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Wilma Carpenter was a 55-year-old woman who underwent a total hip replacement surgery.  The surgery seemed to go uneventful.  However, in recovery, she had an epidural catheter placed for pain management following an episode of hypotension.  Kelly, an RN was assigned to the patient and unfamiliar to the floor. Mrs. Carpenter developed a reaction to respiratory therapy, which caused nausea and vomiting.  According to Kelly, Joseph, an LPN, found her blue and unresponsive.  A code was called.  Mrs. Carpenter was intubated and cardiac resuscitation was initiated.  She was transferred to Intensive Care.  Mrs. Carpenter eventually became unresponsive, declared brain dead and taken off the respirator.

Post Operative skills include monitoring, assessment and observation skills (Liddle, C., 2013).  Kelly stated she had assessed the patient, checked IV’s, and questioned her about pain.  She stated the patient as responsive, alert to place and was stable.  It is uncertain whether vital signs or epidural site were assessed. Although she stated a motor and sensory level assessment were done and found fine.


This case shows a lack of communication between the recovery room and the RN, Kelly.  It also states that Kelly had never worked on that unit before and was providing care for the entire floor.  Staffing may not have been adequate. There are also discrepancies, of details, between Kelly and Joseph.  Litigations, in this case, can be on grounds of staffing, scope of practice, standards of care, assessment, communication, and documentation.  A nurse can be held liable for negligence and can face restrictions or revocation of their license (Westrick, S. J., 2014).


Liddle, C. (2013). Principles of monitoring postoperative patients. NursingTimes.Net.  Retrieved from


Westrick, S. J. (2014). Regulation of Nursing Practice.  Essentials of Nursing Law and Ethics. Burlington, MA: Jones and Barlett Learning.

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