(Solved):   1. Where did the chain of command break down? Describe the chain of command that the nurse s ...

 

1. Where did the chain of command break down? Describe the chain of command that the nurse should have taken.

2. Who is to blame? Why?

3. What is your take away from this article? will you use it in your clinical experience and future career as a nurse? why or why not?

Compartment Syndrome: Nurses Failed To Report Signs, Symptoms To Physicians, Did Not Initiate Nursing Chain Of Command. In otherwise healthy thirty-nine year- ball. He went to the hospital and was ad- mitted for treatment. Before he left the hospital his injured leg had to be amputated. The Court of Appeals of Texas upheld his lawsuit against the hospital. The Court endorsed the patient's ex- perts' opinions that linked the amputation to negligence by the nurse who cared for him his second through fourth days in the hospital and failure by the nurse's charge nurse on the orthopedic unit to advocate for the patient by initiating the nursing chain of command. Signs/Symptoms Of Compartment Syndrome On his second day on the hospital's orthopedic unit the patient told his nurse he was losing sensation in his injured leg. The nurse checked the leg and found the ulse was weak. Both of those changes, diminished sensation and weakening pulse, pointed to compartment syndrome starting to develop in his injured extremity. According to the Court, these were changes his nurse should have reported to the orthopedist or the hospitalist under a nurse's general legal duty to report any and all significant changes in a patient's health status to the physician. On the fourth hospital day the same nurse was caring for the patient. She fi- Time is of the essence in recognizing and treating nally paged a physicians assistant when the compartment syndrome. Compartment syndrome is not typically present at the time of an injury but devel- ops hours to days later. came back with an alarm- ingly high CK value she recognized as a sign of tissue death. It is critically important that it be recognized and treated swiftly once it is recognized from the signs and symptoms. This patient's ischemic tis- sue injury, muscle necrosis and the amputation were caused by the failure timely to diagnose and treat the compartment syndrome. His nurse knew about and The next day the same nurse cared for a the patient. She found and noted pitting noted decreased sensation, edema the nurse rated as 3+ and the patient reported pain in the leg 8/10. These new and significant changes in the patient's health status were not reported to a physi- cian. Duty to Advocate For Patient When one of the physicians saw the patient on his third day the physician him- self found that the posterior tibial pulse was weak or absent. The physician tried but was unable to obtain a dorsalis pedis pulse with the Doppler. However, when the physician took no further action in the face of these develop- ents the nurse was required to go her narge nurse. Because the pressure in the patient's leg was not de- creased and relieved there longed decrease of blood was significant and pro- flow to the muscles that caused tissue death and the need for amputation. chain of command. Despite the fact the situation called for the immediate attention of a vascular sur- geon the nurse waited four hours for a re- fore she went to her charge nurse with the turn call from the physicians assistant be- ominous lab value and the fact the physi- cians assistant was not responding to her page. Nurses Share Blame With Physicians The hospital's attorneys argued in the hospital's defense that the physicians were to blame for not being more attentive to the patient. Several times during the patient's course before his amputation the physi- cians themselves found signs of developing compartment syndrome and took no appro- priate action. One physician reportedly ordered anticoagulants for the patient which were wholly inappropriate. weaker pulse, pitting edema and significant pain, but for two days failed to report to the physician. under the law different parties with differ- However, the Court pointed out that ent involvements can share responsibility for an unfortunate outcome. When she did phone the physicians assistant he did not respond. Four hours later the nurse went to her charge nurse, who should have initiated the nursing failure to recognize those errors and omis- Even if the physicians themselves were guilty of negligent acts and omis- sions, the nurses can still be faulted for sions and advocate against them and initi- ate the chain of command to have them overruled. Med. Ctr. v. Shelby, 2018 WL 6187437 (Tex. App., November 27, 2018). COURT OF APPEALS OF TEXAS November 27, 2018 con- The charge nurse did not try to contact the physicians assistant's supervising phy- sician and tried only unsuccessfully tact the patient's orthopedist, the hospital- ist, a vascular surgeon and the emergency department physician. At this point the charge nurse had the responsibility to advocate for the patient by going directly to the medical administra- tion of the hospital to get something done. The patient's experts agreed that ap- propriate advocacy by the nurses more probably than not would have prevented the catastrophic outcome.