皮埃尔·居里(PierreCurie)-国立高雄科技大学第一校区.pptVIP

事實 On December 20, 1996, R10, a ventilator-dependent resident at Fairfax suffered respiratory distress and required emergency .one therapist turned off R10s ventilator because the alarm was sounding. Once R10 was stabilized, the therapists left, but neglected to turn the ventilator back on. As a result, R10 died. Fairfax began to develop a policy (vital signs/respiratory status oxygen stats [saturation]/lung sounds/vent settings/level of consciousness/odor color and consistency of secretions comfort level of the resident for the care of ventilator-dependent residents. Q 15 minutes X 4 That policy was completed in February 1997 and was implemented in early March of that year. 事實 R126 was observed to have a low oxygen saturation level, an elevated pulse and temperature, and to be breathing rapidly. R126s physician was called; he ordered a chest x-ray and gave several other instructions. However, contrary to Fairfaxs policy, R126s medical chart did not reflect whether these orders were carried out. R126 died . 事實 On March 5, 1997, R127 was found with low oxygen saturation and mottled extremities. Fairfax staff failed to make a complete assessment, took no vital signs, made no follow-up assessments and did not notify a physician. On March 7, R127 was found cyanotic and required five minutes of ambu-bagging. during the 7 a.m. to 3 p.m. shift, three episodes of respiratory distress were noted, each of which required ambu-bagging, but only observed R127s color and oxygen saturation and took no other vital signs No physician was called. On March 10, R127s skin was observed turning blue, but there was no record of treatment for respiratory distress and no vital signs or assessments were charted. On March 21, R127 had another episode, this time with mottled legs, shaking and a dangerously low oxygen saturation. The physician was present; R127 was ambu-bagged and administered Valium. There was no complete assessment and no follow-up. On March 25, R127 was fo