April 2021

Critical Veterinary Patient? Don’t Forget Kirby’s Rule of 20

by Amy Newfield, CVT, VTS (ECC), Technician CE Coordinator, VETgirl.

In this VETgirl online veterinary continuing education blog, Amy Newfield, CVT, VTS (ECC) reviews the importance of “Kirby’s Rule of 20” for the critically ill veterinary patient.

Rebecca Kirby, DVM, DACVIM, DACVECC is a pioneer in veterinary medicine and many years wrote “Kirby’s Rule of 20”. The list was meant to serve as a reminder for the veterinary team to check off 20 very important items in critical patients at least once a day. Critical patients can change their state very quickly. The success of these patients often lies in noticing details, not forgetting the obvious and excellent nursing and medical care by the entire veterinary team. Years since it was first published this list continues to serve as a reminder to everyone to never overlook these 20 important things in your sick patient.

1) Fluid balance/Colloidal Osmotic Pressure: How hydrated is your patient? Check the mucous membrane, skin turgor and body weight. Watch for evidence of edema or effusion. Be sure to note losses of fluids (vomit, blood, diarrhea) so that fluid adjustments can be made to keep up with the patient.

Fluid Pump - Bag

2) Oxygenation/ventilation: Even if your patient didn’t present with respiratory distress it is important to remember that critical patients are at risk for aspiration pneumonia and changes in their respiratory function. Ausculting lungs, monitoring respiratory rate and effort and pulse oximetry is important in critical patients.

3) Blood pressure: Check how your patient’s pulses feel and check your patient’s blood pressure. Remember that how pulses feel does not always correlate with blood pressure. Monitor capillary refill time (CRT).

4) Heart rate, rhythm and contractility: Listen to the heart with the stethoscope. Don’t just rely on feeling pulses. Perform a spot-check ECG to truly get an assessment of what the heart is doing. It takes just a few minutes to perform and tells you a lot about the heart.

5) Glucose/blood sugar: Patients should maintain glucose levels between 80 and 120 mg/dL. At least once a day critical patients should have their blood glucose levels checked. Critical patients may not be able to regulate their blood glucose levels normally.

Glucometer reading showing hyperglycemia on an Alphatrak
6) Temperature: Be sure to take your patient’s temperature throughout the day.

7) Albumin: Albumin is the number one plasma protein and is responsible for colloid osmotic pressure (COP). Critical patients may experience a decrease in albumin. If there is presence of effusion or edema then a low albumin may be suspected.

8) Electrolyte/acid-base balance: Potassium is the most common electrolyte to suffer an imbalance during a disease/injury process. Critical patients can also suffer acid/base abnormalities due to the disease or injury they are suffering. At least once a day critical patients should have these values checked. By the time symptoms are present it may be too late. Catching changes early is key.

9) Mentation/attitude: Monitoring changes in your patient’s mentation is important. A declining level of consciousness is a poor prognostic indicator. Your patient’s mentation and attitude should always improve. Any decline should investigated.

10) Red Blood Cell and hemoglobin concentration: Check a PCV and TS at least once a day in a critical patient.

11) Gastrointestinal motility and mucosal integrity: Critically ill patients are at risk for gastric ulcers, ileus, gastritis and other GI disturbances. Is your patient eating? Any vomiting or diarrhea? All of these indicate the health of the GI tract in a critical patient.

12) Nutrition: It use to be thought to withhold food to allow the body to heal. This has been proven incorrect. The earlier nutrition is introduced the faster the body heals. Start thinking about nutrition as soon as you get the patient admitted. It should be introduced as soon as possible.

13) Renal Function: Is your patient producing enough urine? Most critical patients are at risk for organ dysfunction. The kidneys are very sensitive to major changes in the body and may stop producing adequate amounts of urine. Measuring and quantifying urine amounts in critical patients is important. Don’t forget to record urine production.

14) Coagulation/clotting ability: Look for petechiae and ecchymosis. Is you patient bleeding more after a venipuncture stick? These are early signed of disseminated intravascular coagulation. Most critical patients are at risk for developing DIC.

15) Immune status, antibiotic dosage: Critical patients have a decreased immune function. Remember to wear gloves when working with them. Minimize risk to your immune compromised patient by keeping it away from other sick patients. Think about using antibiotics when appropriate.

16) Drug dosages and metabolism: Critical patients usually receive a lot of medications. Appropriate documentation, treatment sheets and a list of drugs that do not interact with each other should be kept. Record what you give and when you gave it.

17) Pain control: Advocate for your patient since they cannot speak. Almost all critical patients need some type of pain management. Be sure to use multimodal pain medication.

18) Nursing care and patient mobilization: Critical patients require extensive nursing care. Turning patients, passive range of motion, keeping the patient free of urine scald and bed sores, bathing and cleaning are important in helping the patient recover.

19) Wound care and bandage change: Any wounds or bandages must be cared for appropriately. Keeping them clean and changing them appropriately is important to ensuring they heal quickly.

VETgirl video on how to apply a splint to a dog

20) Tender Loving Care: Don’t dismiss kindness and love. Allow owners to visit for long periods of time. So often hospitals restrict visitation times to 15 minutes or certain times of the day. Recognize that mental health of your patient plays a direct role in their recovery. Happiness helps with healing. Allow owners of critical patients to be the exception to the hospital rule. You should spend time with your patient truly caring for them. Remember that caring for pets is why you went in to this field. Pet them, talk to them and give them the love they so need at a very critical time.

  1. This is a fantastic reminder and a good reference-resource for anyone just coming into the field.

  2. Absolutely love this! Kirby’s 20 has become an essential part of inpatient nurse training at the ER I work at.

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