DHA/712 Version 4 / 1
University of Phoenix Material
Case Study
Mr. Johnson is a 55-year old man who had a lesion detected on his right lung during a chest X-ray for possible pneumonia in the veterans’ affairs (VA) clinic. He was seen by a pulmonary specialist in another clinic and agreed to have his lung biopsied. The specialist and nurse told Mr. Johnson there would be little discomfort after the procedure. Therefore, he would not have to stay overnight.
He was admitted to the short stay unit (SSU) early on 11/1/09 to have a biopsy performed on his lung by a radiologist using guided computed tomography (CT) scanning. He was mildly sedated and transported to the radiology department that morning. He also had an intravenous catheter placed, and cardiac and blood pressure monitors were attached. The radiologist was assisted by a radiology resident. The resident’s role was to document the procedure, monitor Mr. Johnson, and learn. The CT scan assisted in locating the lesion. The radiologist pushed a needle through the chest wall into the lung and aspirated tissue to be tested. After the needle was withdrawn, both clinicians noticed an expected complication: a pneumothorax, or air outside the lungs. The pneumothorax was small—10%, and the partially sedated Mr. Johnson did not complain. After an unexpected 15-minute delay, the transport person moved Mr. Johnson back to SSU, and monitors were attached.
In the next 30 minutes, nobody directly checked Mr. Johnson. During that time, the pulse oximeter alarm was activated repeatedly, but Mr. Johnson learned to silence the machine earlier due to so many false alarms. He was surprised that his chest hurt, but did not want to complain. Soon after, the nurse noticed Mr. Johnson silencing the alarm and grimacing. After checking vital signs and looking at the chart, she asked for an order for a chest X-ray, and she called the radiologist. Blood pressure, heart rate, and respiratory rate were all elevated. The radiology notes were difficult to read, and she remembered that the resident usually dictates his or her notes. Chest X-rays now showed a 30% pneumothorax. A chest tube was placed for 3 days, with Mr. Johnson mainly bedridden. After 2 more days of observation and without further treatment, he was able to return home. It was thought that a delay in placing a chest tube might have only slightly worsened the complication of a progressing pneumothorax.
Immediate Actions:
a) Mr. Johnson was cared for with intravenous fluids, pain medications, and watched closely with a cardiac monitor and pulse oximeter.
b) The records kept in the radiology department were copied.
c) The pulse oximeter was sent to clinical engineering for malfunction testing.
d) The facility director was told about the case on 11/2/09.
Other Useful Data:
a) Patients are usually evaluated every 5 minutes after a procedure.
b) The pulse oximeter was found to have no malfunctioning parts.
c) The SSU was a new concept for this facility and Mr. Johnson signed a consent form.