May 2024

The Technician’s Role in Monitoring Critical Patients

By Melanie Newton, CVT VTS (ECC), Veterinary Technician Development Coordinator – Cummings School of Veterinary Medicine at Tufts University

In this VETgirl online veterinary continuing education blog, Melanie Newton, CVT, VTS (ECC) reminds us that our best monitoring device for critically ill patients may not be a piece of equipment, but rather the training, experience, and intuition of our veterinary technicians.
As technology advances and we are inundated with devices on the daily, one should not forget the best monitoring device of the century: the veterinary technician! Of course, some machines and monitors have their place in veterinary medicine. A continuous ECG to track heart rate and rhythm, an oscillometric blood pressure machine for ease of use, even a slightly untrustworthy pulse oximeter to alert us to a dropping SPO2 can be found useful in the hospital setting. However, no machine can replicate the monitoring skills of a well-educated technician. From observing the patient over several interactions to the intuition technicians develop over time, the role of the veterinary technician in critical care monitoring should not be dismissed.

Tracking Trends

Monitoring critically ill patients includes noting changes in demeanor or personality of your patient as well as tracking vitals over several interactions.

During rounds on a patient, take note of how they look from afar. Cage-side rounds are an excellent way to evaluate your patient at the start of your time with them. Note their demeanor. Are they resting easily in a position that looks normal? Are they laterally recumbent? Are they pacing and can’t seem to get comfortable? Watch their breathing, is it slow and steady? Are they panting? Are they dyspneic or tachypneic? By noting how they seem at first glance, you will now have a baseline in your mind from which to work.

Next, perform a complete physical exam of your patient, noting any abnormalities or concerns. In addition to taking a set of vitals, an overall assessment of your patient should be performed. Feel their pulses and note if they are strong, weak, or thready. Touch each leg (as the patient allows) and check for any swellings or edema. Run your hands down each side of the patient as well as along the spine and the abdomen – does the patient react to any of this? Note any swellings of the face. Take a mental picture, or better yet a physical picture, of how their eyes look. Are they bright and moist or sunken and seemingly dry? All of this allows the technician to establish what is “normal” in this patient. If throughout their shift the technician notices a large change (e.g., new edema or a change in reactions), this should be considered and addressed.

Vitals are essential in monitoring your patient. Sudden spikes or drops in vitals can alert you and your team to changes in your patient.

The heart rate can be indicative of several different changes in your patient. Changes in volume status, such as dehydration or severe fluid losses, as well as other factors such as pain and anxiety, will cause an elevation in your patient’s heart rate. Ruling out causes for tachycardia using a pain score or evaluating the patient’s level of FAS (fear, anxiety, and stress) can assist in determining their clinical status. Alternatively, a dramatic decrease in a patient’s heart rate may indicate the patient is no longer able to compensate for their illness. Sudden bradycardia may also be observed prior to arrest. Unexpected spikes or drops in heart rate should be noted and further investigated.

The respiratory rate will also change with your patient’s status. Increases in respiratory rate could be indicative of an intolerance to fluids, i.e. fluid overload. However, tachypnea and panting may also be seen with pain and anxiety. Using other clinical context clues, such as skin turgor for hydration, or a pain score to evaluate patient comfort, can help determine possible causes of an increased respiratory rate. Different breathing patterns may indicate pH changes as well. Patients with acidosis may breathe faster to lower CO2 concentrations, which in turn raises the pH levels. Exploring possible causes for a change in the patient’s respiratory pattern is essential to determine clinical stability.

Spikes in temperature should be noted and investigated, along with considerations of the patient’s presenting illness. If they were vomiting frequently, then 24-48 hours later have a fever, could this be indicative of aspiration? Did they recently have gastrointestinal surgery, and could this indicate dehiscence of the incision? While diagnosing is not in the technician’s job description, alerting the veterinarian to your findings and having the knowledge base to be able to discuss possible causes should be encouraged.

Mentation changes should also be included when tracking trends for your patient. A patient who was bright, alert, and happy to see you in the morning and is now suddenly quiet and curled in the corner could indicate a change in the patient’s status. Not every patient progresses in an obvious way, from responsive to comatose, in a short period of time, so subtle changes should be noted and addressed.

Vital trends can be extremely helpful in determining how the patient is clinically. Drastic changes in heart rate, respiratory rate, temperature, and mentation should be used when making clinical judgments and assessing the overall well-being of the patient.

Trusting your “gut”
While vital trends can give us solid information and actual numbers, the technician’s intuition can also be a valuable tool. A study performed in 2017 by Mid Sweden University’s Department of Nursing Sciences reviewed the role of intuition in human nursing processes. The study found that intuition can play an important role in the clinical setting: “The use of intuition deserves an acknowledgment in clinical decision-making guiding the nurse to take action for the patient in combination with evidence-based practices…”.1  This concept occurs in veterinary medicine as well. A technician will raise a red flag due to just feeling that something was off and frequently will be proven right during a further investigation. With time and experience, the technician can develop a strong intuition. The technician is also working with the patients more often than any other hospital team member. From frequent vitals, administering many medications, taking the patient for walks, changing their bedding, and everything in between, the technician will know their patient well and may notice subtle changes sooner. Trusting your technician’s gut feelings will be beneficial to your patient.

Kirby’s Rule of 20
While trends and intuition are both extremely helpful, this checklist of 20 critical parameters can assist you in determining your patient’s clinical status.

So, remember: your best monitoring device is not something that comes in a box- but is actually your veterinary technician!

References
1. Melin‐Johansson, Christina, et al. “Clinical intuition in the nursing process and decision‐making—a mixed‐studies review.” Journal of Clinical Nursing, vol. 26, no. 23–24, 22 June 2017, pp. 3936–3949, https://doi.org/10.1111/joc

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