23 Apr A 67-year-old client had an epidural catheter inserted for pain management following a total knee replacement.
A 67-year-old client had an epidural catheter inserted for pain management following a total knee replacement. After successful treatment of an episode of hypotension in the postanesthesia care unit (PACU), he was transferred to the medical-surgical unit. The registered nurses assessed the client and delegated direct care to an LPN, although the LPN denied this.
Three hours later, the client experienced nausea and vomiting. The client was found cyanotic and unresponsive 10 minutes later and subsequently died of anoxic encephalopathy. Many facts were disputed among the numerous codefendants and there was poor documentation (Nurses Service Organization, 2012).
Citation: NSO. (n.d.) Nurse case study: Failure to assess and monitor the patient post operatively. (2017). https://www.nso.com/Learning/Artifacts/Legal-Cases/Nurse-Case-Study-Failure-to-adequately-assess-and-monitor-the-patient-post-operatively-resulting-in
What priority assessments were missed, and how could this have been avoided?
What steps of the nursing process were done inappropriately or missed completely, and why?
What steps of the delegation were inappropriate, and why?
What could have been done to prevent this outcome?
