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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
- Was a duty owed to the patient by the nurse to provide a higher standard
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
http://www.nursefriendly.com/nursing/clinical.cases/080899.htm
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