Mr. Evans, 40 years old, was admitted to the hospital ’ s 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. Th ree months ago he was started on the new biological 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.

During the next 3 days, his condition worsened. He was in severe pain and needed more analgesics. One evening at 9 p.m., it was discovered that his central venous catheter line was out.

Th e registered nurse (RN) notifi ed the physician, who stated that a surgeon would come in the morning to replace it. Th e nurse failed to ask the physician what to do about the IV steroids, antibiotics, and fl uid 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 documented that the client had no urinary output but forgot to report this information to the nurse assuming care responsibilities on the day shift.

Th e client ’ s physician made rounds at 9 a.m. Th e 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 intensive care unit and intubated. He developed severe sepsis and acute respiratory distress syndrome.

1. List all the problems you can fi nd 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’s 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 ?