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The Lewis Blackman Case Case Study

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The Lewis Blackman case is an unfortunate case of failure to be ready to deal with unexpected problems, failure to recognize the problem, and failure to respond to the crisis at hand. Clinical warning signs and symptoms were clearly present and even recognized by the healthcare team however, they failed to recognize the significance of the data and correlate it to impending crisis which lead to failure to rescue. There was a presence of understanding the data but a lack of cognitive ability to translate the data into meaningful information to guide decision making efforts. The focus of the team was obviously focused on the fact that the expected and anticipated plan of care for Lewis Blackman only accounted for a favorable outcome…show more content…
Blackman’s complaints, signs, and symptoms were downplayed and eventually he was transferred out of the PACU with no further plan of care, assessment of the issues, or action to alleviate his complaints. 3 days postoperative, with continued scheduled Ketorolac administration, Lewis’ pain was unfathomable. Despite repeated attempts to gain the attention of the healthcare team to Blackman’s impending crisis, his pain was once again downplayed. The nurses again failed to recognize the significance of his increasing abdominal pain and deterioration, chalking it up to gas pain, suggesting only movement and a bath as the acceptable plan of care. Lewis’ symptoms continued to progress and he deteriorated to a state of clinical shock evidenced by abnormally low temperature and increased heart rate and respiratory rate accompanied by extreme paleness, enlarged abdomen, with absent bowel sounds. Inexperience, lack of recognition, and failure to rescue eventually led to the unexpected death of Lewis Blackman (Acquaviva, et al., 2013).
Was the healthcare team ready to care for Lewis Blackman? In this case, it appears that the healthcare team was anchored in the fact that Lewis was a healthy, young man. Because of this they were unable to think outside of the expected outcome. While it is clear that signs and symptoms leading up to Lewis’ critical condition and unnecessary death were recognized the healthcare team appears to have been unable to
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