Welcome to the latest edition of the BVNS Neurotransmitter 2.0 Technically Speaking. This publication is written by our technicians for technicians. This issue focuses on nursing care for the “down dog.”
There can be many reasons why a dog (or cat!) would present with the inability to walk, such as intervertebral disc disease, fibrocartilaginous embolism (FCE), tick paralysis, meningitis, trauma, and tumors in the area of the spinal cord. However, the potential complications of the “down” patient and required nursing care is essentially the same.
Possible complications in patients unable to walk include pulmonary atelectasis, aspiration pneumonia, poor gastric motility, fecal retention, urinary bladder damage, urinary tract infections, decubital ulcers, urine scald, muscle atrophy, joint stiffness, pain, inadequate nutritional intake, and patient depression or lethargy. We will take a look at each complication and what we can do as nurses to help prevent their emergence.
With patients that are laterally recumbent, particularly patients who are weak or paralyzed in all four limbs, pulmonary atelectasis is a major concern. When patients lie on the same side consistently, expansion of the down lung is compromised and the lung space collapses. In addition, lung secretions can accumulate. This can lead to tachypnea, dyspnea, and cyanosis.
Nursing Care: The patient should be turned from one side to the other side every 4 hours, or kept sternal if possible. Pillows and rolled up blankets can be used to prop the patient in a sternal position or provide support for their head. Respiratory patterns should be monitored and lung fields auscultated often. Coupage may be necessary to loosen any accumulated lung secretions.
Aspiration pneumonia is caused by the inhalation of foreign material into the lungs. Patients that have megaesophagus, a history of regurgitation, or are brachycephalic, are at increased risk of aspiration pneumonia.
Nursing Care: Feed patients while they are supported in a sternal position. Patients should be maintained in a sternal position for at least 20 minutes after feeding.
Decubital Ulcers/Urine Scald
Bedding is an important consideration for patients unable to move themselves, or patients who may be able to move, but are on strict crate rest. Decubital ulcers are caused by pressure that limits blood supply to the affected area; turning a patient frequently, massaging areas of potential ulcer formation, and passive range of motion exercises will all help to mitigate the formation of ulcers. Once formed, ulcers are very difficult to heal, and may require surgery to close the wounds.
Nursing Care: Bedding should be thick and soft, but yet not too thick, as the patient may struggle to reposition and reinjure himself. The top layer should be absorbent or otherwise non-retentive, in order to prevent urine scald. Sheepskin, waterproof foam mattresses, air mattresses, and “trampoline” beds can all be used for bedding. Large dogs in lateral recumbency may appreciate having some padding tucked in between their legs.
Bedding should be checked frequently for soiling, and changed out as necessary to provide a clean, dry surface. Make sure that any bony prominences, such as hip points, elbows, and shoulders are well padded, and check frequently for signs of ulcer development by parting the hair over high-risk areas and looking for moisture and redness. Early signs of ulcer formation include redness, swelling, and tenderness, followed by serum exudation and hair loss.
To help prevent ulcer formation, patients should be rotated from side to side in order to relieve pressure on any bony prominences. Patients that are down only in the pelvic limbs only need to have their hind end rotated; patients down in all four limbs should be rotated through left lateral, sternal, and right lateral recumbency. Care should be taken when turning a patient with a known or suspected spinal cord injury; two people may be needed to move the patient as a whole without twisting the spine.
Any patient that soils itself should have the affected area bathed and dried. Watch for signs of urine scald – the fur may need to be shaved, skin washed with a mild shampoo, and a barrier cream, such as Desitin or A+D Ointment, applied.
Urinary Bladder Damage/Urinary Tract Infections
Spinal cord lesions lead to an increase in urethral sphincter tone and relaxation of the detrusor muscle, leading to an overfilling of the bladder that is difficult to express. Overdistension of the bladder can lead to permanent detrusor muscle damage and loss of bladder tone. Usually, patients able to move their pelvic limbs are also able to control their bladders, but should still be monitored. However, the bladder of a patient unable to move his pelvic limbs must be carefully managed in order to prevent permanent damage to the bladder.
Roughly ⅓ of all patients with spinal cord injuries will develop a urinary tract infection within the first three months after the injury.
Nursing Care: Ideally, a patient should be taken outside about every 6 hours and given the opportunity to urinate on his or her own, supported into a normal elimination position if necessary.
If possible, particularly in patients who do not have motor function in their pelvic limbs, an indwelling (Foley) urinary catheter should be placed with a closed collection system. If an indwelling urinary catheter cannot be placed, the patient’s bladder should be palpated to estimate its size every 4-6 hours, even with evidence of urination on the patient’s bedding. In these patients, urine on the bedding may indicate simply an overflow of the bladder rather than true voiding. Palpation of the bladder will help differentiate between the two possibilities. Express the bladder as needed to avoid overdistension of the bladder. Diazepam and prazosin are two drugs that can be used to help decrease the urethral sphincter tone (if appropriate), allowing the bladder to be more easily expressed. If using diazepam, the best time to attempt bladder expression is 20-30 minutes after oral administration of the drug.
Along with monitoring of the patient’s bladder size, signs of urinary tract infection, such as dark color, strong-smelling urine, frequent urination, or straining to urinate, must be watched for.
Muscle Atrophy/Joint Stiffness
Since patients unable to walk are not exercising and using their muscles as they normally would, they can very quickly lose muscle mass. In addition, their muscles and joints can stiffen up, causing contracture. Rehabilitation can run the gamut from massage and basic stretching exercises to more advanced techniques such as ultrasound, acupuncture, hydrotherapy, and electrical stimulation.
Manipulation of the affected tissue by massage can loosen stiff muscles, increase circulation, and minimize muscle atrophy. In addition, massage can be beneficial prior to range of motion exercises in order to warm up the muscles and relax the patient.
Passive range of motion exercises help to improve circulation and lymphatic drainage, maintain flexibility of the joints in the affected legs, prevention of tissue adhesions, and can help increase awareness of the affected limbs. Passive range of motion exercises should never cause pain – the exercises are designed to put the joint through a range of movement that is normal for the patient and should never be forced.
Assisted standing – Patients should be assisted to stand and encouraged to support their own weight several times a day. Make sure to support the patient under the chest and abdomen; a Help ‘Em Up harness is ideal for this support, but slings, sheets, or towels may also be of use. Place the patient’s feet in the correct position, squarely under their body, and have the patient hold the position for up to a minute.
Massage – Massage therapy should be performed 3-4 times a day for 10-15 minutes. There are many different massage techniques, but the most common are effleurage (deep stroking movement) and petrissage (kneading the muscle perpendicular to the direction of the muscle fibers).
Effleurage is designed to increase venous blood flow and encourage lymphatic drainage, and begins by starting at the distal end of the affected limb and running fingers with light to moderate pressure proximally before returning to the distal end and releasing pressure.
Petrissage consists of short, quick strokes with moderate to deep pressure across the muscle belly.
Passive Range of Motion – Passive range of motion exercises should be performed 3-4 times daily, and can be done in conjunction with massage. As much as possible, the limb which is being worked should be parallel to the ground (assuming lateral recumbency) in order to prevent to torqueing of the joints, and supported above and below the joint in question. Starting with the toes, flex and extend several times before moving up to the next joint (either carpus or tarsus) and flexing and extending that joint several times. Repeat with each joint moving distal to proximal on the limb. (See Figure 1) After each individual joint has been worked, the entire limb can be moved through a “bicycling” motion. Performing the exercises on individual joints before involving the entire limb can help reduce pain and spasm. Also be aware of geriatric patients who may have a more limited range of motion due to age-related changes.
You can also view video guides of the passive range of motion exercises on our website at http://bvns.net/video-resources.
Nutrition and Hydration
Neurologic patients are often stressed both physically and psychologically. Stress increases a patient’s metabolic rate and breakdown of protein, which can lead to the loss of lean body mass. It is important to be sure the patient is receiving adequate calories in order to provide the nutrition necessary to recover and minimize the tendency to deplete body protein.
Nursing Care: The patient should be offered high-quality, palatable meals several times a day. A patient’s resting energy requirement should be calculated, and then multiplied by an illness factor of 1.2 to 1.6, depending on the severity of the illness, the phase of recovery, and the patient’s body condition score. Patients should be weighed on the same scale daily in order to help assess if their nutrition and hydration needs are being met.
Part of the psychological stress that a neurologic patient experiences is due to the patient’s inability to walk, in addition to being hospitalized and away from his owners.
Nursing Care: If at all possible, the patient should be taken outside several times a day, both for the practical reason of bathroom duties, but also for the mental stimulation of the change of scenery and scents. Of course, interaction with the patient during physical therapy exercises is also helpful, as well as spending time with the patient when not performing nursing tasks, whenever possible.
Nursing care for a “down” patient is a very involved and potentially challenging process, but can be very rewarding as the patient recovers function.
BSAVA Manual of Canine and Feline Neurology, 4th edition
Practical Guide to Canine and Feline Neurology, 3rd edition
Click HERE for a printable PDF version of this handout.