Expert Witness for Plaintiff in Case Study Three

Qualifications to Render Opinion

I was asked to render an opinion on this case by the plaintiff, by use of my
medical knowledge as a Registered Nurse (RN) and nurse manager on intensive care
units (ICU). Over twenty-five years, I cared for hundreds of bowel resection recoveries.
My comparative patients featured all known complications, including advanced age.
Consistent ICU nursing care is directly preventative of emergent complications.
Reviewed Case Information
While forming my opinion, I reviewed:
1.
2.
3.
4.
5.
6.
7.

Past medical history (PMH) of patient

Reason for admission
Care plan
Abridged chronology of care
Provider orders
Documentation
Patient outcome

Chronology of Facts
Patient care was reviewed, including:
1. Day 1: Hospital admission for rectal bleed. Colon resection performed.
2. Day 2 through Day 7: Expected recovery of colon resection recovery from
four to seven days. Maximum recovery time is explainable by age (Bagnall,
Malietzis, Kennedy, Athanasiou, Faiz & Darzi, 2014).
3. Day 8
a. 1100: Shortness of breath (SOB) in chair. Incentive spirometer (IS)
initiated by nurse without evaluation. Oxygen saturation adequate. No
system assessments of respiratory, gastrointestinal, or neurovascular
systems.
b. 1345: Vomit description characteristic of bile (Abdelrhim & Paul,
2014). Nebulizer given by pulmonologist order without evaluation. No
documented trending for respiratory rate, mental status, or oxygen
saturation. No extra nebulizer treatments were requested. No provider
follow-up coordination. Arterial blood gas draw not indicated due to
lack of monitoring.
c. 1500: High respiratory rate of 47 breaths per minute (bpm) for
unknown duration. No indication of nurse alarming provider.
d. 1725: Colorectal surgeon viewed chart and patient. New order
completed for intravenous fluid bolus (IVF). Vomiting lacked
intervention. No evidence of nurse reporting new manifestations or
recommendations.
e. 1800: Physician viewed unresponsive patient, alone and head back.
Patients in similar recovery are in chair for a maximum of 30-45
minutes, as tolerated (Bagnall et al., 2014). Code called to emergency

personnel.
f. After 1800: Yellowish-brown material impeded intubation and bagmask breathing. Suction unsuccessful. Death by cardiac arrest related
to respiratory arrest from aspiration.
Appropriate Standard of Care
Ideal ICU care includes nurse-initiated continuous high-level vigilance, complex
assessment, and high-intensity interventions with evaluation (Latif, Winters, Berenholtz
& Holzmueller, 2016). Vital signs are taken hourly with continuous focused assessment
upon clinical change. The ICU nurse is required to understand the ultimate developments
of clinical manifestations. Requisite competencies form standards of critical care nursing.
The care violated expectations of clinical judgment, caring practices, and collaboration
(Guido, 2014). Clinical decline progressed linearly without escalating intervention.
Critical thinking failed to approach ICU level with history of adequate clinical inquiry
(Latif et al., 2016).
Opinion
Using my education, training, experience, and provided case information, my
opinion is formed with reasonable probability. The nurse failed to apply the standard of
care, evidenced by records, collaboration, and interventions. SOB indicates respiratory
assessment for diminished air tract and aspiration. Incentive spirometer is not appropriate
for acute SOB (Barry, Marsden, & Stewart, 2013). Arterial blood gases were expected
under doctor order. Intensified monitoring of mental status and oxygen saturation prevent
hypoxia. Repeated vomiting from progressively deeper intestine indicates gastrointestinal
assessment. There was failure to assess for bowel sounds, swelling abdomen, tenderness,
and passing gas. Recovery-related ileus is expected three to five days (Paulson &
Thompson, 2015). The colorectal surgeon would rule out bowel obstruction. Diagnostics
for obstruction include CT-scan or x-ray (Paulson & Thompson, 2015). Insertion of
suctioning nasogastric (NG) tube and nothing-by-mouth is expected for aspiration. IVF
bolus is congruent care for bowel obstruction. The body position would have raised head
at least 30 degrees with bed rest for head support (Bagnall et al., 2014).
Conclusion
My opinion is dependent upon the information provided. Consistently inadequate
nursing care failed to disrupt foreseeable clinical decline, allowing the providers
discovery of overwhelming crisis.
Reference
Abdelrhim, H., & Paul, S. (2014). PO-0668 Recognition Of Bilious Vomiting Or Aspirate
At District Hospital. Archives of Disease in Childhood, 99(Suppl 2), A473-A473.
Bagnall, N. M., Malietzis, G., Kennedy, R. H., Athanasiou, T., Faiz, O., & Darzi, A.
(2014). A systematic review of enhanced recovery care after colorectal surgery in elderly
patients. Colorectal Disease, 16(12), 947-956.
Barry, J., Marsden, S., & Stewart, J. (2013). Incentive Spirometry Use Following
Abdominal Surgery.

Guido, G.W. (2014). Legal & Ethical Issues in Nursing. (6th Ed.). Boston, MA: Pearson
Education
Laity, A., Winters, B., Berenholtz, S. M., & Holzmueller, C. (2016). Improving the
Quality of Care in the ICU. In Surgical Intensive Care Medicine (pp. 861-871). Springer
International Publishing.
Paulson, E. K., & Thompson, W. M. (2015). Review of small-bowel obstruction: the
diagnosis and when to worry. Radiology, 275(2), 332-342.