Реферат: Legal Issues Case Study For Nursing Essay

Case 6

prevailing professional standards. Fundamental to the nursing process is a

complete initial nursing assessment and history, followed by continuous

systematic patient assessment.

The initial nursing assessment in the record was incomplete. This

assessment of the child should have included such information as follows:

? General appearance: height and weight in relation to age, development of

the body, color of the skin, posture, facial expression, presence of fatigue or

hyperactivity, gait, an presence/absence of apprehension

? Neurological status: level of consciousness, signs of menigeal irritation

? Vital signs: temperature, respiration (rate, rhythm, character), pulse

(rate, rhythm, quality), and blood pressure.

? Skin: color, temperature, presence/absence of eruptions, cyanosis,

erythema, icterus, petechiae, cysts, trauma, and scars

? Developmental status

? Disease status: breath sounds, presence/absence of congestion and/or

distressed breathing, appearance of the tympanic membranes, and appearance of

the throat, mouth and nose

In addition, the nurse’s notes for the entire emergency department

admission were inadequate and incomplete. These notes should have reflected the

execution of the physician’s orders as well as pertinent nursing observations.

Acceptable nursing care for

Case 7

children with respiratory problems involves more detailed nursing observations

than those in Cindy Black’s medical record. A nurse has the knowledge base to

make and record the following nursing observations:

? General appearance of the child (every 15 minutes)

? Body temperature (every 30 minutes)

? Pulse rate, rhythm, quality (every 15 minutes)