Improving Quality of Care Through Legal Nursing

2. Mr. Doe was at risk for developing gangrene.

• History of smoking for many years. Refused to quit smoking, disregarding advise from physician providers, nurses, other members of the health care team as well as family members.
• Diagnosis of arteriosclerotic heart disease and hypertension both are a cause of decreased blood flow, thus decreasing oxygen and tissue perfusion.
• Constriction of vessels can occur in a very emotional resident.
• Combative, aggressive behavior (kicked, cursed) could have injured self. There were several reports of injuries: 01-20-89 "hurt self swinging"; 09-30-89 elbow injury; 11-10-90 ashtray incident, hurt self trying to hurt others, thumb injury, required sutures; 01-27-90 son reported "bloody foot".
• Pedal pulse was diminished: This was documented on the admission physical examination on 05-30-89 and in the physician progress notes of 02-05-90, 10-12-90 and yearly physical examination of 06-12-90.
  

3. The nurse's actions were as follows:

• 01-18-90 "No discoloration, no drainage, pedal pulse present". No unusual findings documented.
•  
  01-20-90 "No complaints or discomfort" are noted.
• 01-22-90 "No acute distress noted".
• 01-27-90 "Discomfort right foot, swollen toe, no drainage" and "cool" are noted. There is no comparison made to the left foot. "Slight  discoloration" noted, this takes a trained eye to detect color changes in dark skin. This is not an emergency and placing a note in the physician's log is appropriate depending somewhat on how frequently the physician reads the log.
• 01-28-90: The foot is worse, there was an appropriate assessment done by the nurse, the physician was notified and the patient was sent to the hospital. There is no problem with this prompt action.

4. Other observations and comments in support of my opinion that Mr. Doe received proper care:

• Stable condition repeatedly documented by physician and nurses.
• Good nutritional status, weight maintained.
• Mobility maintained, he was out of bed daily, up for most of the day.
• No decubitus (pressure) ulcers present.
• Hearing Evaluation was done in an attempt to improve communication.
• Occasional infections, appropriately treated and resolved without complications.
• Received periodic foot care by a professional (07-11-89, 09-20-89, 06-27-90), no problems documented.

Conclusion: I cannot correlate the development of Mr. Doe's gangrene with any nursing care provided by Home Geriatric and Rehabilitation Center staff.

If I can be of any further assistance to you, please feel free to call me.

Sincerely,

Amor C. Agdeppa
RN, BSN, CLNC