The following is from a report that a nurse prepared for a patient’s file to document the steps taken to treat her. The report shows that when a nurse on the team and a resident disagreed as to the treatment called for, the nurse called for another opinion. This type of communication is frequent among medical personnel.
Patty Maloney
Patient Report
(See “Critical Reading” in Chapter 1)
GUIDING QUESTION
How did Maloney and others save a child’s life?
VOCABULARY
The following words are italicized in the excerpt: vital signs, pneumothorax, rupture, resident, attending physician. If you do not know their meanings, look them up in a dictionary or online.
1
Patient: (name), female, age 8, with tumor and disease progression
2
Symptoms at arrival: Child had not eaten much for two days and was withdrawn and uncommunicative.
3
Treatment process: First, we needed to determine if the child was in immediate danger or in need of further medications for pain control. We took her vital signs, which were within the range of normal for her, with a slightly elevated heart rate. Then we interviewed the child’s mother to see if she had administered any breakthrough pain medication during the last 24 hours. We gave the child a short-
COMBINING MODES: If you have already studied illustration, note that illustration is used here to give examples of steps in the process. Also, note that the report uses narration within the process.
4
As a next step, we had a discussion with the doctor in the unit, and we then administered a breakthrough pain medication. We closely monitored the patient’s vital signs, particularly noting if the heart rate came down. We were documenting the signs every hour formally but also checked on the child’s status in the Intensive Care Unit every 15 minutes.
5
During one check, one of our nurses noted that the child looked pale, and her breathing was somewhat shallow. The nurse knew that the child had fragile lungs and felt that she was at risk of the pneumothorax collecting fluid with a possible rupture of the lung lining and collapse of the lung. Following procedure, the nurse immediately alerted the resident, who felt that the child was fine and suggested that nothing but continued observation was necessary.
PAUSE: What do you think will happen next?
6
The nurse disagreed with the resident’s diagnosis and at that point sent another nurse to page the attending physician for another opinion. In the meantime, while waiting for the attending, the nurse called for an x-
7
The child continues in observation in the ICU. Her condition is stable.