chapter 3 | Nursing Practice and the Law 376.Describe the where appropriate standards of care may be found. Explain whether each is an
example of an internal or external standard of care.
7.Explain the importance of federal agencies in setting standards of care in health-care institutions.
8.What is the difference between consent and informed consent?
9.Look at the forms for advance directives and DNR policies in your institution. Do they follow
the guidelines of the Patient Self-Determination Act?10.What should a practicing nurse do to stay out of court? What should a nurse not do?
11.What impact would a law that prevents mandatory overtime have on nurses, nursing care, and
the health-care industry?
Case Study to Promote Critical ReasoningMr. Evans, 40 years old, was admitted to the medical-surgical unit from the emergency department
with a diagnosis of acute abdomen. He had a 20-year history of Crohn’s disease and had been on
prednisone, 20 mg, every day for the past year. Three months ago he was started on the new biolog-
ical agent, etanercept, 50 mg, subcutaneously every week. His last dose was 4 days ago. Because he
was allowed nothing by mouth (NPO), total parenteral nutrition was started through a triple-
lumen central venous catheter line, and his steroids were changed to Solu-Medrol, 60 mg, by
intravenous (IV ) push every 6 hours. He was also receiving several IV antibiotics and medication
for pain and nausea.
Over the next 3 days, his condition worsened. He was in severe pain and needed more anal-
gesics. One evening at 9 p.m., it was discovered that his central venous catheter line was out. The
registered nurse notified the physician, who stated that a surgeon would come in the morning to
replace it. The nurse failed to ask the physician what to do about the IV steroids, antibiotics, and
fluid replacement; the client was still NPO. She also failed to ask about the etanercept. At 7 a.m.,
the night nurse noticed that the client had had no urinary output since 11 p.m. the night before.
She failed to report this information to the day shift.
The client’s physician made rounds at 9 a.m. The nurse for Mr. Evans did not discuss the fact
that the client had not voided since 11 p.m., did not request orders for alternative delivery of the
steroids and antibiotics, and did not ask about administering the etanercept. At 5 p.m. that evening,
while Mr. Evans was having a computed tomography scan, his blood pressure dropped to 70 mm
Hg, and because no one was in the scan room with him, he coded. He was transported to the ICU
and intubated. He developed severe sepsis and acute respiratory distress syndrome.
1.List all the problems you can find with the nursing care in this case.
2.What were the nursing responsibilities in reporting information?
3.What do you think was the possible cause of the drop in Mr. Evans’ blood pressure and his
subsequent code?
4.If you worked in risk management, how would you discuss this situation with the nurse manager
and the staff?