Dalmane

Abstract: Nurse managers aren't only responsible for their own actions and those of their nurses but also for recognizing and acting on physicians' inappropriate care. Learn from a case where nurses failed to take action throughout a patient's care-and the cost was her life. [Nurs Manage 2000:31 (6):22,24]

One responsibility of nurse managers is particularly complex: You need to guide a nurse when, in her professional judgment, her patient's health and well-being are in jeopardy because the physician is responding inappropriately to the patient's condition.

When a patient's condition deteriorates and the physician's response is inadequate, the nursing supervisor must contact the physician directly. In the absence of appropriate action by the physician, the supervisor has to notify the department head or medical director.

Each hospital has its own chain of command, and managers should consult their hospital regulations, policies, and procedures to find out whom to contact. If a nurse and her supervisor fail to question a physician's actions or fail to consult the physician's superiors to save the patient, they may be liable.

Seeds of doubt

Jane Doe's husband stabbed her several times in the abdomen with a knife. She arrived at the ED with a 1.5 to 2.5 cm stab wound to the right upper quadrant (RUQ). The ED physician's notes revealed that the wound penetrated the abdominal wall and the muscle. The physician determined this by using his finger to explore the wound before he sutured it closed. The physician admitted Jane for overnight observation.

The ED nurses were concerned. They felt the physician should have done more objective testing to evaluate the patient. The ED physician was inexperienced in emergency medicine. No history was taken regarding the size of the weapon.

Should the nurses have taken some action to advocate for the patient's welfare?

Entering the decline

On admission to the ED, Jane's vital signs were: blood pressure (BP) 130/100 to 154/108; pulse (P) 92 to 108; respiration (R) 20 to 24. She was awake and complaining of abdominal pain. At 12:15 a.m., she received antibiotics and Demerol 25 mg for pain. When Jane's pain wasn't relieved, she received Demerol 50 mg at 12:45 a.m. Her BP was 150/110 at this time.

Jane was admitted to the inpatient unit at 2:40 am., complaining of abdominal pain. She was alert/oriented, her skin was dry and warm, and she had swelling in the RUQ of her abdomen. She was anxious and agitated. Her vital signs were BP 130/90, P 96, R 24, and temperature (T) 97.2.

Jane couldn't sleep and complained of pain. Crying, she pulled out the nasogastric (NG) tube. This wasn't reported to the physician or to the charge nurse. Although the physician ordered Demerol SO mg/Vistaril 25 mg q.4h. for pain, the nurses gave the pain medication at 3:15 a.m. and then again at 7 a.m. No further vital signs were taken during the night.

What should the nurses have done in this situation? Did the charge nurse breach any standard of care for supervisors?

Missing the signs

Jane's vital signs were finally taken at the morning change of shift, but no one noted her blood pressure. Her temperature had risen to 99.4, and her pulse to 100. At this time, the physician was notified that Jane had removed the NG tube. The physician saw Jane, didn't insert the NG tube, and ordered a clear liquid diet.

Jane had a quiet morning, but began complaining of pain again about an hour after ingesting a clear liquid diet at noon.

Jane was medicated at 1:30 p.m. that day, and her vital signs were BP 140/100, P 98, R 18, and T 100.5. At 5:30 p.m., she complained of pain and again received Demerol 50 mg/Vistaril 25 mg. No vital signs were taken at that time. At 8 p.m., her vital signs were recorded as T 98.8, P 116, R 24, but no blood pressure was recorded.

Jane complained of sleeplessness and agitation. The LPN observed that Jane was very restless and complained of thirst. At 8:30 p.m., Jane asked for a sleeping pill, and the LPN telephoned the physician for an order. At 9 p.m., Jane received Dalmane and the nurse administered her pain medication again-a halfhour early.

Did this situation create any liability for the nurse or her supervisor?

Adverse reaction

At 9 p.m., when Jane received the sleep medication and the Demerol 50 mg/ Vistaril 25 mg for pain, her pulse was 120 and her BP 100/70. At 9:30 p.m., Jane was still restless and drinking frequently. At 10:15 p.m., the nurse notified the physician of Jane's continued restlessness, thirst, and deteriorating vital signs. The nurse told him that Jane drank more than 2 liters of water in addition to LV fluids, and that her output over the same time period was 400 ml. The physician ordered Vistaril 50 mg LM. stat, then ordered 25 mg of Demerol LM. slat when he was called again at 10:50 p.m. He also gave a telephone order to increase the p.rn. pain medication dosage to Demerol 75 mg/Vistaril 25 mg.

What should the charge nurse have done? Was there any role for the charge nurse's supervisor?

Fatal flaws

Unfortunately, the nursing staff's failure to independently initiate appropriate nursing procedures and the charge nurse and supervisor's failure to question the physician's orders continued through the night.

At midnight, the LPN charted that Jane was alert and oriented, but she had pulled her clothing off and was restless. Jane received pain medication again at 1:25 a.m., and still the nurse took no vital signs.

At 2 a.m., the LPN notified the charge nurse that Jane's urine output was 10 ml for the past 3 hours, and Jane received 150 ml/hr of LV fluids. Nothing else appears in the notes until 5 a.m., when the nursing assistant couldn't obtain a pulse or BP Jane's temperature was 91 .

Jane's vital signs were: BP 58/50, P 74 weak, and R 46. These were the first vital signs since 9 p.m. the previous evening. Her skin was cold and clammy. The charge nurse, nursing supervisor, and physician were notified. The orders: blood work, type and crossmatch, and start a second LV At 7:50 a.m. the nursing supervisor requested transfer to the ICU. Records read, "patient is less responsive and BP is 301?."

At 5:10 a.m., Jane arrested. She was pronounced dead at 8:40 a.m.

About the author

Diane Trace Warlick is in private practice with Hart, Buckley & Wallace, PC, in Dallas, Tex., and is a board member and PastPresident of the American Association of Nurse Attorneys.

Copyright Springhouse Corporation Jun 2000
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