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Final Class Project - Case Study Example

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Final Class Project: Nursing Name: University: Textbook Questions 1. Did the lack of documentation affect the ultimate outcome of this case? Documentation plays an important role of providing and communicating vital patient information among different health care service providers…
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Final Class Project

Download file to see previous pages... To add on this, it is through documentation that patient response is reflected. On the contrary, the current case lacks documentation from the patient nurse. Here, the nurse testifies that she only had handwritten notes. Furthermore, in her testimony, the nurse says that she did not document any vital signs during the 2 hours of being informed by the patient’s wife and the time the patient is pronounced dead (Guido, 2009). Evidently, the case lacks documentation and this is likely to affect the final outcome. 2. Was negligence there on the part of the nursing staff in the care of this patient? In the case under study, it is evident that the nursing staff showed negligence in the course of duty. The patient nurse is negligent due to failure to document information on the patient. In her evidence, she testifies that she did not have any documented records on vital signs between the time of being informed and the time the patient is pronounced dead (Guido, 2009). As such, it is clear that no information was available on what went on during the 2 hour period. Additionally, the nurse failed to assess and monitor the patient’s situation after she informed the physician that the patient was bleeding. Given that the patient’s health status could change gradually or suddenly, it was vital for the patient nurse to keep monitoring the situation. On the other hand, the office nurse failed to act as a patient advocate. Here, it is evident that this nurse did not follow up the case to see if the surgeon responded after she informed him. More so, the nurse does not call to check the patient’s progress (Guido, 2009). She only passes the information to the surgeon and that’s it as far as she is concerned. Consequently, it is evident that the nursing department displays negligence while on duty. 3. How does the obvious contradiction in the testimony between the patient’s hospital nurse and the office nurse and the physician’s account of what happened affect your decision in this case? From the case, there is obvious contradiction between the two nurses’ testimony and the physician’s account. This shows a failure to communicate accurately while on duty. There seems to have been lack of communication between the three and hence all are liable to being sentenced for negligence while on duty. Normally, different nursing departments ought to be in constant communication to find the best way possible of helping the patient. This is not the case here. The patient nurse does not keep in touch with the physician to update him on the patient’s situation. Whereas the patient nurse testifies of having informed the physician of the patient’s condition on time, it takes two hours before the physician responds (Guido, 2009). Essentially, the contradiction indicates failure to communicate by all parties involved. 4. What standards for documentation did the patient’s nurse breach? Standards for documentation in nursing entail provision of patient information for communication purposes. Nursing documentation, as a valuable tool, supports effective communication on the patient’s progress for providers. In this particular case, the patient nurse breached these standards. The nurse fails to document the patient’s progress (Guido, 2009). Furthermore, nurses are responsible for their own actions while on duty. As such, documentation forms part of the responsibility. On the contrary, lack of documentation in the case means that the patient’ ...Download file to see next pagesRead More
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