Case Studies

In Case Study A the nurse could have acted as a patient advocate at almost every point of
the situation. In the pre op appointment when the mom reminded the surgeon and the RA of the
diabetes insipidus, the nurse could have taken special note of this concern and include a reminder
in the chart/paperwork. When the surgeon told the mom to make sure she told the
anesthesiologist about the patients condition, the nurse could have communicated with the
anesthesiologist beforehand to make sure he knew. It should not have been the patients
responsibility. When the surgery came along and the resident surgeon had to leave, the nurse
could have informed the new fellow about the patients condition and made sure it was a high
priority. After the surgery was finished, the nurse could have written a note along with the
fellows that reminded the future care team of the patients condition. Or the nurse could have
talked to the fellow before he wrote the post op care to remind him to keep a close watch on the
patients electrolytes. In PACU the nurse could have been more vigilant about looking at nursing
notes to watch electrolytes or could have received a better report from the surgical nurse about
special considerations. If the PACU nurse knew about the patients condition, she could have
relayed the information to the floor nurse and that nurse could follow up on getting labs drawn.
Once the patient was out on the floor and the mother provided an intake/output sheet, the
nurse should have taken it seriously and noted the importance of what the mother was providing.
If the nurse would have just listened and not pushed the information aside the whole situation
could have been avoided. The fact that the nurse assumed the physician had noted the important
information was a mistake in the first place. The nurse should have double checked the
physician orders to make sure it was not missed. Also if the patient was visited by the orthopedic
surgeon every day, it left multiple opportunities for the nurse to ask about the DI and double
check his thoughts on what they were doing to keep on top of controlling it.
4 days after surgery when the patient had become withdrawn and had seizure-like
activity, the nurse should have advocated drawing labs right away. If they had known that
patient had DI but didnt know symptoms, they should have educated themselves and researched.
If they had researched and found out that withdrawn was a symptom of hypernatremia, they
could have fixed the problem sooner. Even if someone had performed a chart review earlier, labs
would have been completed and the problem would not have progressed as far. If one nurse
would have brought to the physicians attention to draw electrolytes at any time of the patients
stay, the end result would have been prevented.
When it comes to persons bias interfering with communication, the nurse should have
never assumed that the other care givers knew the patients condition. Assuming that the doctors
were aware along with the other nurses, the patient suffered the consequences in the end and
should not have happened. Also, no one should assume it is another persons responsibility to
pass on crucial information. Every health care provider should take it as their own responsibility
to relay information about a patient that is crucial to their care.
In a best case scenario, this problem would have been fixed in the beginning. If the
orthopedic fellow was made aware of the patients condition, it would have been a cascading

effect down the line. All it took was the nurse to remind the fellow and he could have written for
post op care appropriate to monitor the patients electrolytes. This would have flagged the PACU
nurse to monitor electrolytes, report to the floor nurse about monitoring electrolytes, and to make
it top priority for the rest of the care givers down the line to keep a close watch. If the problem
would have been corrected from the beginning, the final outcome would have been dramatically
different.

In Cases Study C a lack of attention along with assuming led to the patients death. In the
beginning, a better patient history should have been recorded by the nurse. If more details were
given, the Erhlers Danlos syndrome may have been identified. The vital signs in the beginning
looked normal except for the low temperature of 96.0. Also due to the patient being discharged
previously with narcotics withdrawal, this lead the care team to assume the diagnosis was right.
The nurse should have not assumed and thought about the fact that the patient had not gotten
better since the last ED visit, therefore the diagnosis is questionable.
The diaphoresis and paleness could have been due to narcotic withdrawal but is also a
common with a perforated colon. The respiratory rate rising to 20 also is a sign of a bowel
perforation. The nurse should have noted this change in vital signs and brought it to the
physicians attention. Also that the BP was dropping and the observations of ecchymotic areas
over the entire body should have been focused on. The patient was losing blood out of tissues
and blood vessels, therefore dropping the BP which indicates something was going on inside the
body. Also when the physician noted faint bowel sounds with tenderness in the lower quadrants
bilaterally, the nurse should have focused on these observations more carefully.
The white blood count was high indicating there is an infection somewhere in the body,
and should have been looked at more in depth. Also the platelet count was high which is
contraindicated with the patient taking plavix. Looking at both those values together, the nurse
should have realized there was an infection somewhere in the body that also maybe has included
internal bleeding.
When the doctor made the diagnosis or narcotic withdrawal referring to the patients
history, the nurse should have questioned him and brought up the lab results. It was nave for the
physician to take the easy way out and not dig deeper into why the patient was continuing to
have symptoms with no resolution.
Compazine can cause neuroleptic malignant syndrome which is indicated by diaphoresis,
hypotension, pallor and respiratory distress which the patient was experiencing. This medication
could have exacerbated those symptoms and made the patients symptoms worse. Also Clonidine
is used to decrease blood pressure and the last set of vitals was borderline low for blood pressure.
The patient went home on this medication with the health care providers knowing he was already
low in blood pressure which could bottom the patient out. The nurse should have brought this to
the physicians attention.
Personal bias interfered with communication mostly with the prior diagnosis from the
previous ED visit. The physician assumed the last doctor was correct in diagnosing the patient
without looking at the bigger picture. The nurse may have been afraid to question the
physicians thinking and diagnosis. If the nurse would have communicated some of the
important finding such as the lab results and medication reactions, the physician may have
looked deeper into the case.
In a best case scenario, the nurses and physicians would have looked deeper into why the
patients symptoms had not resided since his last visit. Obviously the prior diagnosis and
treatment were not working and something else was going on. If they would have performed a
CT scan or another scan other than just an x-ray, they may have seen the perforation

immediately. If a little more research were to be done, the patient would probably still be alive
in the end.

Term
Diabetes
Insipidus

Hypernatremia

Definition

Scans/lab tests

Medications

An excessive
excretion of dilute
urine caused by
insufficient amount
of ADH. Renal DI
is caused by the
kidneys having a
decreased
responsiveness to
ADH.

Examine for
dehydration
Urine osmolality
will be low
Blood osmolality
will be high
Serum sodium will
be high
Urine Specific
Gravity and Urine
Electrolytes

Aqueous
Vasopressin
Chlorpropamide
Thiazide Diuretics

A condition when
serum sodium
concentration is
>145mEq/L
An excess of sodium
in relation to water
in the ECF
compartment
Results in cellular
dehydration

High Serum sodium

Elevated BUN
High Serum
Chloride
High serum
osmolarity
Elevated urine
osmolarity
CBC, urine sodium,
serum glucose and
protein level, urine
specific gravity also
Abdominal
ultrasonography for
initial diagnosis
CT scan
Abdominal x-ray
MRI
Aortagraphy

Offer fluids
frequently
IV hypotonic
electrolyte solution
Reduce sodium in
diet

Morphine
Fentanyl
Antihypertensives
and/or diuretics

Can be fatal
Can cause clots after
surgery
Can rupture if HTN
is not controlled

Bone scan
Bone biopsy
Blood cultures and
sensitivities

Antibiotics

Chronic infection
Skeletal and joint
deformities
Immobility
Altered growth and
development

Abdominal aortic A localized out

pouching or dilation
aneurysm

of the arterial wall in

the latter portion of
the descending
segment of the aorta.
Most common type
of arterial aneurysm
The arterial wall
becomes weak, and
degeneration occurs.

Osteomyelitis

An infection of
bone, bone marrow,
and the soft tissue
that surrounds the
bone.
Can be caused by a
bacteria, but also
could result from a
fungal/viral

Complications
Mostly in patients
with decreased
mental alertness due
to a decreased
chance of drinking
when thirsty.
Hypovolemia that
may lead to
hyperosmolarity,
loss of
consciousness,
circulatory collapse,
shock, and central
nervous system
(CNS) damage.
Seizures
Cerebral edema
Decrease level of
consciousness
Muscle twitching
Tremors
Rigid paralysis

infection
May be acute or
chronic
Most commonly
occurs in long bones

Endocarditis

Peritonitis

Ehrlers Danlos
Syndrome

An inflammatory
process that affects a
deformed or
previously damaged
valve.
Typically occurs
when an invading
organism enters the
bloodstream and
attaches to the
leaflets of the valves
or the endocardium
Can occur as acute
or a subacute
condition
Inflammation of the
peritoneal cavity
If contamination of
the peritoneum walls
is massive or
continuous, it may
result in peritonitis

A group on inherited
disorders that affect
your connective
tissues, primarily
your skin, joints, and
blood vessel walls
Usually present with
overly flexible joints
and stretchy, fragile
skin

Blood cultures and

sensitivities
CBC
Computed
tomography
Echocardiograms of
different regions
Two-dimensional
cardiac ultrasound
Doppler
Electrocardiogram

Penicillin G
Oxacillin;
gentamicin or
tobramycin
Acetaminophen

Can be fatal
Heart Failure
Embolization
Heart murmur

Elevated WBC
Abdominal and
chest x-rays
Diagnostic
peritoneal lavage
Serum electrolytes
BUN, Creatinine,
hemoglobin,
hematocrit, blood
cultures and
sensitivities
Blood tests
Genetic tests
Extremely loose
joints, fragile or
stretchy skin, and a
family history are
usually enough to
diagnose

Antibiotics
Analgesics

Intestinal obstruction
which can result in
death
Abscess formation,
bacteremia,
respiratory failure
and shock

Pain relievers
(ibuprofen or Aleve)
Antihypertensives

Joint dislocations
Early-onset arthritis
Prominent scarring