Cindy Black (fictitious name), a four-year-old child with wheezing, was brought into the emergency room by her mother for treatment at XYZ hospital at 9:12 p.m. on Friday, May 13. Initial triage assessment revealed that Cindy was suffering from a sore throat, wheezing bilaterally throughout all lung fields, seal-like cough and shortness of breath (SOB), bilateral ear pain. Vital signs on admission were pulse rate 160, respiratory rate 28 and a temperature of 101.6 Fahrenheit (F) (rectal). Cindy Black was admitted to the emergency department for treatment. Notes written by the emergency department physician on initial examination read CROUPY FEMALE course breath sounds with wheezing….mild bilateral tympanic membrane hyperemia. Chest X-ray reveals bilateral infiltrates. Medication prescribed included Tylenol (acetaminophen) 325 mg orally for elevated temperature, Bronkephrine (ethylnorepinephrine hydrochloride) 0.1 millimeter subcutaneous and monitors results. Nurse Slighta Hand, RN (fictitious name) administered the medication as ordered and the child was observed for thirty minutes. Miss Hand's charting was brief, almost illegible and read…..Medicines given as prescribed. Cindy observed without positive results. Physician notified.
The physician examined the child; notes read that the child had minimal clearing in response to the bronchodilator. The following medications were then prescribed…Elixir of turpenhydrate with codeine one milliliter by mouth, Gantrinsin (sulfisoxazole) milliliters and Quibron (theophylline-glycerol guaiacolate) milliliters.
Nurse Slighta Hand, RN charted the medications were given as prescribed. Her note at 11:08 p.m. read, vomiting….unable to retain medicine. Respiration increased (54), temperature 101.4 F wheezing with increased difficulty breathing. No further notes were made regarding Cindy's condition on the emergency department record by the nurse, except to state that at 12:04 am child released from emergency department.
Thirty minutes after discharge from the emergency department, Cindy Black was brought back to the hospital. This time her vital signs were absent, her skin was warm without mottling and the pupils of the eye were dilated but reacted slowly to light. Cardiopulmonary resuscitation was instituted without success, and Cindy Black was pronounced dead. Departure from professional standards of nursing care…
In every nursing malpractice case the defendant nurse's conduct is measured against that of a reasonably prudent nurse under the same or similar circumstances. Departure from the professional standards of nursing care for the first admission to the emergency department included the following deviations….
Failure to assess Cindy Black comprehensively upon discharge
Failure to assess the patient systematically for the duration of the emergency department visit
Failure of Miss Slighta Hand, RN to inform the physician that the patient did not improve after treatment Legal implications…
Analysis of the legal implications of the various nursing actions which would affect the outcome of a lawsuit includes monitoring the patient's condition and reporting changes therein to the physician, failure to communicate pertinent observations to the physician and inadequate charting of important information. Monitoring the patient's condition and reporting changes therein is one of the nurse's prime responsibilities. Nurses who fail to record their observations run the risk of being unable to convince a jury that such observations actually were made. Nurses must constantly evaluate a wealth of information and results and as soon as they become aware of any significant medical data, dangerous circumstances, or a dramatic worsening of the patient's condition ….they are required to communicate this information to the treating physician at once. Their failure to communicate these observations can have disastrous consequences and will certainly increase the chances for malpractice litigation.
Alterations in the nurse's behavior….Children with respiratory problems need skilled and competent nursing care. The symptoms of hypoxemia, a complication of respiratory problems, are often insidious. Frequently, there is peripheral vasoconstriction with accompanying skin color changes. Tachypnea, tachycardia, anxiety, and confusion may ensue. It is the nurse's responsibility to observe, evaluate, and document the patient's condition. In the emergency department, the nurse is the member of the health-care team who has the greatest contact with the patient. Any significant change in the patient's condition, based upon nursing observation, must be promptly communicated to the physician. The nurse should have informed the physician promptly of the 11:08 p.m. observations. These indicated that the child's condition was not improving but was, in fact, deteriorating. Before processing the discharge order, the nurse should have communicated to the physician that the child had failed to improve with treatment and more aggressive therapy would have been followed, possibly including hospital admission.
Conforming to legal standards and high quality care… Nursing malpractice exists because it is human to make mistakes under stress, and nurses must function in a stressful environment. Nursing malpractice can be minimized if the nurse utilizes the nursing process and delivers patient care that conforms to the prevailing professional standards. Fundamental to the nursing process is a complete initial nursing assessment and history, followed by continuous systematic patient assessment.
The initial nursing assessment in the record was incomplete. This assessment of the child should have included such information as follows…
General appearance: height and weight in relation to age, development of the body, color of the skin, posture, facial expression, presence of fatigue or hyperactivity, gait and presence/absence of apprehension
Neurological status…level of consciousness, signs of menigeal Irritation • Vital signs: temperature, respiration (rate, rhythm and character), pulse (rate, rhythm, quality) and blood pressure.
Skin : color, temperature, presence/absence of eruptions, cyanosis, erythema, icterus, petechiae, cysts, trauma and scars
Disease status : breath sounds, presence/absence of congestion and/or distressed breathing, appearance of the tympanic membranes, and appearance of the throat, mouth and nose In addition, the nurse's notes for the entire emergency department admission were inadequate and incomplete. These notes should have reflected the execution of the physician's orders as well as pertinent nursing observations. Acceptable nursing care for children with respiratory problems involves more detailed nursing observations than those in Cindy Black's medical record. A nurse has the knowledge base to make and record the following nursing observations…
• General appearance of the child (every 15 minutes)
• Body temperature (every 30 minutes)
• Pulse rate, rhythm, quality (every 15 minutes)
• Respiratory rate, rhythm, character (every 15 minutes)
• Patency of the airway (at least every 15 minutes, more if in distress)
• Blood pressure (every 30 to 60 minutes)
• Skin color and temperature (every 15 minutes)
• Level of consciousness (every 15 minutes)
• Emesis amount, character and frequency
Communication throughout the nursing process is crucial for the provision of safe patient care consistent with the prevailing professional standard. Spoken communication among all members of the health-care team and especially between nurse and physician for clarifying orders, planning patient care, and reporting significant patient observations is vital to the nursing process. Equally important is written communication by the nurse in the form of prompt and accurate entries in the medical record.