Legal issues essay help?

[blue eyes]

Having trouble with a lega issues paper and woud like to ask if anyone could help me fish out some of these possible legal issues and concepts. I've made a start and have come up with a few points I intend to address - negligence/breach of DOC, consent, I noted there had been a verbal consent, but further down a written consent was taken out AFTER the patient had recieved premed.

(text in brackets are notes made myself)

______

Ms Butt was admitted to Tarella Base Hospital for an elective caesarean section. This was her second pregnancy, she had a three year old who was being cared for by her partner of six years. Ms Butt was a 32 year-old woman who had been diagnosed with diabetes in her early twenties but was relatively well controlled apart from the difficulties that occasionally arose as a result of her excessive weight (she weighed 118 kgs on admission and her height was 150 cms) (pre-existing condition). She arrived to Tarella Base at 1700 hours on the Thursday evening and the caesarean section was scheduled for 0900 hours the following morning. Doctor Scalpel had seen her in his consulting rooms a few days prior to her admission as he was monitoring her diabetes and overall condition. It was he who decided that it was time to deliver the baby at 36 weeks and Ms Butt was quite satisfied with this decision, she had clearly provided her verbal consent.

On the morning of the procedure Ms Butt was prepared for the surgery on the ward. Nurse Wary asked her to complete a written consent form. The patient happily completed the form herself. She had been given a premedication and was duly wheeled to the operating room feeling drowsy, nervous and excited. As nurse Careful was checking Ms Butt's notes in the operating suite he noticed that the consent form had not been witnessed (no witness). He notified doctor Scalpel who was already in one of the operating rooms with another patient. He directed the nurse to "sort it out with the patient". Nurse Careful returned to the patient and pointed to the signature on the consent form and asked if this was her signature. When the patient responded positively nurse Careful signed the witness section of the consent form. A healthy baby girl was delivered at 9.15am by caesarean section.

Ms Butt was in some pain post operatively and she was also frightened that she may rupture her suture line(1). This inhibited her movement considerably, despite the nurses' attempts to get her moving. On the third day post surgery she complained of pain in her right ® leg. Upon examination the posterior area of her calf was red and inflamed. She was diagnosed with a right deep vein thrombosis (DVT), for which she was required to commence anti-coagulant therapy and to maintain strict bed rest(1). She was also fitted with special elastic stockings to both lower legs to maintain an even pressure and to assist the oedema of the right leg. Ms Butt continued to complain of pain in her legs. The pain was so intense that she was ordered very strong analgesia, pethidine 75mgs every 4 hours (? dosage/strength appropriate).

Five days after the surgery nurse Wary went in to wash Ms Butt. The patient again complained of severe pain in her left (L) leg and the nurse decided to give the pethidine (? observtion/assessment not done). Nurse Wary only assisted the patient to wash her back and in so doing did not take the opportunity to observe all of the patient's pressure areas (imp. point). An entry she had written in the patient's notes later that day identified red and bruised buttocks and elbow area. There was no entry of what nursing care had been provided nor the outcome for the patient. Although the nursing care plan had a number of nurses' signatures in the section referring to the completion of pressure area care[.color] (poor note takin?/lacks detail). Ms Butt became despondent with the care provided and made several complaints to staff and her husband, with little result. She believed that the pain in her lower legs could be better controlled (??). She said "that if she were just able to get up and walk around, the pain would improve" (possible reluctance to assist --> re:comments made by nurses). Some of the nurses believed that she was a difficult patient (? have addressed issue in 1201) who made matters worse as "she couldn't possibly have the severe pain she keeps complaining about!!!" Ms Butt overheard them discussing her reluctance to move and comments about her size, on several occasions. She felt dreadful and pleaded with the nurses to allow her to at least have a shower on the sixth day of her admission (been on bed rest). At this time when her elastic stockings were removed her entire (L) heel was black and necrotic (picked up earlier, assessment of patient/notes details).

While in the midwifery unit baby Butt showed signs of developing an infection. Dr Sham the paediatrician, ordered some pathology tests but before the results returned the next day she decided to commence the baby on antibiotics (? waited, correct antibiotic). That evening when the unit was particularly busy, nurse Slick asked nurse Slack to check the drug dose ordered by the doctor. Nurse Slack gave the drug chart a cursory glance and then another quick look at the syringe, before nodding her head and stating "that looks fine" (??). Nurse Slick went to the baby's cot and administered the intramuscular antibiotic. Within the hour the baby started to fit uncontrollably and lapsed into a coma. She died the following week. (???)

The autopsy revealed that the baby had been given 10 times the amount of antibiotic and this was the cause of death(imp point). Moreover, the pathology results were negative, as it turned out, the baby did not require the antibiotic. Nurse Slick argued that doctor Sham's handwriting was unclear (vicarious/personal liability). The doctor denied that this was the case and there was disagreement amongst staff as to who was correct. Mr Butt was devastated at the loss of his daughter and required psychiatric treatment for an ongoing period of time after the event.

QUESTION

Consider the material addressed in this unit. Discuss the possible legal issues and options that arise in the above scenario.

[Farkinott, RN]

I REALLY don't envy you! This would make one helluva long essay. There is so much to cover! I would make an appointment to see the course facilitator and find out EXACTLY what they want. I did fairly well at uni but I remember law and ethics was one of the hardest subjects and gave me one of the lowest essay marks I ever had (I barely passed).

I think with so many issues involved that without input from the assessment creator you will be pushing it uphill. Good luck (and I mean it!)

[Katnip, RN]

Wow. I'm sure I'll miss some, but here goes:

1. Nurse asked the patient about signature after pt was medicated.

2. Possible improper pain management in the first place, so pt. would not get moving. (Though I've had enough fights with pts even when they were properly medicated)-Negligence on doctor and nursing staff's part?

3. Failure to asses the pt properly. Did they not take off the stockings to look, for heaven's sake? And did they not do something when they noticed pt's redness? Breach of duty there

4. The baby's antibiotc: the doctor ordered the wrong dose, the nurses are required to be familiar with correct dosage parameters for their patients. Got negligence and breach of duty there I think.

It's been a while since I've done the law and ethics stuff. I forget a lot of the terminology

[blue eyes]

Thanks. This is a 2500w essay +/- 10% - have 655 words alone on negligence, DOC, breach of DOC, damages/loss and reasonably forseeable.

I was going to touch on the left heel becoming black and necrotic, but wasn't sure of what might have caused the necrosis. Would it have been pre-existing condition? Stocking being left on for too long, pointing towards lack of assessment)? Or as a complication of the DVT?

[gwenith, BSN, RN]

Pressure area pure and simple = often (well not if I can help it but still) see them on heels of patients who are lying in bed not moving their legs.

[talaxandra]

Further to cyberjat's note about pain relief - postop patients are reluctant to move unless they have adequate analgesia. Moving hurts! As a ballpark, pethidine should be dosed as 1mg/kg 3-4 hourly (taking age, renal/hepatic function etc into account) You of course then see how effective the dose is, and titrate accordingly. 75mg is therefore a good 40mg short of Mrs Butt's estimated analgesic requirements - of course she'd be reluctant to move!

Fat patients are often not only undermedicated but have less adequate care, particularly regarding mobilisation. The bias against fat patients (partly because of societal prejudices and partly because they are more difficult to turn, assist with ambulation and hygeine, etc) is reflected in the nurses' comments; fat patients who are unwilling to mobilise (even in bed) are lazy or lying; as they can be more difficult for nurses to assist, they are more likely to be left in one position.

Her size and diabetes increased her risk of dehiscence (the suture wound breaking down), so her concern here was not unreasonable - the answer would have been reassurance, better analgesic management, and she should have/may have had tension sutures to reduce this risk. Her risk of DVT would have therefore been diminished, though not eliminated.

As a result of her DVT her mobility was further impaired (bed rest and leg pain). The necrosis is not a pre-existing condition - there's no evidence that the patient was immobile prior to admission. Her pressure area is solely due to inadequate pressure care, it's slow detection contributed to by inadequate hygeine (TED stocking removal) and/or documentation. Her size, pain issues, DVT and diabetes all increased her foreseeable risk of pressure sores - there is no excuse for pressure care not being a priority.

I think it's interesting that all the professionals in this scenario are given names that match their actions (nurses Slack, Slick, Careful and Wary, doctors Scalpel and Sham), and the patient is not named Wronged or Unfortunate but Butts. Coincidence?

Good luck, and keep us posted!

[blue eyes]

thanks for helping.

i've covered negligence issues, law of consent and drug issues: admin of drugs, drug order forms, giving the wrong dosage, failure to check for adverse effects and unclear orders, with confidentiality, discrimination left, and incident report writing left.

[gwenith, BSN, RN]

Lots of luck!!! Hope you get a good mark after all your hard work!

[blue eyes]

Got my assignment back after the exam today - distinction. Lost marks for leaving out the 5 rights of administering medication, verbal (medication) orders/requirements and some arguments did not have enough detail.

[blue eyes]

Got my assignment back after the exam today - distinction. Lost marks for leaving out the 5 rights of administering medication, verbal (medication) orders/requirements and some arguments did not have enough detail.

[eirthjona]

good on you!!!!!!!! :) :) :)

[eirthjona]

good on you!!!!!!!! :) :) :)