Blog

As you read, think about what ‘went wrong’ or ‘what is wrong’ or perhaps just ‘what could be better’. What should have been done to prevent the negative outcome and what could you, as an advanced practice provider/leader, do to improve the outcome? Review the key themes below and use one of those to guide your discussion. If you don’t see one that you would like to use listed, it is fine to choose a different one.
Be sure to come back to these throughout the semester as you learn more. Also, be sure to read through the replies from your peers and interact with each other.
* Note: These are general issues. In other words, you are not expected to be able to diagnose and treat in these cases. Additionally, you are not expected to know if the correct medication and/or dose was ordered. Again, these are general ‘concepts’.
Key Themes:
Advanced practice nurse role
Legal
Ethics (any principle)
Leadership
Healthcare technology
Financial (billing, coding, financial waste in healthcare)
Patient (and/or community) health literacy
Cultural competency
Case Study
The Hospitalist Nurse Practitioner (NP) was called to the ER to see patient for possible admission. The patient is a 72 y/o female who was brought in by her daughter-Jane (who has documentation on file of being the patient’s medical power of attorney)- because patient appeared pale and weak. Jane states that her mother usually walks around a lot “fumbling through things” but over the past few days, she has only been in bed. Jane states that she has been able to get mother to eat, but only a little. Jane noticed that her mother looks more pale than usual. She states that she checks mother’s BP and BG daily and is always WNL. Jane administers her mother’s medicine due to patient’s confusion (secondary to Alzheimer’s). Jane denies any associated manifestations.
According to Jane and previous admission records, patient has history of Alzheimer’s Disease, Coronary Artery Disease (CAD), Type II Diabetes, and Chronic Kidney Disease- Stage II. Current medication includes Donepezil (Aricept) 10 mg po qday, Metformin 500 mg po bid, and Aspirin 325 mg po qday.
PE: Patient is alert, confused. HRR. 68; BP: 118/68; Temp: 97.4; RR: 18; O2 sat: 97%. LCTAB. Abd soft, no masses palpated. No edema. Pulses: 2+ (radial, DP). Skin is dry, intact, pale.
Abnormal Labs: Hgb: 8.0, Hct: 26.4%.; Na: 148
CXR: No acute findings.
Pt has peripheral IV with NS infusing at 75 cc/hr-ordered by ER NP.
The Hospitalist NP writes the following admission orders:
Admit to Med/Surg
Telemetry
VS q 4hr ( Call if Temp > 101; HR >100; RR>28 or < 12; BP < 90/50) Clear liquid diet Fall precautions, Up with assistance SCDs bilaterally NS at 75 cc/hr T&C, transfuse 2 units PRBCs CBC 1 hour post transfusion; CBC and BMP in a.m.; Stool for occult Later, the nurse on M/S unit calls the hospitalist NP to notify him that the patient has advance directive in records that states “No Blood Transfusion”. The nurse called Jane (who had gone home) and she concurred- “No Blood Transfusion.” The NP goes to room to see patient and talks to patient’s cousin who is in the room. He explained that the transfusion would help improve weakness and paleness. The cousin agrees for patient to have it. The NP orders for PRBCs to be given. The next a.m., Jane arrives to the unit and requests update from nurse who informed her of patient’s status overnight and that patient had received 2 units PRBCs. Jane is very upset and requests to speak with administration.