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Veterinarian Technician February 2013 (Vol 34, No 2)

Educating Clients on Postoperative Care of Orthopedic Patients

by Stephanie Summerlott, BS, RVT

    Veterinary technicians can have many responsibilities, including educating clients on the proper care of their pets. Although your workplace may not perform orthopedic procedures, it is likely that some of your patients have had or will have orthopedic surgery. The most common orthopedic surgery is for treating cranial cruciate ligament diseases or conditions. In 2003, pet owners spent $1.32 billion on surgeries for cranial cruciate ligament ruptures.1 Other common orthopedic surgeries include fracture repair, total hip replacement, medial patellar luxation surgery, and arthroscopy. Whether the procedure is performed at a general practice or a referral hospital, good postoperative management and client communication are key to a successful outcome. Therefore, it is very important for clients to fully understand all aspects of the postoperative management plan. The instructions should be communicated not only verbally but also in writing for clients to refer to at home. If the procedure was not performed in your workplace, it is important to stay in contact with the surgeon and his or her staff regarding the patient’s progress and aftercare. These veterinary colleagues can be an excellent resource during long-term care of a patient. While patient care varies according to each patient and procedure, this article discusses the basics of typical aftercare for patients that undergo orthopedic surgery.

    Strict Rest

    According to orthopedic surgeons at the University of Missouri Veterinary Medical Teaching Hospital, strict rest is the most critical aspect of postoperative management of orthopedic patients. However, it is the aspect of care with which clients most often have difficulty complying. Clients often have a goal of returning their pet to a normal level of activity and comfort. However, if a patient is too active before healing is complete, the surgical repair can fail and/or the patient can have a poor outcome (e.g., the inability to return to a normal activity level). When communicating with clients about postoperative care, it is important that they understand the importance of strict rest and how to achieve it. If clients fully understand all their aftercare responsibilities, they are more likely to successfully care for their pet at home and, after healing is complete, gradually return their pet to its normal activity level. This can increase client satisfaction with the results of surgery and with the veterinary staff. Helping clients understand the reasons behind our recommendations can also increase compliance.

    Some surgeons recommend limited activity and rehabilitation for a few weeks after surgery to limit muscle contracture, stiffness, muscle atrophy, etc. Postoperative activity restriction recommendations may include several weeks of cage rest but should be based on the surgeon’s preferences. Confinement to a room of the client’s house without a crate or kennel may not restrict movement enough to prevent reinjury. Patients can be removed from the crate or kennel on a short leash only to urinate and defecate. Uncontrolled activity outside the crate or kennel should not be allowed.

    Sling Walking

    Some patients that have had hindlimb procedures may be sling walked for the first week or longer after surgery. Sling walking involves placing a sling or a large towel under the patient’s belly, cranial to the hindlimbs, to help support the patient’s weight while allowing weight bearing. It is important not to pull up on the sling: the client should provide support in case the patient becomes unsteady, but the patient should be allowed to use the affected limb. The sling should act as a “safety net” to prevent the patient from falling and possibly injuring itself, but the patient should be allowed to bear its own weight.

    Incision Care

    If the incision is not bandaged, the client must check it twice daily for discharge, missing sutures, dehiscence (opening of the surgical incision), excessive inflammation, abnormal odor, or discoloration, all of which could signal a problem. Any abnormal change in the incision should be reported immediately to a veterinarian and assessed as soon as possible to avoid potentially serious sequelae.

    Elizabethan Collar

    The use of an Elizabethan collar is strongly recommended to prevent patients from licking or chewing the incision or bandage. The Elizabethan collar should stay on at all times until the sutures, staples, or bandages are removed. If a patient is allowed to lick or chew the bandages or incision, the risk for complications, infection, or dehiscence increases greatly.

    Medications

    After the procedure, the veterinarian will prescribe pain medications and may also prescribe antibiotics. It is important for technicians to be familiar with the commonly prescribed pain medications, such as NSAIDs and tramadol, and antibiotics. It is also very important that clients understand the purpose, instructions for use, and potential adverse effects of each prescribed medication.

    Nursing Care

    The client must be advised to keep the patient clean and dry during recovery to help minimize the risk of contamination of the incision. Clients should not keep a recovering patient outdoors. If the patient needs to be cleaned, the client can gently use a washcloth and warm water, followed by gentle drying with a towel. The patient should not be bathed using a hose or tub until the incision has healed completely. In addition, clean, comfortable bedding is important for the patient.

    Orthopedic patients can have difficulty ambulating normally, and smooth surfaces can increase the difficulty, resulting in falls. Therefore, patients should be walked on surfaces that provide good footing, such as carpet or grass. If smooth surfaces are unavoidable, the client must be very diligent about sling walking the patient on smooth surfaces for as long as necessary.

    Casts, Splints, and Bandages

    It is not uncommon for orthopedic patients to go home wearing a cast, splint, or bandage. The bandaged limb must be assessed at least twice daily. The patient’s toes (if visible) must be checked for swelling, coolness, weeping serum, or a change in color. The limb must be checked for soiling of the bandage, drainage, a foul odor, or a change in how the limb is used. If any of these is present, the patient must be examined by a veterinarian and the bandage changed immediately.

    To prevent the bandage from becoming wet or soiled, it should be protected when the patient is outside. Protective coverings are commercially available or can be made by taping empty, dry intravenous fluid bags or plastic bags over the bandage. The covering should be removed when the patient is indoors.

    The type of surgery and the surgeon’s preference dictate the frequency of bandage changes and the duration for which a bandage must be used. It is important for clients to understand that complications related to improper care of a cast, splint, or bandage can result in permanent damage. It is also important to note that atrophy, stiffness, and pressure wounds can occur with long-term use of bandages.2

    Weight Management

    The obesity rate of the American pet population continues to rise. According to a survey published by the Association for Pet Obesity Prevention, 53% to 55% of American pets are overweight.3 Even more alarming is that only 8% to 9% of pet owners classified their pets as overweight or obese.3 This same survey also showed that 69.4% of clients trusted their veterinarian’s opinion on what food to feed their pet. In addition, 76% of clients obtained their nutritional information from their veterinarian.3 Orthopedic conditions are among the many conditions that are worsened by excess body weight. Lean patients typically recover more quickly after surgery, have lower complication rates, and show less severe signs of lameness than overweight patients.4 It is important for clients to understand the effects of obesity on their pet. Body condition scoring and regular weigh-ins can be used to help clients understand what their pet should weigh.4 Teaching clients the proper amount to feed and to provide it in meals rather than free choice are key in helping patients lose weight.4 Prescription weight loss diets are effective at helping pets lose weight by meeting all of their nutritional needs and helping them to feel full while restricting calories.4 It is also important to discuss treats and snacks with clients so that they can properly measure their pet’s total daily calories.

    Nutritional Considerations

    While some care measures are obvious, such as bandages, Elizabethan collars, and strict rest, it can be easy to overlook the importance of a patient’s nutritional needs. Nutrition is as important as the other types of care that technicians provide. Proper nutrition can significantly reduce a patient’s recovery time5; it also enhances wound healing, the immune response, and the speed of therapeutic effects from other treatments and helps to meet a patient’s metabolic needs.6 It is important to monitor a patient’s nutritional intake during hospitalization to ensure adequate caloric intake. Malnutrition has been associated with compromised immune function, increased surgical wound breakdown, and increased postsurgical complications.5

    Clients often do not understand how to calculate their pet’s daily caloric needs. This may lead to overfeeding or underfeeding. It is important for clients to understand how to properly feed their pet over its lifetime, but especially during postoperative recovery. Pet food labels are beginning to list the calories per serving. Technicians can help clients by calculating the patient’s daily caloric needs and then determining the number of calories in one 8-oz cup of the patient’s regular food. Then the calories should be converted into cups per day. Clients should be reminded that 1 cup equals 8 oz. In my experience, clients can better understand how many cups, rather than calories, to feed their pet. If a client feeds canned food, the nutritional label may list the number of calories in each serving and the number of servings per can.

    A patient’s resting energy requirement (RER) can be calculated as follows:

    RER = 70 × Body weight (kg[0.75])

    or

    RER = 30 × Body weight (kg) + 70

    The estimated protein requirement for dogs is 5 to 7.5 g per 100 kcal fed; for cats, it is 6 to 9 g per 100 kcal fed.5

    The patient’s nutritional intake should be increased to the full amount in the course of 2 or 3 days after surgery.5 This gives the patient’s metabolism and gastrointestinal tract time to adjust.5 One method of gradually increasing a patient’s nutritional intake is to calculate the patient’s RER; divide it into thirds; and feed one-third of the RER on day 1 after surgery, two-thirds of the RER on day 2, and the full amount on day 3. The RER is just a starting point for calculating any patient’s nutritional requirements; the RER may increase or decrease throughout a patient’s life. Various stressors (e.g., surgery) can affect a patient’s nutritional requirements. If weight loss is needed, feeding an amount slightly lower than the RER is acceptable, but only until the patient reaches a healthy weight; then the patient’s nutritional intake should be increased to maintain a healthy weight. If a patient does not need to lose weight, and its energy requirements increase, the patient’s nutritional intake needs to increase as well. This should be done slowly, in the course of 2 or 3 days, if the patient is recovering from surgery.

    Rehabilitation

    Many patients can benefit from physical rehabilitation. A recommendation for rehabilitation and the specific rehabilitation protocol depend on the type of surgery and the surgeon’s preference; the protocol also depends on the predicted timeframe for rehabilitation. If the surgeon prescribes physical therapy for a canine patient, and the client is willing to take the pet to a certified canine rehabilitation practitioner (CCRP), encourage the client to do so. CCRPs have specific training, skills, equipment, and facilities that can optimize the benefit to patients. If cost or distance is a limiting factor for seeking professional rehabilitation, many clients can be taught at-home exercises. Contact the patient’s surgeon for a CCRP recommendation or for recommended rehabilitation exercises. Ensure that you and the client fully understand how to safely perform the rehabilitation exercises. It is important to explain these exercises verbally and in writing and to demonstrate the exercises on the patient or another animal. In addition, the client should be taught how to recognize pain or anxiety in the patient and to stop the exercises to avoid causing the patient to become aggressive.

    Joint Health Products

    A wide variety of joint supplements and diets are commercially available, so deciding which product to use can often be overwhelming to clients. Not all products are equal. Make a list of prescription joint diets and supplements that you and your veterinarian are familiar with and trust so that you can make recommendations when clients ask questions.

    Conclusion

    Veterinary technicians can play an important role in the recovery and management of postoperative orthopedic patients. We can help with many aspects of recovery, whether they are very basic or as complex as managing a patient’s nutritional needs. Our veterinarians and clients rely on our knowledge and on our willingness to help our patients.

    1. Wilke VL, Robinson DA, Evans RB, et al. Estimate of the annual economic impact of treatment of cranial cruciate ligament injury in dogs in the United States. J Am Vet Med Assoc 2005;227(10):1604-1607.

    2. Swaim SF, Renburg WC, Shike KM. Small Animal Bandaging, Casting, and Splinting Techniques. Ames, IA: Blackwell Publishing; 2011.

    3. Association for Pet Obesity Prevention. Big Pets Get Bigger: Latest Survey Shows Dog and Cat Obesity Epidemic Expanding. http://www.petobesityprevention.com/big-pets-get-bigger-latest-survey-shows-dog-and-cat-obesity-epidemic-expanding/. Accessed February 6, 2012.

    4. Hand MS, Zicker SC, Novotny BJ. Small Animal Clinical Nutrition Quick Consult. Topeka, KS: Mark Morris Institute; 2011.

    5. Lindley S, Watson P. BSAVA Manual of Canine and Feline Rehabilitation, Supportive, and Palliative Care: Case Studies in Patient Management. Quedgeley, Gloucester, UK: British Small Animal Veterinary Association; 2010.

    6. Harari J. Small Animal Surgery Secrets. 2nd ed. Philadelphia, PA: Hanley & Belfus; 2004.

    References »

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