A nurse is caring for Mrs. W. who is recovering from a cerebral vascular accident and has been making a good recovery. The physician ordered vital signs and neurological checks every four hours. As the nurse is performing her first assessment the patient complains of a headache and had a moment where she forgot where she was. The nurse gives her Tylenol for her headache and goes about the rest of her assessments without documenting her patient’s complaint. Four hours later the nurse returns to her room and finds her unresponsive. Although the nurse followed through with the ordered vital signs and neurological checks, it was also the nurse’s responsibility to continue to monitor after giving the Tylenol as well as notifying …show more content…
According to (Parker, 2014) “failure to identify and intervene in a timely manner on behalf of patients who are deteriorating physiologically has been correlated with an increase risk of death.” He goes further to say, “a nurses main role in patient safety is to function as “an around the clock surveillance system in hospitals for early detection and prompt intervention when patients conditions deteriorate.” (p.159) Nurses do not need a physician’s order to increase assessment frequency or monitoring, we must make a clinical judgement to do these things if we feel our patients’ assessment warrants it. Just as in the example above, the nurse should have followed up with Mrs. W’s complaint by assessing her again after the Tylenol was given, and then monitor her more closely thereafter. Nurses are the eyes and ears of the physician, so when we notice a patient making a turn in the wrong direction it is imperative that the nurse identify, gather data needed and communicate to the physician in a timely manner. Assessment and monitoring of patients plays a huge part in nursing and failing to do so can lead to …show more content…
Rapid response teams (RRT) were implemented in acute care settings to address immediate management of the patient who is declining. Before the nurse is able to activate this system she must first recognize that there is a problem. (Fujita, L. & Hang, S. 2015) says, “ Nurses play a critical role in the viligant detection of patient decline and subsequent treatment to prevent FTR situations. Rapid rapid response teams and adult emergency protocols address immediate management, but persistent decline must be addressed. “ Having a thorough baseline assessment is important if the nurse is to identify a change in patient status. Nurses must also be able to critically think through each situation and make a clinical judgement when it comes time to activate