Case Outcome 2

Do you think that Nurse Amy met the standard of care?

Pancreatitis is an inflammation of the pancreas, the large gland behind the stomach that is responsible for the release of digestive enzymes into the small intestine and the release of insulin or glucagon into the bloodstream. Pancreatic inflammation happens when the digestive enzymes are activated before they are released into the intestine and begin attacking the pancreas itself. The most common causes are gall stones and chronic alcohol use. There are two forms of pancreatitis: acute and chronic. Acute pancreatitis affects approximately one per cent of the population (Lam and Lombard, 1999) and about 70 per cent of attacks are mild. However, of those individuals who develop severe forms of the disease, one in four will die (Forrest et al, 1995).

The main symptom of pancreatitis is a sudden onset of abdominal pain in the epigastric region that may radiate to the back and be associated with nausea and vomiting (Alexander et al, 2000). A serum amylase more than four times the upper limit is diagnostic of pancreatitis. Physically, the patient may appear acutely unwell with signs of shock, abdominal tenderness and guarding or rigidity (Henry and Thompson, 2001). The nursing plan of care includes the administration of analgesia, antibiotics and anti-nausea medications, IV fluids, accurate measurement of intake and output and regular observation of vital signs. In the acute stage it may be necessary to take the patient’s blood pressure, pulse, temperature and respirations every hour and respond to the results accordingly. Signs and symptoms of septic or hypovolemic shock, such as falling BP, rising pulse, lack of urinary output and decreased temperature, must be reported immediately due to the risk of injury to the patient.

The lawyer representing Margaret in this lawsuit retained a nursing expert to review the medical records and determine whether or not Nurse Amy had met the standard of care. The reviewing nurse discovered that, at 10:20 p.m., Nurse Amy had drawn a small downward arrow next to the blood pressure and a small upward arrow beside the pulse on the graphic record. This indicated that Nurse Amy recognized that the blood pressure had fallen and that the pulse had risen, yet she had failed to reassess the vital signs until nearly 8 hours later. When Nurse Amy was asked why she didn’t reassess Margaret’s vital signs, she referred to the doctors’ orders which said to monitor vital signs as per protocol and the unit policy which said to assess vital signs QID. She said that Margaret had looked tired and unwell at 10:20 p.m. and said that it was important for her to get some rest. She also said that she had never looked after a patient with pancreatitis.

The nurse expert responded that hospital polices provide minimum guidelines for assessment and that doctors’ orders can only be altered if the doctor is made aware of a change in the patient’s condition. She also said that regardless of Nurse Amy’s inexperience with pancreatitis, it is the expected knowledge of all nurses that unstable vital signs in an acutely ill patient can indicate impending decompensation. The nurse expert stated that patients can present as stable, but very quickly become unstable; that there are no hospital policies or doctors’ order that can adequately cover all of the emergency situations that develop on medical units. For that reason, nurses are required to use critical thinking in situations involving the risk of injury and to assess patients more frequently based on their clinical condition. She confirmed that a nurse does not need a doctors’ order or change in hospital policy to assess vital signs more frequently than ordered. Her opinion was that Nurse Amy failed to meet the standard of care by not revising the plan of care to include reassessment of Margaret’s vital signs within 15 to 30 minutes and urgent communication with the charge nurse or the doctor no later than 10:30 p.m. This case settled out of court for an undisclosed amount of money.

Use this case study to spark a conversation on nursing assessment with your colleagues. Note any similarities between this case and the Kolesar vs. Jeffries judgement which sparked the ‘nothing written, nothing done’ saying we’re all so familiar with. Were you able to identify issues with both communication and assessment? How would you rate the level of nursing assessments in your workplace? Have you ever witnessed, or been part of a situation, where a lack of assessment caused a problem? Did the patient suffer as a result? What currently guides your patient assessments? Is it doctors’ orders, hospital policy, what the charge nurse says, the ‘culture’ on your unit or the patient’s clinical condition? What will you do differently now that you know the outcome of this case? Want to learn more? Watch for more articles coming up!

 

Chris Rokosh is a popular speaker on medical legal issues in nursing across Canada and the U.S. She is an RN and founder of Connect Medical Legal Experts, a Calgary-based leader in Expert Witness Services, with a database of hundreds of medical, nursing and cost of future care experts across the country. Explore this website for more information on courses and books on Legal Issues in Nursing and the role of the Legal Nurse Consultant.