aafpandisfmfeline-friendly nursingcareguidelinesspecial article the aafp and isfm welcome...

S P E C I A L AR T I C L E

The AAFP and ISFM welcomeendorsement of these guide-lines by the American AnimalHospital Association(AAHA).

Journal of Feline Medicine and Surgery (2012) 14, 337–349

Hazel C CarneyDVM MS DABVP (Canine and Feline)

Guidelines Co-Chair

Susan LittleDVM DABVP (Feline)Guidelines Co-Chair

Dawn Brownlee-TomassoRVT

Andrea M HarveyBVSc DSAM (Feline) DEVCIM-CA

MRCVS

Erica MattoxCVT VTS (ECC)

Sheilah RobertsonBVMS (Hons) PhD DACVA DECVAA

CVA MRCVS

Renee RucinskyDVM DABVP (Feline)

Donna Stephens ManleyDVM

AAFP and ISFM Feline-FriendlyNursing Care Guidelines

JFMS CLINICAL PRACTICE337DOI: 10.1177/1098612X12445002© ISFM and AAFP 2012

Nursing care: The term nursing care means different things to different people. The authorsof these AAFP and ISFM Feline-Friendly Nursing Care Guidelines define nursing care asany interaction between the cat and the veterinary team (veterinarian, technician or nurse,receptionist or other support staff) in the clinic, or between the cat and its owner at home,that promotes wellness or recovery from illness or injury and addresses the patient’s physical

and emotional wellbeing. Nursing care also helps the sick or convalescing cat engage in activitiesthat it would be unable to perform without help.

Guidelines rationale: The purpose of the Guidelines is to help all members of the veterinary teamunderstand the basic concepts of nursing care, both in the clinic and at home. This includes methodsfor keeping the patient warm, comfortable, well nourished, clean and groomed. The Guidelines providenumerous practical tips gleaned from the authors’ many years of clinical experience and encourageveterinary team members to look at feline nursing care in ways they previously may not have considered.Overarching goal: The primary goal of feline-friendly nursing care is to make the cat feel safe and securethroughout its medical experience.

The art of nursing care

Veterinarymedicine is a combination of scienceand art. Science uses research evidence anddata to guide it, while the art of healing relieson clinical experience, observation, patient-or client-directed feedback and the ability tointerpret the patient’s state of mind. Thepatient’s behavioral response to treatment isthe central focus in the art of nursing care.To provide optimal support to a well, sick,injured or recovering cat, the art of nursingcare is as important as medical science.Most cat owners can readily detect which

members of the veterinary team truly connectand exhibit empathy with their cats. Vet-erinary team members who apply both the artand science of veterinary nursing care will notonly deliver optimal healthcare to the cat butearn the confidence and appreciation of thepractice’s clients. Involving the cat owner is akey aspect of successful feline nursing careand requires client education, guidance andsupport from the veterinary team.The previously published AAFP and ISFM

Feline-Friendly Handling Guidelines provide

essential primary information regarding theimportance of reducing the stress that catsexperience before, during and after the vet-erinary visit.1 These Feline-Friendly NursingCare Guidelines supplement the recommen-dations of the predecessor Feline-FriendlyHandling Guidelines by placing greateremphasis on the art of veterinary medicinedelivered by the veterinary team in the clinicand by the cat owner at home. The primarygoal of these Guidelines is to make the cat feelsafe and secure throughout its medical experi-ence. By making the cat feel safe and secure,many challenges of handling the feline patientsubside or disappear altogether (Figure 1).

Principal goals of nursing careof the feline patient� Make the cat feel safe and secure inthe clinical setting and at home followingdischarge� Minimize stress to the patient duringin-clinic and at-home treatment� Contribute to successful recovery fromillness, surgery or other treatment, and injury

While most veterinary medical guidelinesaddress the veterinarian, these Guidelinescontain nursing care concepts and methodsthat will also benefit other members of theveterinary team, especially the veterinarytechnician/nurse. An appreciable number ofveterinarians are not comfortable workingwith cats or do not consider the feline patientto be their first preference. An important goalof these Guidelines is to provide practicalrecommendations for veterinarians and othermembers of the veterinary team who findworking with cats challenging. Many felinepractitioners will find that the Guidelinescover familiar territory. However, the authorshope to provide insights that even experi-enced clinicians may find helpful.Clinical improvement in the hospital is only

one aspect of treatment success. The ability ofthe cat owner to provide a continuum of careat home will contribute substantially to asuccessful case outcome. Thus a key focus ofthese Guidelines is how to involve the ownerin the proper handling of the cat, both in theclinic and at home following discharge. Theveterinary team that fails to provide home-care education or initiate communication withthe cat owner after discharge may compro-mise even the best hospital treatment.

338 JFMS CLINICAL PRACTICE

Making the cat feel safeand secure

Understanding fear and stressfrom the cat’s perspectiveAnticipating stressful situationsCats are notoriously sensitive to their sur-roundings and have a well developed fight-or-flight response. These self-protective respons-es, normally essential for survival, may bedetrimental in a veterinary clinic or domesticsetting or when they persist for a prolongedperiod of time. Unfamiliar circumstances (seebox below) that cats encounter in veterinaryclinics may lead to the adverse effects of anxi-ety and fear. These adverse effects suppressnormal behaviors (such as rest and feeding),and increase vigilance, hiding and dysfunc-tional signs such as anorexia, vomiting anddiarrhea or even lack of elimination.2,3Undesirable physiologic responses to stressinclude hyperglycemia, decreased serumpotassium concentrations, elevated serumcreatinine phosphokinase concentrations,lymphopenia, neutrophilia, erratic response tosedation and anesthesia, immunosuppression,hypertension and cardiac murmurs.4–6 Thesechanges can complicate clinical evaluation andtreatment of cats, and prolong hospitalization.

Common s t re s so r s f o r c a t s i n v e t e r i n a r y ho sp i t a l s� Other animals and humans� Noise (eg, medical equipment, telephones, barking, human

conversation)� Smells and odors (eg, other animals, disinfectants)

� A cage environment that does not allow hiding� Unfamiliar caretakers� Unfamiliar food and feeding routines� Sensory overload from busy hospital environments

Veterinary team

members who

apply both the

art and science

of veterinary

nursing care

will not only

deliver optimal

healthcare to

the cat but earn

the confidence

of clients.

Understanding fear and stress from the cat’s perspective

Figure 1 Ensuringa sense of safety andsecurity is the ultimategoal for managing felinepatients in the veterinaryclinic. When cats do notfeel safe and secure,they display behaviorsassociated with fear oraggression. Both fear-induced withdrawal(left-hand arrow) andaggression (right-handarrow) make treatmentdifficult or impossible. Inaddition, the physiologiceffects of stress impairrecovery from illness orinjury. ‘Frozen fear’ and‘Content patient’ imagescourtesy of Hazel Carney.‘Aggressive “bad cat”’©iStockphoto.com/Anna Sematkina

Goal: To make our feline patients feel safe and secure

Upon entering the clinic and throughout their visit, cats perceive a gauntlet of predators(reception area, exam room, treatment/surgery, hospitalization)

Without a sense of securityand wellbeing

With appropriate nursingcare and handling

Frozen fear Aggressive ‘bad cat’

Content patient� Does not move� Does not eat� Does not drinkCat looks like it does notneed care, but it does

� Vocalizes� Bites/scratchesCat feels like it hasno other options

SPEC IAL ART ICLE / AAFP/ISFM guidelines on feline-friendly nursing care

JFMS CLINICAL PRACTICE339


Avoiding

excessive

restraint of the

fearful cat is

very important.

A heavy-handed

approach will

most likely

increase the

cat’s anxiety

and make

handling even

more difficult.

While the veterinary team cannot eliminateall stressors, it can identify at least somefactors to modify or eliminate. The Feline-Friendly Handling Guidelines contain moreinformation on environmental factors affect-ing hospitalized cats.1

Recognizing fear and anxietyFear and anxiety in cats may first manifest aschanges in ear position, eyes and facial expres-sion, body posture, sweating from the pawpads, and tail movement. Fearful cats mayattempt to escape. Vocalization (eg, mewing,growling, hissing, spitting) may indicate anescalating stress reaction. Some cats then showovertly aggressive behavior such as biting,scratching or attacking. Others respond to fearand anxiety by ‘freezing’, whereby they becomeimmobile, silent andwide-eyed, or by engagingin displacement behaviors such as franticgrooming. Distinguishing behaviors associatedwith fear and anxiety from those associatedwith pain may not be easy. The Feline-FriendlyHandling Guidelines contain more informationabout recognition of fear and anxiety.1

Appropriate responses to the fearfuland anxious catAvoiding excessive restraint of the fearful cat isvery important. Aheavy-handed approach willmost likely increase the cat’s anxiety and makehandling evenmore difficult. The clinician, vet-erinary assistants and cat owner should remaincalm and patient. The veterinary team shouldbe flexible and willing to tailor the visit tothe needs of the individual patient. The staffshould adopt an alternate approach to accom-plishing the goals of the visit if the cat is fearfuland resists handling. This may include seda-tion or a period when medical activity tem-porarily stops in order to allow the cat to calmdown. If the cat’s behavior suggests the pres-ence of pain, however slight, provide analgesiaand reassess the cat’s response.

Benefits of reducing in-clinic stress in catsImproved patient outcomesFavorable response of cats to a synthet-ic analog of feline facial pheromone(FFP) is an example of how nursingcare can improve patient out-comes in a veterinary hospitalsetting. Hospitalized cats thathad synthetic FFP applied to atowel in their cages significantlyincreased both their groomingbehaviors and food intake.7Exposing cats to synthetic FFPduring premedication activitiesprior to anesthesia also made thecats calmer at the time of venouscatheterization.8

Anesthetic complications are more commonin cats than dogs and are associated withhealth status, age, weight, procedure type andurgency.9,10 Careful attention to patient assess-ment and management before anesthesia canreduce perioperative complications. However,the cat’s response to fear and anxiety maycomplicate or even preclude a thoroughpreanesthetic evaluation. Reducing or pre-empting stress in hospitalized cats canfacilitate the presurgical examination andpreoperative laboratory testing, ultimatelyimproving patient safety.

Satisfied owners and increased feline visitsRecently published studies have revealed anunderutilization of veterinary healthcare forcats in the US and Canada. While cat ownersgenerally have a higher level of educationthan dog owners, they are less likely to taketheir cat to the veterinarian than dog owners.11Focus groups found that one of the mostimportant factors contributing to fewer felinevisits to veterinarians is signs of stress exhibit-ed by the cat.12 Both the difficulty of gettinga cat into a carrier, and the vocalization andphysical signs of tension displayed by catswhile in the veterinary hospital waiting roomand during examinations, distress owners. Asa result, many cat owners avoid the unpleas-ant aspects of the veterinary hospital visit bysimply not taking their cat to the veterinarian.Improving the cat and owner experiencebefore, during and after the clinic visit, includ-ing hospitalization, will encourage cat ownersto present their pets more frequently forwellness exams and earlier in the course ofdisease.

Improved safety and job satisfactionfor the veterinary teamAggression is one of the most commonlyreported feline behavior problems. Fear andpain encountered in the clinic are commonsources of feline aggression. Attacks on veteri-nary staff typically involve biting or scratch-

ing. The infection rate in untreated injuriesfrom cat attacks is high, ranging from30–50%.13,14 Hand wounds areespecially prone to infection.Improving the hospitalizationexperience for the feline patientdecreases fear-based aggression,and better recognition and man-agement of pain reduces pain-based aggression.Decreasing fear and anxiety in

the hospitalized cat has otherbenefits. Improved handling andhousing of cats reduces stress notonly for feline patients but also for

the veterinary team. Staff members

Facial pheromones benefit cats at all stagesof the clinic visit

A study at The Ohio State University College of VeterinaryMedicine found that exposing clinically sick cats to a topicalsynthetic FFP produced significant increases in facial rubbing,grooming, walking and interest in food compared with theresponse in cats given a placebo. Cats also ate significantly morein 24 hours if they had access to a small cat carrier in which to hideand FFP was in the environment.7 Furthermore, exposing cats toFFP during premedication for anesthesia made cats calmer atthe time of venipuncture compared with the response inplacebo-exposed cats.8 These results suggest that FFPtreatment and the provision of a private place to rest arebeneficial in hospitalized cats. Synthetic FFP sprayis useful in cages and on tables and blankets,

while an area diffuser best permeatescat housing areas.



may experience increased job satisfaction ifpatients show signs of improved wellbeing,better case outcomes and less stress-inducednegative behavior. Finally, reduced timerequired for handling fractious and uncooper-ative cats improves treatment efficiency andwork flow in the veterinary practice.

Nursing care recommendations applicable at each location in a typical veterinary clinic

Exam room� Keep the room and table warm, with a non-slip surface

for the cat� Distract and reward with treats or play� Provide guidance to owners for appropriate interaction

with the cat� Read the cat’s personality and adjust your behavior

to meet the cat’s needs� Make sure all necessary supplies and equipment are

available in the room and avoid unnecessary trafficinto and out of the room

� Use calming synthetic pheromones in the environment

In all areas . . .� Minimize noise� Separate from dogs� Minimize traffic� Keep cat carriers

elevated off the floor� Allow cat to hide

when possible

Nursing care in the clinic:a ‘cat’s eye’ view

Actions that reduce the stress from the cat’sperspective as it progresses through theclinic can be implemented at each locationwithin the clinic (see box below).

Hospitalization� Cage should be large enough to accommodate a place to hide

and for the litter box to be away from food, bedding and water� Provide familiar bedding, toys, food and litter from home,

and only remove when soiled� Using calming synthetic pheromones in the cage will increase

grooming behavior and food intake� Ideally separate cat and dog wards. Other cats and dogs should

be out of line of sight whenever possible� Consider the microclimate of each cage based on patient

needs. Sick, geriatric, sedated and pediatric cats require ahigher ambient temperature

� Consider lowering light levels to encourage rest and to calmanxious cats

� For receptive cats, provide positive interaction (grooming, playingor petting) that is unrelated to medical treatment

Diagno

sis&

treatme

nt areas

Hospitalization

Diagnosis & treatment areas� Choose the quietest, least distracting

place for procedures; this may be theexam room or treatment area

� Avoid exposure to other animals incommon hospital areas such asradiology or treatment room Reception area

� Optimal carrier selection andacclimation will decrease stress

� Provide an elevated surface(table, chair, shelf, windowledge) for the cat carrier

� Consider using panels or plantsto create separate areas for catsand dogs in waiting rooms

� Consider immediate placementof cats into an exam roomwhen possible

� Use calming syntheticpheromones in the environment

Surgery� Do everything possible to minimize presurgical stress; eg, keep cat isolated until

after induction, keep something familiar with the cat, create a calming environment,lower noise levels in the presurgical area (talking, vacuuming, radio, etc)

� Perisurgical management of room and body temperature, as well as pain andhydration, is imperative

� Close patient observation is also imperative (most anesthetic-related deaths occurduring recovery)

Reception

area

Surgery

Exam room



Veterinary team considerationsUse a team approachMonitor and respond appropriately to anyevidence of stress in a feline patient at everystage of the hospital visit; this is an approachthat will help improve safety and efficiencyfor staff and cat owners. To minimize thepatient’s stress, each member of the veterinaryteam plays a role in the cat’s experience fromthe time it enters the door until it leaves theclinic, and even afterward in monitoringhome care. The entire veterinary team shouldunderstand what makes a patient’s visit gosmoothly and without mishap. This broadumbrella of responsibility includes educatingcat owners about stress-free transportation oftheir cats to the clinic, utilizing patient-friend-ly examination techniques, recognizing felinebehavior patterns, and creating a low-stresshome environment for the patient.The veterinary team should have a

common interest in practicing safe and effec-tive handling techniques, in sharing knowl-edge to maintain a high level of serviceprovision and in creating a culture of continu-ous improvement.

Optimize the value of the veterinarytechnician or nurseThe veterinary technician/nurse plays a vitalrole within the team. Involving the techniciancan help improve efficiency and productivity

in feline case management. When employedto their full potential, technicians can carryout many tasks typically performed by theveterinarian and can delegate certain duties toother team members. An experienced techni-cian understands the basic needs of the cat,normal feline behavior, feline disease process-es, and subtle clinical signs that owners mayoverlook. For many technicians, effectivecommunication with owners is a core compe-tency and a skill that increases in value whenthe veterinarian’s time is limited. By maintain-ing an open dialogue with the cat owner, thetechnician is well positioned to alert the vet-erinarian to any concerns the owner may haveregarding their cat.

Recommendations for reducing stressin the reception area� Instruct reception personnel on providingsuggestions to owners for optimal carrierdesign and transportation of the patient(see Feline-Friendly Handling Guidelinesfor additional details).1� Provide an elevated surface (eg, table,shelf, chair, bench) to keep cat carriers off thefloor.� Separate dogs from cats or minimize timein the waiting room to avoid encountersbetween canine and feline patients.� Figure 2 shows features of a cat-friendlyreception area.

Features of a cat-friendly reception area

a b

c d

Figure 2 (a) Receptionpersonnel are readilyaccessible to the catowner in order torespond to questionsor concerns. (b) Thewaiting room includesa separate area forowners who wantadditional privacy or toisolate their cats fromother pets or clients.(c) Bench seating allowsfor elevation of the catcarrier and placementnext to the owner.(d) A towel draped overthe cat carrier providesan impromptu hidingplace in the receptionarea. Images courtesyof FAB/ISFM

Each member

of the

veterinary team

plays a role

in the cat’s

experience

from the time it

enters the door

until it leaves

the clinic, and

even afterward

in monitoring

home care.

Recommendations for reducingstress in the exam room� Provide a warm, quiet roomwith a comfortable, non-slipexamination surface.� Ensure that all necessarysupplies and equipment areimmediately available to avoidunnecessary traffic into and out ofthe room and interruption of theexamination.� Evaluate the cat’s personalityand temperament at the timeof presentation and adjust theapproach accordingly.� Offer guidance on how the catowner can appropriately interactwith the patient during theexamination (Figure 3).

Recommendations for reducingstress during the physical exam� The mindset and physicalapproach of the veterinary teamis critical to successful interactionwith cats. Be patient, calm, positiveand confident.� Taking time with feline patients actuallyimproves efficiency. A hurried approach maycreate anxiety in the patient or result in anincomplete examination or treatment. If thecat remains calm and relaxed during theexamination, its owner will gain confidencein the clinician.� Note in the patient’s medical recordapproaches that have previously worked ornot worked.� Open the carrier door or remove thecarrier top to allow the cat to exit on its own.This will give the cat a sense of control andsafety. Avoid forceful removal of the cat fromthe carrier. Food or toys may entice cats toexit that do not do so voluntarily.� Examine the cat where it wants to beexamined. This may be on the exam table,floor, scale or in the carrier.� The cat may perceive someone staringdirectly into its eyes as a threat. Slow blinkingconveys trust and friendliness.15� If a cat becomes tense or agitated,temporarily interrupt the exam and allow thecat to relax. In a busy practice, it is temptingto overlook this simple approach.� The most important thing to rememberwhen examining a cat is not to overreact withforcible restraint or correction of resistantbehavior. Cats that exhibit minordemonstrations of anxiety, such as fidgeting,may respond best if the clinician continues theexamination in a neutral, deliberate manner.� Always look for an opportunity to rewardpositive behavior with a treat or petting. This



encourages the cat to relax. Positivebehaviors may be subtle, such as achange in facial expression orrelaxation of body tension.

Recommendations forreducing stress in diagnosisand treatment areasCats can experience considerablepain and distress from diagnosticor emergency procedures such asrepeated venipuncture, cystocente-sis or placement of a large-borecentral line.16 The effect of theseinterventions can be both cum-ulative and additive when thesame procedure is repeated or ifseveral different procedures areperformed in succession. Use ofanalgesics such as transmucosalbuprenorphine may greatly facili-tate execution of these tasks. Ifappropriate physical restraint hasfailed, if the cat is already in pain,or if the intervention required willbe repeated or painful (eg, wounddebridement, bandaging), chemi-

cal sedation or general anesthesia combinedwith analgesic agents is appropriate.Tips for reducing stress during diagnosis

and treatment include:� Location Choose a quiet area for performingdiagnostic or therapeutic procedures.� Positioning the patient Place the cat on asoft, non-slip surface and in the most naturalposition for the planned procedure. Forexample, perform cystocentesis in theposition that is most comfortable for the cat.This may be in a standing position or inlateral instead of dorsal recumbency.� Feline facial pheromone Using syntheticFFP in cages, tables or on blankets inprocedure rooms and housing areas10–15 minutes prior to a procedure producesa calming effect.8� Venipuncture Jugular, cephalic ormedial saphenous veins are appropriatechoices for blood collection. Medialsaphenous vein catheter placement is a goodoption for short procedures and blood draws.Positioning the cat for venipuncture of themedial saphenous vein usually requiresthe least restraint and may be the mostcomfortable for many cats (Figure 4). Shavingis usually not required, making the procedurequicker and removing a step that may alarmor upset the cat.� IV catheter placement Avoid multiplevenipunctures by placing an intravenous (IV)catheter for repeated blood samples, fluidtherapy and/or IV treatments, or in caseemergency access should become necessary.

Figure 3 The cat owner’spresence during theexamination can helpminimize the cat’s anxiety inresponse to environmentalor procedural stress.Courtesy of FAB/ISFM

Taking time

with feline

patients

improves

efficiency.

A hurried

approach may

create anxiety

in the patient

or result in an

incomplete

examination or

treatment.



Topical application of local anesthetic creamsto desensitize the skin can facilitate catheterplacement in non-emergency situations. Twotopical anesthetics are available, lidocaine ina liposome-encapsulated formulation and aeutectic mixture of lidocaine and prilocaine.Minimal systemic absorption occurs afterapplication of either product.17 Use a minimalamount of restrictive tape to secure catheters.Check tape and bandages frequently toensure they are not overly tight and havenot shrunk after becoming wet. Considersuturing jugular catheters in place andcovering them with a small amount of elastic,self-adhesive bandage.� Administering subcutaneous fluidsWarming subcutaneous (SC) fluids to thecat’s body temperature can lessen discomfortassociated with administration. Warming isusually done using a microwave or a warmwater bath. Each veterinary practice shoulddevelop a protocol for achieving the correcttemperature that avoids burning the patient.To determine the practice protocol, take a bagstored under stable temperature conditions,cut open the access port, and place the bagupright in a container to avoid spillage.Microwave the bag at 15 second intervals.Because the bag has an irregular shape,agitate the contents after each cycle and theninsert a thermometer through the open accessport until a temperature of approximately100–102°F (37.8–38.9°C) is reached. Recordthe power setting and time needed to reachthe target temperature in an accessible place,such as next to the microwave or in a writtenprotocol for SC fluid therapy.� Avoid exposure to other animals Thisincludes realistic photos or models of animals(illustrations are preferable).

Recommendations for reducingperioperative stress� Do everything possible to minimize thecat’s exposure to presurgical stress:− Keep the cat isolated in a quiet place untilafter induction;− Provide a familiar object such as beddingfrom home or a toy (Figure 5a; alsoappropriate for the post-surgical environment);− Create a calming environment byminimizinglevels of ambient noise, conversation,or operation of equipment and appliances;− Use synthetic FFP in the cat’s cage and inthe procedure room.� Maintain appropriate perioperative roomand body temperature, and ensure adequatepain control and hydration (Figure 5b).� Monitor the patient closely duringrecovery, which is when most anesthetic-related deaths occur.10

Figure 4 Medial saphenous vein catheter placement is a good option for short proceduresand blood draws. Courtesy of Sheilah Robertson

Figure 5 (a) Familiar objectscreate a less threateningpresurgical environment.(b) A cat bag provides warmthand gentle restraint.(c) Placement of an IVcatheter provides venousaccess for multiple injectionprocedures or repeated blooddraws, minimizing discomfortin a feline surgical patient.Images courtesy of SheilahRobertson

a

b

c

Techniques to minimize perioperative stress


Recommendations for reducing stressduring hospitalizationEnvironment� Maintain separate cat and dog wardsif possible.� Keep patients out of each other’s fieldof vision.� Maintain low levels of light to calmanxious cats and encourage them to rest.� Instead of a one-size-fits-all approach,create a cage environment designed for eachindividual cat’s needs and preferences.� Use cages large enough to provide a placefor the cat to hide and to maintain the litterbox separate from food, bedding and water.18� Litter box size and height must match thecat’s size and mobility (Figure 6). Use thecat’s preferred litter when possible.� Provide familiar bedding, toys, food andlitter from home; change bedding only whensoiled.� Adjust the microclimate of each cage basedon individual needs; sick, geriatric, sedatedand pediatric patients require a warmerambient temperature.� To maintain the cat’s body heat, providecomfortable bedding such as thick towels orfleece, orthopedic bedding or yoga mats.� Provide an inside-the-cage hiding placesuch as a sturdy paper bag, cardboard box,cat bed or carrier (Figure 7).


Figure 6 A hospitalized catcan readily access a litter boxwith low sides (a), whereas ahigh-sided litter box (b) wouldbe much more difficult toaccess. Images courtesy ofSusan Little

Figure 7 Three examples of inside-the-cage hiding placesthat provide security for the hospitalized cat. Images courtesyof FAB/ISFM

Instead of a

one-size-fits-all

approach,

create a cage

environment

designed for

each individual

cat’s needs

and

preferences.

a

a

b

c

b

Stress-reducing methods suitablefor all areas of the clinic� Minimize the cat’s exposure to noise� Minimize the cat’s exposure to human

traffic� Separate cats from dogs and other

animal species� Keep cat carriers elevated off the floor� Allow the cat to hide when possible� Use calming synthetic pheromones



Cat-friendly equipment and accessoriesThe following equipment and accessories willhelp reduce the stress of hospitalization forthe feline patient:� Easy-to-use scale with elevated sides(Figure 8a).� Small, quiet fur clippers.� Small-volume blood collection tubes(Figure 8b).� Large, thick bath towels or fleece forrestraint or placement in cages (Figure 9).

Figure 9 A thick towel orfleece provides warmth andsecurity for the hospitalizedcat. Courtesy of FAB/ISFM

Figure 10 Hand feeding of small amounts of food, short-term use of appetite stimulants,and petting may encourage convalescent cats to resume eating. Courtesy of FAB/ISFM

Figure 11 Many cats benefit from a feeding tube when otherstrategies to encourage eating have failed.19 Note that a softElizabethan collar is preferable where available. Courtesy ofFAB/ISFM

Figure 8 Examples of cat-friendly equipment. (a) Cat scale with elevated sides. (b) Small bloodcollection tubes. Images courtesy of Dawn Brownlee-Tomasso

ba� Yoga mat material or non-slip rug pads forlining cage bottoms, kennels, or examinationtables to provide warmth and non-slipsurfaces.� Washable oven or protective glovesdesigned for handling animals, preferablywith long cuffs to protect the handler’s handsand arms.� Cat masks to minimize visual stimulationand calm some cats.� Cat bags for gentle restraint.

Feeding� Feed the cat its regular diet duringhospitalization. Ask the owner to bring infavorite treats if appropriate.� Start therapeutic diets when the cat returnshome and its normal appetite returns.� Flat food dishes, such as small paperplates, and shallow water bowls will improveintake by making food and water moreaccessible.� Warm canned food to the cat’s bodytemperature by microwaving or addingwarm water. Additions of chicken broth ortuna juice may enhance palatability.� Do not leave food in cages of cats thatdisplay food aversion (drooling, licking lips,ignoring the food bowl, vomiting).� Food should always be fresh, provided insmall portions and replenished as needed.� Appetite stimulants may be useful inselected cases for brief periods (2 days) inconjunction with the methods outlinedabove.19� Figures 10 and 11 illustrate other feedingtechniques for the hospitalized cat.

General tipsFigures 12–14 illustrate some general tips thatwill minimize stress and hasten recovery forcats during hospitalization.



General tips for minimizing stress during hospitalization

Figure 12 (a) Brief periodsof exercise out of the cagein a quiet room with a litterbox and food may improveappetite and eliminationin hospitalized cats. Catsshould be kept out of directline of sight of each other;in this instance, there wereno other cats in the ward.(b) A technician or nursecan encourage out-of-cageactivity during the cat’shospitalization and ensureits safety. Images courtesy ofSusan Little

Figure 13 For receptive cats,non-medical interaction such asgrooming, petting, hand feeding orplaying may improve mental and physicalwellbeing and speed recovery.Courtesy of (a) Heather O’Steen and(b) FAB/ISFM

a b

b

Courtesy of FAB/ISFM Courtesy of FAB/ISFM

Courtesy of FAB/ISFMCourtesy of Susan LittleCourtesy of Sheilah Robertson

a b

c d e

Examples of good nursing care in a hospital setting

Figure 14 (a) The individual cagearrangement pictured contributesto a low-stress hospitalenvironment by preventing directline of sight among patients.(b) A convalescing cat has softbedding and a cardboard box inwhich to hide; a soft neck wrapcomfortably secures the jugularcatheter. (c) A cat bed provideswarmth and security.(d) Providing the postsurgicalpatient with food from homehelps re-establish a familiarroutine. (e) Positive staffinteraction with receptive catscontributes to the patient’s senseof security

a



Practical nursing care tips for theveterinary team and cat owner

Pet owner behavior in the exam roomCats are not alone in experiencing anxietyduring a visit to the veterinary clinic. The catowner who accompanies the patient into theexam room often feels some apprehension aswell. When a cat senses its owner’s apprehen-sion, the animal’s anxiety often increases.The following pointerswill help the pet owner

to be a calming influence in the exam room:� Avoid human behaviors that, whileintended to comfort the cat, may actuallyincrease its anxiety. Examples includeclutching the cat, talking or staring in its face,and disturbing or invading its personal space.Human sounds intended to soothe or quiet(like ‘shhhh’) may mimic another cat hissing.� Physical correction such as tapping thecat’s head and delivering stern vocalcorrections may startle the cat and provokethe fight-or-flight response. Cat owners andveterinary team members should rememberthat despite being family members, cats arenot human and react differently to discipline.� The cat will dictate when it wants to behandled. In the clinic setting, instruct theowner not to handle or remove their cat fromits carrier until a member of the veterinaryteam requests otherwise.� Reinforce the cat’s positive behavior andignore negative behavior rather than tryingto correct it.

Home care nursing tips forpet ownersThe veterinary team’sresponsibilitiesSuccessful case outcomes are oftendependent on the ability of the catowner to continue at home the nursingcare that began in the clinic. The veteri-nary team’s responsibility is to ensurethat the owner maintains optimal careof the patient at home. Appropriateowner education, guidance and on-going support by the team can alsoenable early discharge of the felinepatient, which may benefit everyone.When discussing treatment options

with an owner, the technician/nursemay describe drug formulations thatare available and ask the ownerwhichoption best matches both the cat’spersonality and the owner’s physicalabilities. If an owner has no priorexperience of administering medica-tion, the technician/nurse can offersuggestions, such as a flavored liquidthat may be easier to administer thana bitter tablet or a capsule. The techni-

cian/nurse may also demonstrate severaladministration techniques to help ownersdecide which option might be best for them.Owner education is especially important

because administering home nursing care is notintuitive tomost cat owners. The veterinary teamcan facilitate the process in the following ways:� Reinforce nursing care instructions forthe cat owner by providing them verballyand in writing, as well as using availablemultimedia and online resources; ifappropriate, demonstrating techniques(eg, administering medications or SC fluids)can be helpful. An owner instruction sheetthat includes the rationale for the patient’smedical treatment, along with follow-upinstructions and tips for appropriate homenursing care, will help ensure compliance.� Following the cat’s discharge, communicatewith the owner to confirm successfultreatment and address unexpected issues.

The pet owner’s role at homeThe following nursing care tips will help thecat owner become an extension of the veteri-nary team after the patient leaves the clinic:� For acute home care, identify a quiet,familiar, private space such as a smallenclosure or alcove with good light wherethe owner can easily access their cat. A smallspace allows for close monitoring of the catand provides it with a sense of security.� Establish a routine for administering oralmedication to the cat.� Abathroom sink lined with a soft towel orfleece provides an enclosed, secure place foradministering medication to a cat.� Give the cat positive reinforcement (eg, treats,brushing, petting) for acceptingmedication.� Except when medications must beadministered with food (eg, phosphatebinders), do not use food as an aid to givingmedications, especially if this causes aversionand reduces the cat’s food intake.� Forcing the cat to accept medication isstressful for both the owner and the cat.Do not forcibly remove the cat froma hiding place or interrupt eating,grooming or elimination for purposesof administering medication.� Welcome questions and encourage ownersto call if they have any concerns abouthome nursing care, including administeringmedication. Offer alternate ways(eg, different medication formulations) toaccomplish the treatment goal.� Explain to the owner healthy cat behaviorsand signs of wellbeing that signal full recovery.Cats that feel good tend to sleep most often ina curled position. They groom themselves,follow a normal routine, interact with theirowner, and eat and eliminate regularly.

Home care nursing

� Successful patientoutcomes are dependenton the ability of owners toprovide a continuum of care� With appropriate clienteducation, guidance andongoing support cats canbe discharged sooner,which is beneficial to all� Optimal nursing careis not intuitive to mostowners; therefore, clienteducation is very important� Proactive follow-upcommunication with theowner will confirmsuccessful treatment oridentify unexpected issues� Give nursing instructionsverbally, in writing andusing practicaldemonstrations and/orother multimedia resourceswhen possible

The ability of

the cat owner

to provide a

continuum of

care at home

will contribute

substantially to

a successful

case outcome.



Figure 15 A soft Elizabethan collar (a) is more comfortable than a rigid collar (b). A flexibleself-adhesive bandage (c) is preferable to a stiff, restrictive bandage (d). Images courtesy ofSheilah Robertson

a b

c d

Two common nursing practices that can be annoyingto cats, and alternatives to each

Avoid things that annoy cats� When an Elizabethan collar is required,use one made of soft material instead of rigidplastic (Figure 15a,b).� Cats do not like tight or restrictivedressings and bandages. Cats like to stretchand move freely. Elastic, self-adhesive andnon-restrictive bandages are well tolerated(Figure 15c,d). Most cats prefer a tubularstockinette instead of white zinc oxide tapeor non-expandable gauze dressings.� Many cats react negatively to alcohol forskin cleaning or ‘wetting down’ an area priorto venipuncture because they dislike thesmell or sudden cold sensation as the alcoholevaporates. Use warm sterile saline or wateras an alternative.� Cats mark their territory with facialpheromones and will exhibit this behaviorin a hospital cage. They may display facialrubbing of bedding, boxes, cage walls anddoors. Avoid cleaning some of the markedareas in the cage.� Cats are well known for cleanliness andattention to grooming. Sick or debilitated catsare typically less able to groom and needcaregivers to groom them. Remove anyblood or medicinal solutions from the cat’sskin or hair to decrease the personal hygienethe cat must perform. Remove substancesthat may taste unpleasant to the cat whenit grooms.

� Designate a clinic champion to lead theeffort to implement the Guidelines in yourpractice Select a trained individual whounderstands feline behavior, needs and diseaseprocesses, and is willing to coach othermembers of the veterinary team and educateowners about feline nursing care. Encouragethe nursing care champion to recommendchanges to facilities, equipment, proceduresand staff behaviors that will enhance felinenursing care.� Use action planning to implement theGuidelines Include follow-up team meetings toassess progress and make adjustments to theoriginal plan (see right).� Pick two or three nursing care initiatives tofocus on initially Incremental progress will bemore successful than trying to implement all therecommendations in the Guidelines at once.� Hold periodic meetings of the veterinaryteam Discuss the best approaches forimplementing recommendations in theGuidelines, review progress that has beenmade, and find solutions to problem issues.

Using action planningSimply put, an action plan is a series of steps designed to achieve yourobjective – in this case, implementing these Guidelines in your practice.A good action plan is SMART: specific, measurable, attainable, realisticand time-specific. Develop a separate action plan for each initiative youwant to focus on. An action plan should include the following elements:� A stated objective� Specific tasks to accomplish the objective� A person responsible for each task� Target date for completion� Expected outcomes

Tips for putting together a SMART action plan� Involve all members of your veterinary team in preparationof the action plan, or at least those individuals who will beresponsible for the tasks involved� Clarify the success factor-related goal and create a prioritizedlist of tasks to achieve the goal� Identify any barriers or constraints that will keep you fromreaching the goal, and ways of overcoming the barriers� List any resources that are critical to achieving your goal

F i r s t s t e p s i n imp l emen t i n g t h e Gu i d e l i n e s



Collaborating to build a future of unparalleled cat care by:

� Raising the profile of the cat in the veterinary clinic � Creating continuing education opportunities for veterinary care professionals

� Developing practice guidelines to facilitate high standards of feline health care � Providing tools and resources to improve veterinary skills and knowledge

STRATEGIC PARTNERS IN FELINE HEALTH AND WELFARETOGETHER IMPROVING CATS’ LIVES WORLDWIDE

for anaesthetic-related death in cats: results from theconfidential enquiry into perioperative small animal fatalities(CEPSAF). Br J Anaesth 2007; 99: 617–623.

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11 Perrin T.The Business of UrbanAnimals Survey: the facts and sta-tistics on companion animals in Canada. Can Vet J 2009; 50: 48–52.

12 Volk JO, Felsted KE, Thomas JG and Siren CW. Executive summa-ry of the Bayer veterinary care usage study. J Am Vet Med Assoc2011; 238: 1275–1282.

13 Westling K, Farra A, Cars B, Ekblom AG, Sandstedt K, SettergrenB, et al. Cat bite wound infections: a prospective clinical andmicrobiological study at three emergency wards in Stockholm,Sweden. J Infect 2006; 53: 403–407.

14 Palacio J, León-Artozqui M, Pastor-Villalba E, Carrera-Martín Fand García-Belenguer S. Incidence of and risk factors for catbites: a first step in prevention and treatment of feline aggres-sion. J Feline Med Surg 2007; 9: 188–195.

15 Natoli E, Baggio B and Pontier D.Male and female agonistic andaffiliative relationships in a social group of farm cats (Feliscatus L.). Behav Processes 2001; 53: 137–143.

16 AAHA/AAFP Pain Management Guidelines Task ForceMembers, Hellyer P, Rodan I, Brunt J, Downing R, Hagedorn JEand Robertson SA. AAHA/AAFP pain management guidelinesfor dogs and cats. J Feline Med Surg 2007; 9: 466–480.

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References

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Acknowledgements

TheAAFP and ISFMwould like to thank Boehringer Ingelheim andNestlé Purina for their sponsorship of these guidelines and for theircommitment to helping the veterinary community develop projectsthat will improve the lives of cats. Grateful thanks also to all thepractices that are photographed within these guidelines.

� Veterinary practices that care about their feline patients enough to utilize nursingmethods that accommodate the specialized needs of cats will reap numerous rewards:– Veterinary team members will provide better care that facilitates treatment and recoveryof their feline patients;– Owners will appreciate and respond to an approach that emphasizes the cat’s safety and security;– Veterinarians will earn owner loyalty and will have a more productive, safer and happier veterinary team.

� These Guidelines are comprehensive and may seem daunting. However, even small improvements andincremental progress in feline nursing care can pay immediate dividends and start building a culture ofskilled and compassionate feline care.

SUMMARY POINTS

Available online at jfms.com, www.catvets.com and www.isfm.netReprints and permission: sagepub.co.uk/journalsPermissions.nav

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