This case involves a 52-year-old patient who was admitted to the hospital for evaluation of abdominal pain and constipation. Imaging was ordered two days later with the findings being consistent with probable colonic bowel obstruction. Despite the suspicion, the patient was discharged home. Two days later she presented to a different hospital and was admitted for management of possible bowel obstruction. The obstruction was later confirmed by imaging. A general surgeon was consulted who chose to delay surgery, watch, and wait. At that time, the surgeon tentatively scheduled surgery in the next two weeks if her condition did not improve. About a week later, the patient’s condition worsened. The following day, the patient’s condition continued to deteriorate. Her pain was reported as 10/10. The physician was not alerted to the change in status. It is alleged that the nurses failed to consider further workup and delayed the escalation of care. The patient was later found unresponsive with vomit on her gown, and ultimately passed away. An autopsy revealed bowel perforation.
The types of changes in a patient’s condition that should be reported depend on the patient’s situation and stability with attention to any standing physician orders.
Due to the vast amount of patient changes, it is not possible to list every change in a patient’s condition that should be reported. However, aside from the changes in the chief complaint and related symptoms, the following are some of the major changes that nurses should immediately report.
Adverse drug reactions, agitation, bleeding, blood glucose levels, blood pressure, fever, bruising, rash or skin color changes, chest pain or cardiac rhythm change, altered mental status, loss of consciousness and confusion, labored respiration or low oxygen saturation, falls, facial droop and slurred speech, extreme fatigue, loss of body movement or function, weakness, muscle spasms, neurological changes, pain level, skin breakdown including pressure sores and ulcers.
Because every patient experience is different, the nursing staff will normally use their judgment to determine the most effective way to report a deterioration in a patient’s status. Based on the severity of the change, the nurse should also report any specific significant changes as dictated by the doctor’s instructions and orders.
In addition to being time sensitive, the nurse’s report of a changed condition must provide the doctor with adequate information sufficient to determine the appropriate course of treatment. In this case, immediate surgery would likely have been next steps, possibly saving the patient’s life, because the nursing staff is almost always more familiar with the patient’s condition and baseline levels than the doctor. Physicians rely on the proximity and decision making of the nurse to protect their patients. Therefore, the nurse must adhere to protocol, ethics, and orders and report important changes along with pertinent details. In this case a reasonably prudent nurse under similar circumstances would have reported the change in this patient’s pain levels. The duty to report the change was ignored, likely contributing to the patient’s demise.
Expert Witness Q&A
- Briefly, what factors should influence a nurse’s recognition of and response to patient deterioration?
- How might a delay in escalation of care affect prognosis?
- What is the ethical and legal liability of a nurse regarding failure to follow physician’s orders and report significant patient changes?
Expert Witness Involvement
Expert Specialty: Nursing. A nursing expert can opine on the importance of notifying the attending physician to report changes in a patient’s condition and give insight into the repercussions of not following orders and standard of care.