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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

Case 6

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, an presence/absence of apprehension

? Neurological status: level of consciousness, signs of menigeal irritation

? Vital signs: temperature, respiration (rate, rhythm, character), pulse

(rate, rhythm, quality), and blood pressure.

? Skin: color, temperature, presence/absence of eruptions, cyanosis,

erythema, icterus, petechiae, cysts, trauma, and scars

? Developmental status

? 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

Case 7

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

Summary:

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.

References

Bernzweig, E. (1996). The nurse’s liability for malpractice. (6th ed.). St.

Louis: Mosby

Creasia, J. and Parker, B. (1991). Conceptual foundations of professional

nursing practice. St. Louis: Mosby

Earnest, V. (1993). Clinical skills in nursing practice. (2nd ed.).

Philadelphia: J. B. Lippincott

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