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Nursefriendly.com (homepage) About Us Add URL Contact Us Gifts For Nurses Linking Policy Privacy Policy Search Our Sites Top Nursing Topics: A to Z Nursing Topics About Nursing: Certified Nursing Assistants, CNAs Disabled Nurses Impaired Nurses LPNs, LVNs Registered Nurses Advanced Practice Nurses Clinical Nurse Specialists Nurse Practitioners Ask The Nurse Associations (Nursing) Authors (Nursing) Boards of Nursing Burnout (Nursing) Businesses (Nurse-Owned) Brainteasers Care Plans (Nursing) Careers In Nursing Case Studies (Malpractice) CEUs (Nursing) Commonly Used Drugs Chat (Nursing) Clothes (Nursing) Colleges (Nursing) Consultants, Nursing Current Events, Nursing News Degrees in Nursing Discussions (Nursing) Drugs (Commonly Used) Education (Nursing) Employment (Nursing) Entrepreneurs (Nurse) Equipment (Medical) Forensic Nursing Gifts For Nurses Going Shopping Health & Wellness Health Insurance Healthcare Unions, Nursing Unions, Organized Labor History of Nursing Hospitals, Medical Centers Informatics Nurses Intravenous (IV) & Infusion Therapy Jobs in Nursing Jokes (Nursing) Journals (Nursing) Legal Nursing Consultants, LNCs Long Term Care, Nursing Homes Male Nurses Malpractice Cases Medical Centers, Hospitals Medical Equipment Medical Humor, Nursing Jokes Men in Nursing Nurse Training Nurse Entrepreneurs Nursing Associations Nursing Authors Nursing Burnout Nursing Care Plans Nursing Careers Nursing (CEUs) Nursing Boards Nursing Clothes, Scrubs, Uniforms Nursing Colleges, Schools Nursing Consultants Nursing Degrees Nursing Discussions Nursing Education Nursing Employment Nursing Entrepreneurs Nursing Gifts Nursing Homes, Long Term Care Nursing Informatics Nursing Jobs Nursing Jokes, Medical Humor Nursing Journals Nursing History Nursing Malpractice Cases Nursing News Nursing Pay Nursing Programs Nursing Refresher Courses Nursing Research Nursing Resumes Nursing Salaries Nursing Scholarships Nursing Schools, Colleges Nursing Scrubs, Uniforms Nursing Shoes Nursing Shortage Nursing Stories Nursing Students Nursing Uniforms Nursing Unions, Organized Labor, Healthcare Unions Nursing Wages Paychecks (Nursing) Prescription Drug Indexes Puzzles, Quizzes Relocation Resources Refresher Courses Research (Nursing) Resumes (Nursing) Salaries (Nursing) Scholarships (Nursing) Schools of Nursing Scrubs, Nursing Uniforms Shoes (Nursing) Shopping (Going) on the Internet Shortage (Nursing) State Nursing Boards Student (Nursing) Training (Nursing) Traveling Nurses Uniforms, Scrubs, Nursing Unions (Nursing), Organized Labor, Healthcare Unions Wages (Nursing) Work At Home Opportunities

See also: Medical, Legal Nurse Consultants, Courtrooms, Disability, Discrimination, Employment, Expert Witnesses, Informed Consent, Medical Malpractice, Nursing Practice Acts, Pensions, Search Engines, Torts and Personal Injury, Unemployment, Workers Compensation, Workplace Safety: To receive each case and supporting resources by E-mail weekly, please click here. Subscriptions to the Case of the Week are Free. Each week a case will be reviewed and supplemented with clinical and legal resources from the web. Legal Nurse Consultants and nursing professionals are welcome to submit relevant articles. Please contact us if you'd like to reproduce our material. Summary: Nursing assessment skills are one of our most valuable assets. They allow us to effectively evaluate our patients and communicate significant findings to physicians and other members of the healthcare team. In this case, a pregnant woman with a previous history of miscarriage complained of vaginal bleeding and abdominal discomfort. The assessment performed by the nurse fell negligently short of the required standard of care. The patient was a prison inmate on the evening in question. On arrest and subsequent questioning, she clearly stated that she was pregnant. The woman's medical history would reveal a previous miscarriage had occurred. "The medical term for a miscarriage is an abortion. Most miscarriages start with vaginal bleeding which is initially slight and painless. This is called a threatened abortion, because the pregnancy is threatened by the bleeding. This bleeding is from the mother, and is not fetal blood. About half the time this stops spontaneously and results in no harm to the pregnancy. At this stage, the most useful test is an ultrasound scan (usually done with a vaginal probe). If a fetal heartbeat can be seen, this means that there is a 95 % chance that the pregnancy will proceed normally."2 While in custody, the patient would complain of vaginal bleeding and abdominal discomfort. She claims that she made the nurse aware of this at that time from her cell. She also claims to have made the nurse aware of her previous miscarriage and that her current symptoms were similar. According to the documentation of the event, the nurse responded by taking her pulse and afterwards informing the pregnant patient that she was "menstruating." The nurse did no further assessment nor did she grant the patient's request for a "sanitary napkin." She instructed her to "lay down" and then left. "In such cases, the bleeding progresses, and the uterus starts contracting. This is felt as painful cramps, and the mouth of the uterus (the cervix) opens. This is called an inevitable abortion (because it cannot be stopped). If some of the pregnancy has already been pushed out by the contractions, this is called an incomplete abortion. In patients with a blighted ovum, missed abortion, inevitable or incomplete abortion, the treatment is a uterine curettage (D&C) - a short surgical procedure which is performed to empty the uterus and remove the pregnant tissue."2 It seems incredible that given this presentation, the nurse would not have taken a closer look. With the combination of physical symptoms and patient history, it would be difficult to justify not taking further action. This was exactly the situation the nurse faced when the issue went to trial. You can consider at this point, what if the nurse was unfamiliar with the symptoms and was unsure of what they represented? This is a familiar scenario in nursing situations especially for the recent graduate or even an agency, travelling or floating nurse. It is a basic Nursing rule that if you are unsure, you ask another nurse, a supervisor or call the physician. The nurse in this case did neither or did not document doing so. This applies when: A patient is exhibiting symptoms which are clearly abnormal, but the nurse does not know what they represent. Different symptoms can represent either benign or emergent conditions in different patients. Only the physician can make an informed decision to treat or not treat based on them. In making this decision they rely on accurate and thorough assessments/history given by the nurse. (Had a supervisor or physician been notified in this case, at the very least, responsibility would have been shared among those notified or liability shifted to the physician if no action was taken. In this case the claim of negligence lied solely on the nurse's inactions). It also applies when a nurse (or a patient) is unsure why a patient is receiving a medication or are unsure if the dosage is correct. (Many mistakes are made when physicians are writing orders or when they are transcribed, lives have been saved or lost when nurses did or did not "catch" errors and called the physician to clarify). The patient's abdominal pain would worsen and she was unable to remain laying down. She continued to complain to the nurse about her pain. The nurse took no further action other than to inform the patient she would be transferred to another cell for being noncompliant. Early in the night the patient would have a miscarriage in her jail cell. The patient would sue the nurse and the facility for failure to provide reasonable and adequate medical care. The nurse would move to have the charges dismissed. The court on review instructed that the issue go to trial. Questions to be answered: Were the assessment and response rendered by the nurse adequate for the complaints and symptomatology presented? Was a duty owed to the patient by the nurse to provide a higher standard of care than was administered? The court clearly recognized that a pregnant patient with active vaginal bleeding and abdominal pain could have presented a medical emergency. Follow-up assessment and further action on the part of the nurse was not a matter of Nursing "judgement," it was mandatory. It noted that the woman was in fact in the early stages of a miscarriage and gave a classic symptomatology & presentation. "Bleeding and cramping are the most common symptoms of miscarriage. Pregnant women with these symptoms should consult their physicians immediately. A physical examination, ultrasound testing and blood tests gauging hormonal levels are used to ascertain whether the fetus has been miscarried"3 The court observed that according to the documentation of the event, the nurse assessed her condition and made decisions based on the single taking of a pulse. In assessing the abdominal pain of a actively bleeding pregnant patient, standards of care as defined by the state Nurse Practice Acts would clearly have dictated a more detailed assessment and physician notification. The nurse whether inexperienced with the situation or indifferent towards the patient's symptoms was clearly negligent. Prudent assessments including a blood pressure, auscultation of bowel sounds & fetal heartbeat, location/duration of abdominal pain, temperature, and respirations were omitted from her evaluation. No physician (or applicable supervisory) notification of the possible medical emergency was made. There was no question that the "prudent nurse," that is an average nurse in the same situation, would have taken more thorough steps to assess the situation and evaluate the patient's condition. By failing to take appropriate actions, the nurse allowed a potentially life-threatening condition to go untreated. It is worthy of note here that complaints against the nurse's license would be expected (either by the plaintiff or the facility later). If the facility was compelled to defend the nurse under an existing employer's malpractice policy, it is likely that a subrogation action could be initiated afterwards. If an award was made because of the nurse's negligence, the hospital could try to recover that amount by suing the nurse as an individual. Filing a complaint and having action taken against the nurse's license, in addition to firing her would strengthen their position. It is certain, that the employer would not defend the nurse against a State Board of Nursing inquiry. A nurse with a separate personal malpractice policy (An average cost today for a 1-3 Million Dollar Policy is near $80/year), would have an attorney hired by the Nurse's insurance company and looking out for his/her interests, not those of the employer. Specific malpractice companies will also provide an attorney if a nurse is called before the State Board of Nursing at no additional fee. This is a benefit you should ask for when obtaining a personal malpractice insurance policy. Related Cases: July 25, 1999: Premature Child of Cocaine Addicted Mother Survives Abortion. Physician Order: Leave To Die? The premature birth of a child under normal circumstances requires highly skilled nursing and medical care if the child is to survive. The birth of a premature child to a known Cocaine addicted mother greatly increased the risks of mortality. In this case, a child intended to be aborted is born alive. When the physician orders that the child be to left to die, it miraculously survives on its own. Were the nurses liable for "following orders?" Hartsell v. Fort Sanders Reg. Med. Ctr. 905 S.W. 2d 944 - TN (1995). http://www.nursefriendly.com/nursing/clinical.cases/072599.htm May 30, 1999: Patient Left Unrestrained, Patient Injured. Nurses Judgement Call The decision to use or not use restraints must be made with caution and good judgement. Their intended purpose must be to protect either the patient or others who may be injured by the patient including the staff caring for the client. The ultimate determination of necessity is left with the physician. Often, the moment to moment necessity is determined by the nurse. In this case a nurse did not feel restraining the patient was necessary. When an injury occurred, the patient sued. Gerard v. Sacred Heart Medical Center - 937 P. 2d 1104 (1997) http://www.nursefriendly.com/nursing/clinical.cases/053099.htm Related Link Sections: Clinical Charting and Documentation, Nurses Notes http://www.nursefriendly.com/nursing/directpatientcare/clinical.documentation.nurses.notes.htm Courtroom Directory: http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/courtrooms.online.htm Direct Patient Care Links http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm Ethics: http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm Medical Legal Consulting Nurse Entrepreneurs: http://www.nursefriendly.com/nursing/ymedlegal.htm Miscarriages, Education & Support, Pregnancy Obstetrics & Gynecology http://www.nursefriendly.com/nursing/directpatientcare/pregnancy.obstetrics.gynecology/miscarriages.htm Nurse Practice Acts http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/nurse.practice.acts.htm Neonatal Intensive Care Unit (NICU) Nurses http://www.nursefriendly.com/nursing/directory/spec/nicu.htm Obstetric Nurses http://www.nursefriendly.com/nursing/directory/spec/obstetric.html Premature Infants, Low Birth Weight Babies : http://www.nursefriendly.com/nursing/directpatientcare/obstetrics/premature.infant.low.birth.weight.baby.htm Sources: 40 RRNL 2 (July 1999) Malpani & Malpani & Cunha. 1998. Getting Pregnant: A Guide To the Infertile Couple. Retrieved August 8, 1999 from the World Wide Web: http://fertilethoughts.net/malpani/Chapter20.htm Medical College of Georgia. May 1996. Miscarriages. Retrieved August 8, 1999 from the World Wide Web: http://www.mcg.edu/News/96features/miscarriages.html The Uniform Resource Locator (URL) or Internet Street Address of this page is http://www.nursefriendly.com/nursing/clinical.cases/080899.htm Send comments and mail to Andrew Lopez, RN Created on August 5, 1999 Last updated by Andrew Lopez, RN on Monday, January 25, 2010

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