Module 4 Medical Records PDF

Module 4 Medical records Record Keeping Most veterinary records are written either by a veterinarian or a veterinary nurse. They should be a comprehensive record of what happened at each visit, and may also be a record of important phone calls or other information. Fortunately, most clinics use...

Module 4 Medical records Record Keeping Most veterinary records are written either by a veterinarian or a veterinary nurse. They should be a comprehensive record of what happened at each visit, and may also be a record of important phone calls or other information. Fortunately, most clinics use a computerised database and record keeping system, which makes input and maintenance of medical records straight forward. Another benefit of a computerised database is the ability to automate invoices and bill payments, as well as maintaining a record of all transactions and stock levels. Medical records are easiest to input when done whilst in a consultation with a client and their pet. This information can be inputted into the computer directly, and invoiced at the same time. There are a few general rules when writing medical records. The main convention for the format of medical records is to follow the SOAP format. This stands for Subjective, Objective, Assessment, Plan. If everyone in the clinic is following the same format for writing medical records, they will be easier to understand. It also means that should another veterinarian need to take over the care of that patient part way through treatment, they will know exactly what has already happened, and what was planned to happen next. It is also a good idea to include in medical records any costs or estimates you may have discussed with a client, so anyone else dealing with that client knows what has already been discussed. This also helps to ensure the client is receiving the same information, regardless of which staff member they talk to. There is legislation that surrounds the writing of veterinary medical records, and a subsection in the Veterinary Code of Conduct. This governs how records are maintained, how long they are kept for, and how they are secured and looked after. This information can be found in the Veterinary Council of New Zealand Code of Professional Conduct. Section 4 of Veterinary Services, in the Veterinary Council of New Zealand Code of Professional Conduct - https://vetcouncil.org.nz/Web/Web/2.Resources/Code_Of_Conduct.aspx 4. Veterinarians must maintain clear and accurate clinical records. The records must: a) Be of such detail that another veterinarian could take over the management of the case at any time; b) Be retained for periods of time as required by statute or for the duration of time for which they remain relevant to the purpose for which they were recorded; c) Not be altered retrospectively unless the changes are marked chronologically on the record, and the additions are dated and noted as being added retrospectively; and d) Be made accessible to clients on request, unless there are justifiable legal reasons to withhold. It is important to remember that whilst a computer database may take care of the storing of daily consultation and surgical records, protocols also need to be in place for the storage of radiographs and biopsy samples, as well as anaesthetic and euthanasia consent forms. Know what system your clinic or place of work uses. Are they filed alphabetically or by date? Are they kept in a particular place? What is S.O.A.P? The acronym S.O.A.P is a standard record keeping acronym used for veterinary medical records. It stands for; a. Subjective b. Objective c. Assessment d. Plan You may also come across the acronym HEAP used. This stands for History, Examination, Assessment, Plan. They are really the same thing, as History is Subjective, and Examination is Objective. A patient's signalment is factual information, and according to SOAP protocol is usually included in the Subjective section (even though it is factual information). In reality, most computer databases have a separate section for including this type of information, away from the individual medical record (and most signalment information will not change over time). Patient signalment includes the following information used to identify an individual: a) Name b) Species c) Breed d) Age e) Sex f) Colour g) Distinguishing characteristics We also include: a) Previous medical history b) Primary complaint c) Routine health care d) Vaccines e) Deworming f) Bathing Subjective Information Subjective information may vary from person to person, and day to day. It is sometimes completely false. It can be destructive in decision making because we're making assumptions based on non- factual information. Subjective information includes all information that is told to you by a client. It is the description of what the owner sees and percieves to be going on with their pet. Objective Information Objective information relates to examinations and tests you have done on the animal, and the results obtained. It is information you can measure from a physical examination, and diagnostic testing. Assessment The assessment is most often done by the veterinarian. It is a summary of aliments found. A list of problems is created based on findings. From there the veterinarian makes a differential diagnosis/rule out list which is a summary of ailments the animal may potentially have. After a diagnosis is reached, the outcome is recorded on the master problem list which is a historical summary of everything this patient has been diagnosed with. Plan The plan tells us where we go from here. It tells us how we're going to confirm or rule out the problems in the rule out list. The plan includes diagnostics, further examinations, and testing. Examples of actual S.O.A.Ps from patient records An example of a simple S.O.A.P S = Cat doesn't want to play as much today, and is not acting her normal self. O = Temp 38.9, HR 180, blood on lower right leg. Mild lameness present. A = Abscess on the right leg P = Clip and clean wound, flush, pain relief and ab’s An example of a complex S.O.A.P. S = Owner reports not acting normally, stumbling occasionally, vacant look. Still wants to play, and enjoying the park. Interacting less with family at home. Eating/toileting normally. No history of seizures, doesn't usually eat things he isn't supposed to. O = Proprioception slow, no nystagmus, rest of neuro exam NAD. Weight stable, T=N, no obvious pain, walking normally in carpark. A = Cushings, brain tumour, toxicity, dementia P = Bloods/ACTH stim/US/UA/xrays/MRI/pain relief trial 1. Pain relief trial 2. Monitor for changes 3. Bloods and UA initially Owner opts for plan 3, then re-evaluate depending on results. Will consider MRI if all results normal. A SOAP format of history and record-taking means that everyone in the clinic is consistent with the way information is recorded, and you are less likely to miss important information. ❑ Tick once the section is complete Injection sites We will only be looking at the most common routes and sites used IV, IM, SQ/SC, and a brief mention of IO and IP. Injection sites We will only be looking at the most common routes and sites used IV, IM , SQ/SC, and a brief mention of IO and IP. Injections and sites How many of the abbreviations can you remember for injection routes? There are a number of routes by which injections can be given including: Subcutaneous (SQ/SC) Intraosseous IO Intrathecal Into the fluid in the spinal canal- the Cerebrospinal Fluid (CSF) e.g. an epidural Intradermal Into the dermis of the skin Intra-articular Into the articular space of a joint Intraperitoneal (IP) Into the peritoneal cavity (abdominal cavity) Intra-arterial Into an artery Intracardiac (IC) Into the heart (or the chambers of the heart) Intra: a prefix that means "inside of/within" but we often say into when describing injection routes. In these notes: "Injection route" refers to the route by which a drug it is being administered e.g. IV, IM... "Injection site" refers to the actual location the drug is being administered to e.g. the cephalic vein Tick once the section is complete Injection For many medicines and most vaccines, injection is the only or best method of administration to an animal. It is crucial that you check the medication you are giving to be sure by what routes it can be administered. Medications given via the wrong route can cause skin or vein necrosis (tissue death), seizures, and even death. Although the purpose of an injection is to benefit the animal an injection has the potential to do harm if an improper technique is used. A poor injection technique can cause animal pain. Improper restraint of the animal, leading to movement while injecting, can also cause pain. Poorly injected products may not be well absorbed and may not work. Abscesses and scarring can form in tissue following an injection. When considering which injection route to use, the main deciding factor will be the drug itself. Not all medications can be injected via all routes. We also need to consider how quickly we want the drug to start working, and whether certain injection routes may cause undue pain to the animal. It is also important to consider what the drug is being used for, how long the treatment needs to be given, and who is giving it. For example, a single antibiotic injection given by a vet nurse at the clinic seems reasonable, but a daily injection of an antibiotic for a month, that an owner is required to give at home is not. ❑ Tick once the section is complete General principle when preparing to inject a medication Read the label. Make sure you are injecting the correct drug, the correct amount, in the correct method to the correct site. Pick an area of clean, dry skin. Choose the correct needle and syringe size for the job Use the smallest needle and syringe reasonable for the product and injection site. This makes the injection easier to administer and also minimises tissue damage. Use the appropriate needle length for the size of the animal and the injection site. Needle length is measured in inches (standard lengths include 5/8, ¾, 1, 1½ inches). Use the appropriate needle gauge for the animal, injection site, and the drug (gauge = diameter of the needle shaft). Some injectable drugs are quite "thick" and require a certain gauge needle to allow them to easily pass through. The lower the gauge number the bigger the needle's diameter is. Common gauges used in small animal medication range between 20-23 gauges. Change the needle and syringe between animals, never reuse them (an exception is in large animal practice e.g. when vaccinating a herd of cows the needle is used for multiple animals in a row but is swapped for a new one at regular intervals). Note: Needles used for injections are called Hypodermic Needles. Preparation Wash your hands before you start. Clean the top of the bottle with a small amount of spirit on a cotton swab. Only use clean sterile needles to withdraw the drug. Never reuse a needle. Insert the needle through the rubber bung in the top of the bottle. You will need to invert the bottle (turn it upside down) to withdraw the medication using the syringe. Do not store bottles with needles left in them.  ❑ Tick once the introduction is complete References Gimenez, D.M. (n.d.). Subcutaneous Injection. Image retrieved from http://www.aces.edu/animalforage/MGSQA/GoodProductionPractice3InjectionSiteManagement.ph p Vet Surgery Central (n.d.). Cat with a vaccine-associated tumor. Image retrieved from http://www.vetsurgerycentral.com/oncology_feline_vas.htm Subcutaneous Injection SQ/SC Subcutaneous injections involve the administration of medication to the "subcutaneous space" under the skin. Common sites Cats/Dogs: Usually given in the scruff of the neck (also in rats/mice/rabbits/guinea pigs). The side of the chest and the flank can also be used. Cattle/sheep/horses: Neck SQ/ SC advantages: Large volumes can be administered (advisable to use multiple areas if a very large volume) Generally less painful than other routes and well-tolerated. SQ/ SC Disadvantages: Slow absorption due to lack of large blood vessels Not useful for fluid administration to animals in emergency situations (does not absorb quick enough into the circulation) Technique 1. Lift the skin over the scruff of the neck to form a tent. 2. Insert the needle at the tent base, being careful to avoid directing the needle at your fingers. Your fingers should be at top of the tent, safely above the point of the needle’s entry. Hold the needle parallel to the animal’s body to also avoid puncturing underlying structures. 3. Aspirate (draw back the plunger) to ensure that the needle has not entered a blood vessel- you will see blood in the hub of the syringe is you do. 4. Inject the full volume at a moderate rate. 5. Withdraw the needle and then press the skin to seal the needle’s exit hole and to prevent the fluid from leaking out.  6. Check the animal for any bleeding. 7. Because the fluid has been deposited into the subcutaneous space, you can often see and feel the bubble of fluid beneath the skin (this is called a bleb). HOW TO GIVE A SQ INJECTION TO A CAT A In this video the demonstration shows how to administer a SQ injection to a cat in a safe and effective way ❑ Tick once subcutaneous injection page is complete Intramuscular injection (IM) Intramuscular injections involve the administration of a drug into a large muscle. Common sites Cats/dogs Proximal hind-leg muscles (quadriceps or semimembranosus/semitendinosus muscles) (the thigh!) The back muscles (paralumbar area) NOTE: There is a risk of damaging the sciatic nerve when giving IM injections in the semimembranosus/semitendinosus muscles (caudal thigh muscles). For this reason, this site is often not the first choice or is avoided by many people. Care must be taken to know your anatomy. IM advantages: Faster absorption than SC for most drugs. IM disadvantages: Can only administer small amounts at each site (it hurts!). To give large volumes you need to split the dose and administer into more than one site. Can be more painful that other routes Accidental IV administration can occur (must check not in a vein first by drawing back on plunger once in the skin). Technique 1. After filling the syringe with the product to be injected, point the syringe upwards and tap the barrel with your finger to make air bubbles move upwards into the syringe tip. Slowly and carefully push the plunger to eject the air bubbles from the syringe before injecting the product. 2. Give IM injections deep into a muscle. Use a needle long enough to penetrate skin, subcutaneous tissue and fat to reach the muscle. The needle should enter the skin perpendicular to the skin surface. Rubbing/tapping the site first can desensitise the animal and it may not notice the actual injection when it is given. 3. Check that the needle is not in a blood vessel by pulling back on the plunger and observing for blood flow in the tip of the syringe. If blood appears, remove the needle and put it in a different location at least one inch away from the original injection site. 4. If giving multiple IM injections or daily injections for a few days it is important to rotate sites (to avoid giving in the same place each time). Canine IM injection A video depicting an intramuscular injection demonstration in a canine. ❑ Tick once intramuscular injection page is complete Dig deeper Cattle/sheep/horses  The neck is the site of choice for most IM injections (although other sites can be used) Horse: IM injection into the neck muscle Intravenous Intravenous injections involve the administration of medication directly into the bloodstream via an accessible vein. Common sites Cats/dogs/rabbits Cephalic vein (front-leg) (Rabbits as well) Medial saphenous (cats& rabbit) or lateral saphenous (dogs) vein (hind-leg) Marginal ear vein (rabbits) (Note: the jugular vein is most commonly used for blood sampling, except for intensive care patients with catheters placed, it is rare to use a jugular for iv injections). Large animals Cattle, sheep, horses: Jugular vein Cattle: Tail (coccygeal vein) If you plan to administer medication intravenously over a long period of time, an intravenous catheter (cannula) may be placed in a vein. This is to avoid repeatedly puncturing the vein (it hurts, plus the vein becomes damaged over time and harder to access). IV Advantages: Drugs administered IV are delivered directly to the bloodstream and quickly reach effective concentrations in the blood. Some drugs that can damage other tissues can be given IV (chemotherapy drugs). IV Disadvantages: An aseptic technique must be used to avoid infection. Drugs must be administered slowly, to reduce the chance of a heart/brain reaction. Accidental extravascular injection of some medications can damage subcutaneous tissues and the skin surrounding the vein. Requires a higher degree of animal restraint than SC injections, not all animals tolerate IV injections conscious. Repeated injections into the same vein can cause phlebitis (inflammation of the vein). Technique Clip and clean the area around the injection site aseptically. After filling the syringe with the product to be injected, point the syringe upwards and tap the barrel with your finger to make air bubbles move upwards into the syringe tip. Slowly and carefully push the plunger to eject the air bubbles from the syringe before injecting the product. Raise the vein (normally done by an assistant). Insert needle into vein, and aspirate a small amount of blood (to ensure you are in the vein). Administer drug at an appropriate rate for the drug type.  After administration, withdraw the needle, and apply light pressure to the injection site to prevent any bleeding. Canine blood sample & IV injection Intravenous (IV - start video at 1 minute) ❑ Tick once the intravenous page is complete Intro to small animal fluid therapy Definitions Solvent: A substance, usually a liquid, capable of dissolving another substance (the solute); water is the main solvent in the body Solution: A mixture in which a solute is dissolved and evenly distributed in a solvent Diffusion: The movement of particles from a region of higher concentration to one of lower concentration so they become evenly distributed. Osmosis: Movement of water through a semi-permeable membrane from an area of low solute concentration to one of high solute concentration. Electrolyte: A substance that breaks down into negative and positive ions when dissolved in water. Crystalloid solution: An aqueous solution of electrolytes, mineral salts or other water-soluble molecule that can pass through a semi-permeable membrane into all body compartments. Colloid solution: A solution in which small particles are permanently suspended and cannot pass through a semi-permeable membrane. Hypotonic fluid: A solution (administered fluid) that contains a lower concentration of impermeable solutes than the solution (extravascular fluid) on the other side of the semi-permeable membrane. Isotonic fluid: Two solution (in the case administered fluid and extravascular fluid) that contain an equal concentration of solutes Hypertonic fluid: A solution (administered fluid) that contains a greater concentration of impermeable solutes than the solution (extravascular fluid) on the other side of the semi-permeable membrane. Intracellular: located or occurring within a cell or cells. Extracellular: located or occurring outside the cells. Interstitial: spaces or interstices between structures. Intravascular: within the blood vessels or lymph vessels. Transcellular: Transport or movement of substances across a cell, involving passage through the cell membrane, cytoplasm, and out through the opposite membrane. (Cooper, B., et al 2021) Useful to know CL- Chloride ion H+ - Hygrongen ion HCO3- - Biocarbonate ion K+ - Potassium ion Mg2+ - Magnesium ion Na+- Sodium ion NaCl – sodium chloride Body water Routes of fluid administration How is water normally acquired and lost on a daily basis? Gains: Drinking fluids Within food Water is also produced when the body metabolises food Losses: Urination Defecation Via the respiratory tract (breathing) and skin (sweat) Vomiting, diarrhoea Indications for fluid therapy There are numerous indications for fluid therapy, including the replacement of fluids during dehydration, expansion and support of intravascular volume, and correction of electrolyte imbalances. When choosing the appropriate fluids for a patient a veterinarian's choice of fluid therapy will depend on the - clinical examination of the patients and their history, vomiting and diarrhoea, water intake, food intake, blood loss, etc. Task 1 Read the basics of fluid therapy for Small Animal Veterinary Technicians  Link to article: https://todaysveterinarynurse.com/internal-medicine/the-basics-of- fluid-therapy-for-small-animal-veterinary- technicians/#:~:text=Veterinary%20professionals%20provide%20fluid%20therapy,the %20wrong%20compartment%20(e.g.%2C%20peritoneal After reading the following article answer the following questions Why is fluid therapy performed? Provide some examples of why fluid therapy might be performed? Fluid types There are two main types of fluid crystalloids and colloids. Crystalloid solution: An aqueous solution of electrolytes, mineral salts or other water-soluble molecule that can pass through a semi-permeable membrane into all body compartments. E.g Hartman’s solution/compound sodium lactate and 0.9% sodium chloride Colloid solution: A solution in which small particles are permanently suspended and cannot pass through a semi-permeable membrane. E.g. gelofusine, dextrans, esterfied starches, whole blood and blood products Task Watch IV fluid made easy Link to video: https://www.youtube.com/watch?v=bRPoizhilr0 Answer the following questions! Hypotonic solutions is? Isotonic solution is? Hypertonic solution is? Setting up an intravenous catheter tray Equipment required Clippers One Alcohol swab Chlorhexidine Prep swab Various catheters (20G, 22G, 22G needle if working with cats and dogs) Tape (Pre-cut into strips) One injection port One T-Port (Flush before use) One Saline Flush One Soffban One Vetrap One 5cm piece of brown tape  Intravenous fluid therapy set up Equipment required 1L or 500ml solution bag as prescribed by the veterinarian Administration set Extension set 1. Unwrapped fluid bag 2. Check that it is not expired 3. Check the bag is intact and no leaks are present (moisture/condensation within the wrapper is normal) 4. Place fluid bag on clean table 5. Unwrap the administration set and roll down the roller 6. Aseptically join the extension set to the administration set. 7. Aseptically remove the blue twist tab of the fluid bag. (Ensure you do not touch edges) 8. Remove the protective cover from the sterile administration spike and gentle insert spike into fluid bag in a twisting motion. (If at any time the aseptic technique become compromised, discard bag and giving set) 7. Once the spike has pierced the fluid bag, hold upright, and squeeze the drip chamber until 1/3 to ½ full – do not fill completely. 8. Slowly open the flow control valve on the giving set to allow the fluid to flow through the tubing and remove any air from the tubing. 9. Close the flow control valve on the giving set once the line is primed and recap the end of the giving set to keep it sterile. 10. Hang the fluid bag on an IV pole or hook, making sure it is secure and no part will become contaminated. Task Watch At Dove Preparing IV fluids Link to video: https://www.atdove.org/video/preparing-iv-fluids  Setting up a fluid pump More accurate than just using a giving set. A giving set is still required but now the pump controls the flow. Need to set the rate (mL/hr) and total volume to be infused. Some pumps require a particular type of giving set, others can just use “regular” giving sets. Task Watch At Dove Fluid Pump Basic to get familiar with how to set up a fluid pump Link to video: https://www.atdove.org/video/fluid-pump-basics IV catheter care Adapted AHHA guidelines: 1. Examine the catheter site at least two times daily. Observe for pain and evaluate for evidence of swelling or thrombophlebitis. If the bandage is not clean and dry, replace the bandage. If there is any evidence of thrombophlebitis and the catheter is still necessary, replace the catheter in a different site. 2. Flush using a saline syringe. Feel above catheter site. You should be able to feel the flush going up the vein under your fingers. 3. Rebandage with softban and vet wrap as loose as possible but not to loss where bandage slips of to prevent swelling. 4. When IV lines are disconnected (e.g., to take a dog for a walk), the sites of connection should be cleaned with isopropyl alcohol single-use wipes and capped with injection caps. Do not reuse injection caps. 5. IV catheter used for fluid administration ideally should be changed every 72 hr, however this may change if patient is critical and has poor circulation/perfusion. Monitoring IV fluid therapy Regularly assess the patient AND the equipment: Check patients' clinical signs – TPR, attitude, urine output? Check the catheter – patient interference, disconnection, extra-vascularisation Check the fluid line and pump – occlusions, incorrect programming Intraosseous Injection (IO) & Intraperitoneal Injection (IP) Intraosseous Injection (IO) Intraosseous injections involve the administration of medication into the marrow cavity of a bone (examples of bones that may be used include the femur and the ilium of the pelvis). This is useful if the IV route is inaccessible (e.g. due to burns) or in very young/small patients (tiny veins). It is most commonly used in birds and neonates (kittens/puppies). There are special intraosseous needles, but in birds and small mammals, hypodermic needles work too. IO Advantages: Can administer large volumes of both fluids and blood via this route IO Disadvantages: Difficult to maintain once the animal is mobile. IO injections should never be attempted by someone who is untrained. Intraperitoneal Injection (IP) Intraperitoneal injections involve the administration of medication into the peritoneal cavity (abdomen). The absorption of drugs is highly variable plus there is a risk of accidentally hitting an abdominal organ. ❑ Tick once Intraosseous Injection (IO) & Intraperitoneal Injection (IP) page is complete Feline Injection Site Sarcoma Feline injection-site sarcoma (FISS) is also known as Vaccine-associated Fibrosarcoma (VAF). Fibrosarcomas are rare malignant tumours of cats that are associated with a previous SC injection site (normally a vaccine). They are most often associated with Rabies and FeLV vaccines but are also associated with other types of vaccines and medications. FeLV vaccines (cats only) and Rabies vaccines are not commonly administered in New Zealand. Individual feline genetics also plays a part in this type of tumour, so the incidence of FISS is rare (although still a concern). These tumours require aggressive surgical excision ± radiation therapy (radiation therapy is currently only available in Christchurch (or Australia)). This is a condition that researchers are working on so it is important to keep up to date with the latest recommendations. NOTE: It must be stressed that although there is a minor risk of injection site sarcoma with vaccination, the risk is minimal. The risk of your cat developing a FISS is much less than that of it contracting a fatal viral disease if not vaccinated. The inside circle is the radius of the tumour. The outside circle is how much tissue must be removed during surgery to have the best chance of completely removing the tumour. Video Advanced Fibrosarcoma Cancer on my Cat ❑ Tick once section is complete Dig deeper Intile, J & Gareau, A (2021) "Feline Injection Site Sarcomas: Risk Factors, Diagnosis, Staging, and Treatment Algorithm. Today's Veterinary Practice. https://todaysveterinarypractice.com/oncology/feline-injection-site-sarcomas/ Dispensing When do we dispensing of medications: Following a veterinary consultation Repeat prescriptions for pets on long-term medication (At veterinary clinics you can also be involved in the dispensing of over-the-counter (OTC) products- products which can be sold over the counter without prior veterinary consultation e.g. routine deworming and flea treatments generally fall into this category) Why is proper dispensing important? To communicate to the client exactly what is required of them so they can safely and correctly medicate their animal. Helps to ensure the patient/animal receives the appropriate therapy for their condition. Helps to ensure the clinic's stock levels are kept accurate (that the stock being invoiced (sold) on the computer is also leaving the shelf in the clinic). However, the most important reason to dispense medication properly is to prevent catastrophic accidents. To stop the patient being overdosed, under-dosed or killed. It also limits the opportunity of accidental misuse by humans (such as ingestion by children). How can dispensing go wrong? There are many steps in the dispensing process where things can go wrong including: The wrong label instructions are printed. The wrong medications may be physically dispensed by accident. Failure of the veterinary staff to clearly explain to the client what was required of them and to ensure they understood. Client error Some common examples of how dispensing can go wrong: Medication names and boxes can easily be mixed-up by accident if you are not paying attention. Either when scrolling the medication list on the computer to generate a label or when taking a medication off the shelf.  The different "strengths" of the same drug may be confused (see example below) Completely unrelated drugs that are named or packaged similarly can lead to the wrong drug being dispensed, perhaps because they are made by the same company and carry the same company logo or colours etc. When a patient is being dispensed multiple types of medications at the same time- accidentally swapping the medication labels around when applying them to the medication containers. The owner misreading the label instructions at home. Example: The medication Baytril® is a type of antibiotic. It is available in different tablet strengths (the box and tablet blister pack for each is shown in the photos below). The packaging for the different strength tablets is very similar and veterinary staff must be very careful to double check they have the correct strength when dispensing this medication for a patient. Legal Requirements The Veterinary Council of New Zealand has produced a Code of Professional Conduct for Veterinarians, prescribed under the Veterinarians Act 2005. This provides the minimum practicing standard that is expected for dispensing and packaging veterinary medicines. Based on this the New Zealand Veterinary Association (NZVA) has published recommended guidelines for the dispensing and packaging of veterinary medicines (NZVA, 2003; NZVA, 2004). The actual legal requirements for packaging and labelling veterinary medications are not as comprehensive as you would think. But in reality, despite this, it is expected that veterinarians dispensing veterinary prescription medicines should meet the same legal requirements as those that govern human medical practitioners and pharmacists. These are much more specific (NZVA, 2003). There is also an ethical obligation to meet professional standards for the dispensing and delivery of veterinary medicines. This is required to protect animals and humans from incorrect usage and unintended access (e.g. children). If a human is harmed as a consequence of poor dispensing, the veterinarian responsible could face criminal charges in addition to a professional misconduct action (NZVA, 2003). Should a human ingest/use the medication and require medical assistance; the label on the package must provide all the information needed by the human medical personnel to immediately identify the active ingredient, determine the likely dose involved and also the ability to contact the veterinary practice and the prescribing veterinarian to obtain further information if required (NZVA, 2003). Therefore, veterinary nurses and clinic support staff play an important role, whenever they dispense medication on behalf of a veterinarian. It is not just counting out pills! You may occasionally be presented with a prescription to fill, from another veterinary clinic. This is perfectly acceptable, but should always be checked with a veterinarian at your practice first. Also, a client may ask for a written prescription for their pets medication, so they can fill it elsewhere. Veterinarians are obligated to do this, and it must be signed by that particular animals veterinarian. Dispensing Most medications you will be dispensing will either be in tablet form or liquid. Tablets are usually sized (labeled) in milligrams per tablets and liquids in milligrams per millilitre (ml). Milligrams (mg) essentially refers to "how much" of the actual active ingredient/drug is in the tablet ("the strength"). Don't get too bogged down on this, as your next topic is all about drug calculations. What information should be on the label? (The following is from the NZVA guidelines). Date dispensed Patient’s name/identity & species Owner’s name Medication name and strength Number (tablets) or volume (liquid) of medication dispensed Directions for use o Dose rate, frequency, route Any precautions or essential warnings o Give with food, wear gloves to apply, special storage requirements… Veterinary Practice name and full contact details o Including 24hr contact number o Prescribing Veterinarian’s name (initials are adequate) Also on the label must be in bold print o Keep out of reach of children o FOR ANIMAL USE ONLY ALL production animals must have the registered withholding time for the medication they receive on the label. o The withholding time is the legal stand-down period, during which products from that animal cannot enter the human supply chain: milk, wool, meat, eggs… o Even if the animal is a pet (horse, backyard chickens, calf/lamb club… etc). o Withholding times also apply to racing animals before the can compete again (horses, greyhounds…). When dispensing medication Take your time, do not rush. Check the medication you are dispensing matches what the veterinarian requested for that patient. If you are unsure ask the veterinarian or a senior nurse. Some clinics have policies in place which require all dispensed medication to be checked by two staff members to minimise the chances of a pet being given the wrong medication. Where possible we should always choose the option that will result in the smallest number of pills/volume of liquid for the client to have to administer to their animal. Obviously common sense is required and consider pill size for smaller animals (one very large pill may be harder to give in this situation than two small ones). As a rule for, prescription medications this will be  determined by the veterinarian. Splitting pills Pills are scored to show you that the company who produced them intended that they can be split into a smaller dose. Split along the scored line, use a pill cutter for accuracy. Not all medications can be split properly e.g. un-scored tablets, capsules containing powder, enteric coated medications, time/slow release medications. Sometimes splitting these tablets cannot be avoided if no other alternative tablet “size” exists for that medication. It is however, important to appreciate the limitations this may place on the effectiveness of the medication. Also remember that the splitting of tablets/capsules may lead to quicker degradation of the medication e.g. moisture damage. Counting out the medication Always use a tray: o Improves accuracy of counting o You can visualise all the pills, to ensure they are all the same and identify damaged pills. o Involves less physical handling by staff, safer for humans and less damage/contamination of pills e.g. avoids sweat from hands… Mind human safety - wear gloves if required for the drug being handled. Expiration Date Every medication should have an expiration date on it, check the medication is in date before dispensing it. For ease when dispensing, you can write these in permanent marker on the box or bottle in the clinic so it is easy to see. Packaging requirements An unopened manufacturer’s package normally meets safety requirements. Loose tablets or capsules must be put in Child Resistant Safety Containers (CRSCs). Blister packs or foil wrapped medications are legally regarded as safety containers and putting them in an additional CRSC is not essential unless requested by the client. As well as packaging, check the client has the equipment they need to administer the medication at home. Storage & Handling  Many medications have specific storage and handling requirements such as ▪ refrigerate ▪ sensitive to light ▪ dispose of after 14 days ▪ wear gloves to apply ▪ shake (or don’t shake) before use… Be sure these are stated on the label and ensure that the client understands (tell them where to keep it!). Disposal instructions may be necessary for the owner e.g. syringes and needles of diabetic patients receiving insulin at home. Client communication and understanding client perspective This is very important! It involves ensuring the owner knows what to give when to give and how! NEVER assume an owner understands the dispensing instructions. Find the best way to say it (Clarification) - use words the owner will understand e.g. it may be better to say give "by mouth" than to say "orally". Always say it the same way (Standardisation) Don’t say more than you need to Ensure that clients with English as a second language understand instructions (use an interpreter if necessary). Get another staff member to double check what you have dispensed. ❑ Tick once section is complete Dig deepers: Veterinary Council Code of Professional conduct - Veterinary Medicines NZVA A guide to veterinary pharmacy and dispensing References and Resources New Zealand Veterinary Association (2003). Packaging and labelling when dispensing animal remedies. Retrieved from http://www.nzva.org.nz/policies/2b-packaging-and-labelling-when- dispensing-animal-remedies New Zealand Veterinary Association (2013). A Guide to Veterinary Authorising (Prescribing) and Dispensing. Retrieved from http://www.nzva.org.nz/sites/default/files/domain- 0/Pharmacy%20%20%20Dispensing%201%20October%202013%20FINAL.pdf Veterinary council of New Zealand (2011). Code of Professional Conduct: Veterinary Medicine. Retrieved from http://www.vetcouncil.org.nz/CPC/VetMed/CPC_VetMedicines.php Intro to wound care & bandaging Definition: "A wound the damage to the continuous structure of in the body" (Dallas, S. et al. 2014) Note you will learn more about wounds in anatomy and physiology below find a very brief overview of wounds. Wounds Wound - an injury to living tissue caused by a cut, blow or other impact. Principles of Bandaging In veterinary medicine, bandages are often categorized into three primary layers: the primary layer, the secondary layer, and the tertiary layer. Primary Layer: The primary layer is the innermost layer of a bandage that comes in direct contact with the wound. Its purpose is to provide a sterile barrier and promote wound healing. Secondary Layer: The secondary layer is the middle layer of a bandage and provides support and protection to the wound. It helps maintain the primary layer in place and adds stability to the bandage. The secondary layer provides a critical role that requires balance to get right. Too little of a secondary layer could result in pressure sores, but too much secondary layer will result in a bulky uncomfortable bandage. Tertiary Layer: The tertiary layer is the outermost layer of a bandage and serves as a durable protective waterproof covering. It functions in keeping the bandage in place while allowing mobility to our patients. Applying bandages correctly can significantly improve our ability to provide effective care for our patients. However, it's important we get it right, improperly positioned bandages can potentially cause harm or worsen the condition that we were initially trying to address. Example of layers and their functions Bandage Bandaging Examples Examples Notes layer Material Primary Sterile Telfa Sterlie dressing Melonin dressing that Allevyn covers wounds to aid healing Secondary Padding / Softban Provides conforming Knit-Fix padding Easfix Keep sterile bandage in place **Care should be taken to not apply too tight will restrict blood flow Tertiary Cohesive Vet wrap Protective Elastoplast waterproof layer Can stick to itself **Care should be taken to not apply to tight will restrict blood flow Reason for bandaging Reason for surgical wound dressings Protect the wound from contamination or trauma Protect the wound from the patients Absorb exudate from the wound Immobilisation of the wound Reduce swelling Bandage management Once a bandage has been applied, regular checks to ensure comfort and prevent any further injury to the patient will have to be performed consistently. Bandages should be checked for the following: Has not slipped Isn't too tight Any odor Edema Discharge Skin irritation Wetness Strikethrough (any bleeding or weeping becoming visible through the bandage) Patient soiling Patient interference While patient interference should be discouraged, it should be noted that interference could mean patient discomfort, irritation, or pain. Increasing mental stimulation through grooming, toys, or food-based enrichment should be considered in combination with Elizabethan collars and/or pet shirts/vests to assist in minimize interference. Task 3 Read bandage complications by Tisha. A. Harper LINK TO ARTILE: https://moodle.unitec.ac.nz/mod/resource/view.php?id=764422 Keeping a limb baggage dry while walking a patient Task 4 Creating a waterproof bootie using IV fluid bags to cover a limb bandage. Watch video: IV bag bootie  Note: shouldn't be left on for long periods Different types of Elizabeth collars Plastic Inflatable Soft Pet shirts examples  Surgical wound bandaging Often, surgical wounds are left without a dressing. If a dressing is applied, it is usually a simple non- adherent dressing used as a primary layer, secured in place with paper tape. After 24 hours, this dressing is removed, provided the wound has not been disturbed. Within this timeframe, a fibrin seal is formed, which helps prevent bacterial contamination. However, in some cases, additional padding may be required for adsorption or stabilization of the surgical site, examples of this is the Robert Jones bandage, used for stabilisation and swelling reduction Examples of non-adhesive primary layers (Non-exhaustive list) Telfa/melonin non-adhesive contact layers. ** Note In reality, they are quite adhesive to exposed wound beds and granulation tissue Care should be taken on removal, remove slowly. Allevyn universal semipermeable non-adherent material with a minor degree of absorption ability. An example of commercial primary layer and tape Primpore has a strip of non-adherent material with an adhesive edge to hold it to the skin  Monitoring the post-operative surgical wound Veterinary nurses often have the responsibility of educating owners on the detection of wound complications. This is accomplished by providing instructions for close and regular observation of the surgical wound, encouraging the owner to attend follow-up appointments, and maintaining open communication with the veterinary clinic. Owners should be encouraged to check the wound site daily for any changes or signs of concern. Key points to advise owners on: Swelling and Redness: Significant swelling or redness may indicate an infection or inflammation. Discharge: Any signs of abnormal discharge from the wound, such as pus or excessive fluid. Odor: Unusual odors emanating from the wound could be a sign of infection. Heat and Pain: If there is warmth or tenderness around the wound area, it may indicate an infection or excessive inflammation. Patient Interference: Excessive licking can be an indication of pain or discomfort, and patient interference with the wound can introduce bacteria delaying the healing process. If this is observed, it is best to discuss strategies for preventing this behavior, such as using Elizabethan collars or alternative deterrents like bandages. Sutures or Staples: If the wound was closed with sutures or staples, owners should monitor for any signs of suture line opening or failure. If they notice any loose or broken sutures, it's important to have this evaluated by a veterinarian as soon as possible. If any of the following are observed by an owner at home it is best for the patient to be seen by a veterinarian as soon as possible, as interventions or medication doses may require adjustment. Task Put it all together and read Dallas, S. (2014). Animal biology and care. Oxford, UK: Blackwell Pub Chapter 18 + 19: Section on Wounds, and Types of wounds & bandaging pages 290 – 356 Link to https://ebookcentral.proquest.com/lib/unitec/reader.action?docID=1666469&ppg=307 book Task Read the following pages in Chapter 4 of Surgical Patient Care for Veterinary Technicians and Nurses, Holzman & Raffel (2015) Aftercare and homecare (PAGE 192- 201): https://ebookcentral.proquest.com/lib/unitec/reader.action?docID=4040049&ppg =109 Activit 10 mins y time ❑ Tick once the section is complete Dig Deeper Read Wounds pg 793 to 801 of Cooper, B., Mullineaux, E., & Turner, L. (2020). BSAVA Textbook of Veterinary Nursing. 6th Edition. British Small Animal Veterinary Association. Gloucester. References: Dallas, Sue, et al. Animal Biology and Care, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, https://ebookcentral.proquest.com/lib/unitec/detail.action?docID=1666469. O’Dwyer, L. (2012). Factors resulting in delayed wound healing.The Veterinary Nurse,3(2), 80-87. Cooper, B., Mullineaux, E., & Turner, L. (2020). BSAVA Textbook of Veterinary Nursing. 6th Edition. British Small Animal Veterinary Association. Gloucester.