the urine output to be maintained at approximately 2 to 3 mLs/kg/hr. Increasing the fluid therapy is one way of increasing urinary output, however if the kidneys are not working properly, this increase in fluid can lead to fluid overload. Sometimes diuretics may be administered to ensure that fluid overload does not occur, and urinary output is raised.