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ELOPEMENT FROM A HEALTH CARE FACILITY
If it is discovered that a patient is missing or has left the health care facility without having said anything about leaving (called “elopement”), the unit must be searched immediately, and the nurse manager, the patient’s physician, and family must be alerted. The police need to be notified if the patient is at risk of harming self or others.
The legal consequences of a patient leaving the facility without medical permission can be particularly severe, especially if the patient is confused, mentally incompetent, or injured or if death from exposure occurs as a result of that absence.
Essential Documentation
The time of discovering the patient missing, attempts to find the patient, and the people notified of the fact must all be documented. The standard form provided by the facility to record patient elopement should be used.
EMERGENCY TREATMENT, PATIENT REFUSAL OF
A competent adult has the right to refuse emergency treatment. The family cannot overrule that refusal decision, and the health care provider is not allowed to give the expressly refused treatment, even if the patient becomes unconscious.
In most cases, the health care personnel who are responsible for the patient can remain free from legal jeopardy as long as they fully inform
the patient about the medical condition and the likely consequences of refusing treatment. The courts recognize a competent adult’s right to refuse medical treatment, even when that refusal will clearly result in death. If the patient understands the risks but still refuses treatment, the nurse should notify the nursing supervisor and the patient’s health care provider.
the patient about the medical condition and the likely consequences of refusing treatment. The courts recognize a competent adult’s right to refuse medical treatment, even when that refusal will clearly result in death. If the patient understands the risks but still refuses treatment, the nurse should notify the nursing supervisor and the patient’s health care provider.
The courts recognize several circumstances that justify overruling a patient’s refusal of treatment. These include instances when refusing treatment endangers the life of another, when a parent’s decision threatens the child’s life, or when, despite refusing treatment, the patient makes statements to indicate the desire to live. If none of these grounds exists, then the nurse has an ethical duty to defend the patient’s right to refuse treatment and also to attempt to explain the patient’s choice to the family, with emphasis on the fact that the decision belongs to the patient as long as the patient is competent.
ACCUCHARTREFUSAL-OF-TREATMENT FORM
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Essential Documentation
When a patient refuses care, it is important for the nurse to document that he or she has (1) explained the care and the risks involved in not receiving it; (2) documented the patient’s understanding of the risks, using the patient’s own words; (3) recorded the names of the nursing supervisor and health care provider notified and the time of notification; and (4) documented that the health care provider saw the patient and explained the risks of refusing emergency treatment.
The patient needs to be asked to complete a refusal-of-treatment form as provided by the health care facility. The signed form requires a witnessed signature. (See Refusal-of-treatment form, page 122). The signed form indicates that appropriate treatment would have been given had the patient consented. If the patient refuses to sign the release form, the nurse’s note should include documentation in the form of writing “refused to sign” on the patient’s signature line and adding the nurse’s initials and date. For additional protection, the facility may also require the patient’s spouse or closest relative to sign a refusal-of-treatment form that indicates who completes it, the spouse or a relative.
END-OF-LIFE CARE
Nurses must meet the physical and emotional end-of-life needs of both the dying patient and those of the family. The dying patient may experience a variety of physical symptoms, including pain, respiratory distress, loss of appetite, nausea and vomiting, and bowel problems. Emotional concerns may include confusion, depression, anxiety, sleep disturbances, and spiritual distress. Nursing interventions should be individualized to the specific needs of the patient. The nurse can also make the death more comfortable and meaningful for the family. These actions may help:
if they want to hear about it, telling the family what to expect
encouraging them to talk to and touch the patient
allowing them to help with care, if they desire
providing them with a comfortable environment
encouraging verbalization of concerns and feelings
determining whether they would like a member of the clergy to visit
Essential Documentation
The nurse should call the provider and document the time and date of notification, the orders given by the provider, and whether the provider visited the patient. The documentation should include the names of others on the health care team who were notified (note the time called and the response).
The nurse should document interventions that were provided to meet the needs of the family, the names of family members, the teaching provided to the family, and their responses. This may be documented on a standardized teaching record provided by the health care facility.
ENDOTRACHEAL EXTUBATION
When the patient no longer requires endotracheal (ET) intubation, the airway can be removed. The nurse needs to explain this procedure to the patient, and the respiratory therapist needs to be contacted to extubate the patient as ordered by the health care provider. The patient needs to be instructed to cough and breathe deeply after the ET tube is removed and needs to be assessed frequently for signs of respiratory distress.
Essential Documentation
On a flow sheet provided by the facility, the nurse should record the name of the respiratory therapist, the date and time of extubation, the presence or absence of stridor or other signs of upper airway edema, breath sounds, the type and amount of supplemental oxygen administered, any complications and required subsequent therapy, and the patient’s tolerance of the procedure. Document patient teaching and support given.
Endotracheal Extubation
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ENDOTRACHEAL INTUBATION
ET intubation involves the oral or nasal insertion of a flexible tube through the larynx into the trachea for the purpose of controlling the airway and mechanically ventilating the patient. Performed by a health care provider, anesthetist, or respiratory therapist, ET intubation usually occurs in emergencies, such as cardiopulmonary arrest, or in diseases such as epiglottitis. However, ET intubation may also occur under more controlled circumstances—for example, just before surgery. In these cases, a consent form will be used and signed by the patient and provider before surgery. The nurse will witness and sign the form to indicate that the patient was given an explanation of the procedure and that the patient verbalized understanding.
ET intubation establishes and maintains a patent airway, protects against aspiration by sealing off the trachea from the digestive tract, permits removal of tracheobronchial secretions in patients who cannot cough effectively, and provides a route for mechanical ventilation.
Essential Documentation
An electronic health record (EHR) will document the indication for the intubation procedure; the success or failure of the procedure will be documented by the health care provider performing the intubation. The type and size of tube, cuff size, amount of inflation, and inflation technique will be recorded by the provider. Information will also be provided by the respiratory therapist, who would also be at the bedside at the time of intubation. The provider or respiratory therapist will indicate whether drugs were administered, and these drugs should be documented on the electronic medication administration record (MAR). Also, the initiation of supplemental oxygen or ventilation therapy will be recorded. The provider or respiratory therapist will record the results of chest auscultation and chest x-ray and note the occurrence of any complications, necessary interventions, and the patient’s response. The nurse can document patient education provided on a teaching record that is provided by the health care facility.
Endotracheal Intubation
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ENDOTRACHEAL TUBE, PATIENT REMOVAL OF
Because an ET tube is used to provide mechanical ventilation and maintain a patent airway, the removal of an ET tube by a patient may be an emergency situation. The patient may not have spontaneous respirations, may be in severe respiratory distress, or may suffer trauma to the larynx or vocal cords.
If a patient removes the ET tube, the nurse needs to stay and call for help and assign someone to notify the health care provider while assessing the patient’s respiratory status. If the patient is in distress, manual ventilation needs to be performed while others prepare for reinsertion of the ET tube and monitor vital signs. If the patient is alert, the nurse needs to speak calmly and explain the reintubation procedure. If the patient is not in distress, oxygen therapy needs to be provided. If the decision is made not to reintubate the patient, respiratory status and vital signs need to be monitored every 15 minutes for 2 to 3 hours, or as ordered by the health care provider. Some facilities also require that an incident report be completed.
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