Assignment
You are a nursing informaticist reviewing documentation of pneumonia patients to improve outcomes. You review the following case in the EHR: 68 year old female admitted to nursing unit with diagnosis of pneumonia and history of heart disease. Temperature at 101° F; blood pressure 148/92; heart rate 96/min (regular rate and rhythm); respiratory rate 28/min; and pulse oximetry 93%. Patient denies pain but complains of increasing fatigue, cough and shortness of breath. The admitting RN documents the initiation of intake and output; daily weights; and vital signs; including pulse oximetry, four times daily.
1) Over the course of the next few days, the RN staff collects pertinent data. Intake and output records reveal an alarming fluid volume overload. Vital signs reveal a decrease in fever but a steady increase in systolic and diastolic pressures, increasing heart rate, and slowly declining oxygen saturation.
2) There is apparently no attempt to analyze the data or report it to the attending physician. Fluid volume overload is not mentioned in the patient record, although the patient's fall risk and skin integrity are noted.
3) No expected outcomes are identified. There is also no mention of the increasing risk of pulmonary edema/congestive heart failure due to increasing fluid volume overload. On the fourth day, the patient develops acute pulmonary edema and is transferred to Intensive Care Unit (ICU).
4) While the prior plan of care included appropriate surveillance activities (e.g. intake and output, daily weights, pulse oximetry and appropriate vital sign monitoring), nothing was done to conduct surveillance at regular intervals or to adapt the plan of care appropriately - i.e., report and control fluid volume overload and report signs of impending heart failure to the physician. In other words, electronic nursing documentation of surveillance activity was haphazard and findings did not lead to appropriate implementation.
5) This case scenario begins and ends with the collection of data. There was no documented professional analysis of the data or diagnosis, nor was a plan of care appropriate to the patient's needs documented.
6) There was no documented coordination of patient care.
7) There was no documented health teaching or health promotion. Patient outcomes (pulmonary edema) could have been prevented had assessment data been correctly analyzed and the diagnosis of fluid volume overload recognized. As it was, the patient was admitted to ICU, appropriate treatment was initiated, and patient was discharged home, but length of hospital stay had been extended and the patient now has a history of congestive heart failure, recent onset.
Task
A. As a nursing informaticist, what other questions would be important to keep in mind? Could this be an issue in other cases?
B. To evaluate data, the nurse informaticist must keep context in mind. Let's say that the case occurred on a COVID-19 ward. Would that influence your action plan?
C. From an informatics perspective, what sort of action plan would you put in place for the original event? Explain briefly.
D. Is this a nursing-only issue?