Vn117 Animal Nursing Practice History taking Diagnostic process and hospital records

Hx and PE are the minimum date required for diagnosis Need unbiased hx from the client – skilled question technique THE CLIENT MAY NOT ALWAYS BE RIGHT – BUT THE CLIENT IS ALWAYS THE CLIENT Enthusiastic voice and body language, audience awareness for language, non leading questions, review the client and animal details beforehand and empathy if owner upset

Routine sequence Chief complaint Past hx Environmental hx Nutrition hx Value Breed and breeding hx Property profile(production animals only)

The diagnostic process The steps and actions directed to meeting the needs and solving the problems of the animal patient

4 steps of the diagnostic process Data gathering Defining the problem Formulating the initial plan Evaluating the response to the plan The nurse will be involved more in the first and last of these steps

Data gathering Results of hx, PE, and lab results Observation = key Subjective data, the nurses’/owner’s impression of how the animal feels Objective data, measurable observations independent of human opinion

Define the problem Establish the problem list Prioritise for severity and urgency The vets job, but uses all sources of input

plan You may be asked to educate the owner about how to pill the cat Click here here To gather more data To tx To educate the owner The vets job, but may require the nurse to carry it out

Evaluation of the plan Observe record in progress notes and report significant change This can result in alteration to the initial plan to suit the ongoing needs of the animal

Nursing care plans The vets plan directs the nurse to their particular responsibilities for an animal Formal nursing care plans may then be formulated for a patient in the care of the nursing team, which is focused on the nursing role and the nursing problems Text book gives examples of 2 types of such care plans (Orem’s model and the RTL model)

task Look at the 2 nursing care plan models in the text book and discuss the differences in these records from each other and traditional hospital records

Hospital records/inpatient records Accurate id of patient and link to inpatient record required to prevent – Incorrect tx – Discharging the wrong animal to the owner – Legal action being taken against the clinic How are the following species identified in a clinic? Cats and dogs, horses, cattle, sheep pigs goats and deer.

hospital record Records stay with the animal-cage clips, whiteboards Updated at least twice a day

Record of routine care of patients will include On arrival: status and any discharges Time Urination (normal 20ml/kg/day) Defecation Appetite and food consumed Water consumed (normal 50ml/kg/day) Vomit TPR and CRT Meds Bandages drips and drains Daily weight (must be once daily for inpatients)