1 July 2015 PRACTICAL NURSING COMMITTED TO EXCELLENCE AGM and Annual CLPNM Awards Dinner Held in Winnipeg June 1, 2015
2 2 PRESIDENT Cheryl Geisel LPN BOARD OF DIRECTORS District I Elisa Wiebe LPN District II Vacant District III Rodney Hintz LPN District IV Lindsay Maryniuk LPN District V Jodi La France LPN District VI Patricia Smythe LPN Public Members Darlene Barbe Tricia Conroy Judy Harapiak Diwa Marcelino Susan Swan EXECUTIVE DIRECTOR Jennifer Breton LPN, RN, BN EXECUTIVE OFFICE Vicky Bering Executive Assistant Barbara Palz, HB Com, CGA Business Manager Renata Neufeld, BA (Hons), MPA Consultant, Policy, Process and Communications REGISTRATION DEPARTMENT Carrie Funk, LPN Consultant, Regulatory Services Dina Bering Administrative Assistant CREDENTIAL ASSESSMENT DEPARTMENT Kathy Halligan, BA (Hons), CTESL, CACE Consultant, Credential Assessment PROFESSIONAL CONDUCT DEPARTMENT Cristie Perfas, BScN, RN, MN, GNC (C) Consultant, Conduct PROFESSIONAL NURSING PRACTICE DEPARTMENT Tracy Olson, LPN Consultant, Practice EDUCATION AND PROGRAM EVALUATION DEPARTMENT Michael Roach, BScN Consultant, Education and Program Evaluation ADVERTISING To advertise in the Practical Nursing Journal, please contact: McCrone Publications Inc. Toll Free: Fax: TABLE OF CONTENTS President s Message Registration Renewal Preauthorized Payment Plan /2016 Fee Schedule 10 Legal Issues in Nursing: Assessment 12 Ask a Practice Consultant 16 Wanted: CCP Auditors Continuing Competence Program Audit Report 19 Have You Been Accepted into a Practical Nursing Program in Manitoba? 2015 Office Closure Dates August 3, 2015 September 7, 2015 Fragrance-Free Notice October 12, 2015 November 11, 2015 Office closed 2:00pm December 23, 2015 and re-opens 9:30am January 4, In response to health concerns, CLPNM has a Fragrance-Free Policy and is a scent-free environment. Please do not use scented products while on the CLPNM premises for work, education, appointments, or other business. College of Licensed Practical Nurses of Manitoba 463 St. Anne s Road Winnipeg, MB R2M 3C9 Telephone: (204) Toll Free: Fax: (204) Publications Agreement #
3 3 PRESIDENT S MESSAGE As the newly-elected President of the College of Licensed Practical Nurses of Manitoba (CLPNM) I look forward to upholding the mission, values and duty of the CLPNM in my new role. My name is Cheryl Geisel, and I was elected President of the CLPNM Board on June 1, I am a licensed practical nurse living and working in Dauphin, MB. I was previously employed at our local medical clinic, the Dr. Gendreau PCH in Ste. Rose, MB, and I am currently with the DRHC, with 13 years of nursing experience in medicine, surgery, post-partum maternal care, pediatrics, and geriatrics. I served on the Board of Directors for 2 years prior to my appointment as its President. It is an honour and privilege to serve as President, and I thank the Board for the opportunity. I would also like to thank our outgoing President, Christy Froese, for her three years of service, and for her previous commitment as a member of the Board and various CLPNM committees. Christy s presence, dedication and leadership will be missed. As well, thank you to departing Board member Yvonne Maguet for her service. We look forward to having her expertise on the CLPNM Continuing Competence Committee. I also wish to congratulate our new LPN graduates as they venture forth in their new careers. I invite all new and existing members to consider becoming involved in the self-regulation of the practical nursing profession. Self-regulation is a privilege and responsibility granted to the profession, recognizing that practical nurses are in the best position to hold one another accountable for providing safe and effective care that serves the interests of the public. You can get involved by serving as a CLPNM Board or committee member, by acting as a continuing competence program (CCP) or practice auditor, or even just by attending a CLPNM Quarterly Board Meeting, and/or our Annual General Meeting to vote on motions and share your voice as a member of the profession. It is hard to believe that the 69th Annual General Meeting and Excellence Awards dinner has come and gone. Here are some highlights from the event, which was held at the Viscount Gort Hotel in Winnipeg on June 1, th CLPNM Annual General Meeting Highlights The rules of procedure were presented and approved. Vera Chernecki was the parliamentarian for the proceedings. The Credentials Report was: Voting: 11 Non-Voting: 18 Board Members for the 2016 year were introduced. They are: President Cheryl Geisel LPN District I Elisa Wiebe LPN District II Vacant District III Rodney Hintz LPN District IV Lindsay Maryniuk LPN District V Jodi La France LPN District VI Patricia Smythe LPN Public Members: Tricia Conroy Judy Harapiak Diwa Marcelino Darlene Barbe Susan Swan Annual Report Tony Gauthier CA, of Craig and Ross Chartered Accountants, presented the 2014 audited statements. The 2014 auditor s report was adopted as presented. Cheryl Geisel, LPN
4 4 Previous Wording Approved June 1, Associate Members Associate members shall include the following categories; nonpracticing and honorary members, as defined by registration policies. The current 2.7 would be deleted and replaced with: 2.7 Honorary Members The Board may confer honorary memberships upon any individual, in accordance with Board policies. 3.2 Term of Office a] Subject to subsection 3.3, the term of office of all Board members except the President shall be two years. b] Appointed Board members, who are not members of the College and subject to the Act, may serve indefinite two (2) year terms at the discretion of the Board. c] The President shall provide written notice of his/her intent to seek re-election or intent to resign at the spring Board meeting, 1 year prior to that event. d] The Vice-President s term of office will be determined by the Board upon appointment. 3.2 Term of Office a] Subject to subsection 3.3, the term of office of all elected Board members shall be two years; however, the incumbent may continue to hold office upon completion of a term until a successor is elected or, if required, subject to 3.8, appointed by the Board. b] The President may serve more than one term but not more than three consecutive terms; however, the President may continue to hold office upon completion of a term until a successor is appointed or elected by the Board. c] Before the end of the two year term, the incumbent President shall provide written notice of his/her intent to seek re-election or intent to resign. d] Appointed Board members, who are not members of the College and subject to the Act, may serve indefinite two (2) year terms at the discretion of the Board. e] The Vice-President s term of office will be determined by the Board upon appointment. 3.3 Eligibility to Hold Office a] Registrants on the register of practising licensed practical nurses who are in good standing shall be eligible for election or re-election to the Board, with the following exceptions: i. employees of the College; or ii. individuals who hold office on the Board of a nursing bargaining unit. b] If an elected registrant ceases to be a practising licensed practical nurse, they shall cease to be a member of the Board. c] Board members seeking election to the position of President shall: i. Declare in writing their intention to run for office at the spring Board meeting prior to the annual meeting. ii. Submit a resume. iii. Provide evidence their nomination has been supported by at least three Board members. d] The President shall be eligible for re-election for indefinite terms at the discretion of the Board. e] The Vice-President must be a member of the Board to be eligible for the nominations. 3.3 Eligibility to Hold Office a] Registrants on the register of practising licensed practical nurses who are in good standing shall be eligible for election or re-election to the Board, with the following exceptions: i. Employees of the College; or ii. Individuals who hold office on the Board of a nursing bargaining unit. b] If an elected registrant ceases to be a practising licensed practical nurse, they shall cease to be a member of the Board. c] Board members seeking election to the position of President shall: i. Declare in writing their intention to run for office at the spring Board meeting prior to the annual meeting. ii. Submit a resume. iii. Provide evidence their nomination has been supported by at least three Board members. d] The Vice-President must be a member of the Board to be eligible for the nominations.
5 5 Previous Wording Approved June 1, Meetings d] Written notice of meetings of the Board, stating the business to be transacted, shall be given to each Director not less than fifteen (15) calendar days before the meeting. Notice of any meeting or any irregularity in any meeting notice may be waived by any Director. 3.7 Meetings d] Written notice of meetings of the Board, stating the business to be transacted, shall be given to each Director not less than fourteen (14) calendar days before the meeting. Notice of any meeting or any irregularity in any meeting notice may be waived by any Director. 3.8 Vacancies a] If a Board member resigns, or dies, or is suspended and is removed from the Board, the Board shall declare the office vacated and may appoint a successor, in the manner hereinafter set out, to hold office until the end of the current term of office. b] Vacancies on the Board, so long as a quorum of Board members remains in office, shall be filled in the manner hereinafter set out: i. Vacancies among the officers shall be filled by appointment by the Board of a then incumbent Board member. 3.8 Vacancies Add: e] In the event that the President position becomes vacant before the end of a term; if there is a Vice- President appointed, they shall assume the role of President for the remainder of the predecessor s term. If there is no Vice-President, the Board shall convene and appoint a new President subject to Article 3 of the College By-laws. Delete 3.8 b(iii) ii. If an elected Director is elected to the office of President or Vice-President, the Board shall declare the Director s position vacant and shall order that a by-election be held within the electoral district. iii. If there is a Vice-President, that person shall fill the vacancy in the office of President for the remainder of the predecessors term. iv. A vacancy among the Directors in the first year of the vacating Director s term shall be filled by calling a by-election in the electoral health district from which the vacancy occurred. v. A vacancy among the Directors in the second year of the vacating Director s term shall be filled by appointment by the Board. c] A vacancy that cannot be filled by a member in the electoral health district from which the vacancy occurs; the Board shall fill that vacancy by appointment. d] If vacancies on the Board number such that there is not a quorum of elected Directors remaining, the remaining Board Directors shall be forthwith call an election to fill the vacancies.
6 6 Previous Wording Approved June 1, 2015 Article IV Duties of Officers 4.1 The President a] The President shall preside at all meetings of the Board and the annual or special meetings, within the term elected. The President shall see that all orders and resolutions of the Board are carried into effect. b] The President shall submit a report for the year to the registrants at the annual meeting, and report to the Board, matters which in the interest of the College may be required to be brought to the Board s attention. c] An elected Director could fulfill the President s duties in his/ her absence. 4.2 The Vice-President a] The Vice-President is voted by and from the Board when required by the Board. b] The Vice-President works under the direction of the President. c] The Vice-President performs the duties in the absence or inability of the President. d] The Vice-President performs such duties as may be assigned by the President or the Board. Add: 4.3 Executive Director a] The Executive Director shall be a licensed practical nurse appointed by and responsible to the Board. b] The Executive Director shall: i. Be an ex officio, non-voting member of the Board. ii. Be an ex officio, non-voting member of the College. iii. Be an ex officio, non-voting member of all committees of the College with the exception of the Investigation Committee and the Discipline Committee. c] The Executive Director shall act as treasurer of the College, including: i. Keeping all records of the College, including a record of all meetings of the College and not the Board. ii. Issuing all notices required by statute, by the By-laws, or by resolution of the Board. iii. Having custody of the seal of the College. e] The Executive Director is authorized to prescribe such forms, certificates or other documents as may be required for the purposes of the Act, Regulations, or the By-laws. f] In accordance with 6(6) of The Licensed Practical Nurses Act, the Executive Director may appoint any other staff necessary to perform the work of the College. The Executive Director shall set out the duties and remuneration for these staff in accordance with the policies and guidelines set by the Board. CLPNM Excellence Awards Three LPNs were selected to receive Excellence Awards from the CLPNM Board of Directors. Congratulations to the following award recipients: May Schultz, Maureen Gove and Dianne Kolesar. Nursing Practice Award The 2015 recipient was May Schultz. May has been employed with Actionmarguerite since April of 2011, where she currently holds an internal float position and works on all seven units within the facility. May was nominated by her manager who noted her integrity, commitment to excellence, respect for cultural diversity, and strengths in critical thinking and clinical reasoning.
7 7 Nursing Mentor and Preceptor Award The 2015 recipient was Maureen Grove. Maureen has practiced as an LPN at Middlechurch Home of Winnipeg since 1996, and has been the Minimum Data Set (MDS) coordinator at the facility since February, Maureen was nominated for her role in supporting the adoption and success of the MDS by demonstrating initiative, leadership and a commitment to ongoing learning. Educator Award The 2015 recipient was Dianne Kolesar. Diane is the Nursing Lab and Theory Instructor at Assiniboine Community College. She was nominated by her students who value her approach to teaching, her talent for keeping her students engaged, and her willingness to support them even outside of dedicated classroom hours. Licensed Practical Nurses Foundation of Manitoba (LPNFM) Scholarships The following first-year Practical Nursing (PN) students were awarded LPNFM Scholarships in the amount of $500: Reesa Atnikov Meladie Chaikowsky Stephanie Martel The following second-year PN students were awarded LPNFM Scholarships in the amount of $1000: Reanna Wallcraft Susan Haverstock Yaroslava Lupanchuk The 2015 Nursing Practice award recipient, May Schultz and CLPNM President Cheryl Geisel. The 2015 Nursing Educator award recipient, Dianne Kolesar and CLPNM President Cheryl Geisel. The 2015 Nursing Mentor/Preceptor award recipient, Maureen Grove and CLPNM President Cheryl Geisel. Cheryl Geisel President and former CLPNM President Christy Froese. Cheryl Geisel President, CLPNM Executive Director Jennifer Breton, and former CLPNM President Christy Froese.
8 REGISTRATION RENEWAL It is time once again for registration renewal with the College of Licensed Practical Nurses of Manitoba (CLPNM). The 2016 renewal season opens August 15, 2015, and the administrative deadline for renewal is October 15, It is important to note that active practicing registration expires on November 30, After this date, registrants cannot practice as an LPN unless their license has been approved by the CLPNM for the coming year. The privilege of using the title Licensed Practical Nurse is sanctioned, and as such only those who hold current active practicing registration are permitted to use the designation or work in that capacity. RENEW EARLY! All renewal applications must be assessed and processed by the CLPNM prior to being granted approval. Early renewal will allow the CLPNM time to contact you should there be an issue with your application. A complete 2016 registration renewal application includes: an accurate and completed renewal application via the CLPNM s online registration system; projected practice hours for the period from December 1, 2014 to November 30, 2015; a declaration of participation in the Continuing Competence Program (CCP); full payment of all applicable fees, and full payment of any outstanding amounts owed to the CLPNM. Please note that the CLPNM may contact you prior to approving your renewal to request additional information. All follow-up documents must be received before the administrative deadline of October 15 or late fees will apply. All registrants applying to renew their registration must comply with the CCP requirements. Information regarding the CCP is available on the CLPNM website. Registrants who are required to submit verification of hours and/or who have been randomly selected to participate in the CCP audit will not have their registration renewal approved until the required documents have been received by the CLPNM. It is the registrant s responsibility to ensure these documents, in their entirety, have been received by the CLPNM. October 16, 2015 November 30, 2015 If a complete 2016 registration renewal application, requested documents or requirements (if applicable), and/or the associated fees are not received by the CLPNM by October 15, 2015, late fees will apply ($105.00). Late fees are in addition to the registration renewal fee and are not part of the Preauthorized Payment Plan (PPP) withdrawals. Applications will not be processed and renewals will not be approved until all fees are paid in full. It is the registrant s responsibility to ensure all requirements have been met. December 1, 2015 December 14, 2015 Registrants who have not completed the renewal process in its entirety by November 30, 2015, as per LPN Regulation 22(1), are considered to be in default and are no longer authorized to practice as an LPN in Manitoba. Individuals who practice as an LPN without current registration are subject to an unauthorized practice penalty fee and may be referred to the CLPNM s Investigation Committee for professional misconduct. Registrants who miss the November 30th deadline may reactivate their registration between December 1, 2015 and December 14, Registrants must submit the online renewal application form, provide any outstanding documentation or requirements, as well as pay the following fees:
9 registration renewal fee of $ Administrative late fee of $ Default reactivation fee of $ Unauthorized practice fee (if applicable) of $ After December 15, 2015 Registration is cancelled for all registrants who have not completed the renewal process in its entirety by December 15, The registrant is now considered a former member of CLPNM. If a former member wishes to regain active practicing registration after this date, they must begin the reinstatement process. Verification of Registration Status Registrants can verify their registration status by visiting the CLPNM website and selecting Find an LPN on the homepage. This link will lead the user to the Public Register where all LPNs with active practicing registration can be searched by entering a name or registration number. Employers can verify registration status by accessing the CLPNM s Employer Verification System, also located under the Find an LPN link on the website. Resignations If you are retiring or resigning from the profession for the 2016 registration year, please log into the online renewal system during renewal time and change your status to former member. It is important for the CLPNM to maintain records of retirements and resignations for the purposes of health human resources planning and in the case of a public health emergency. Payment Options Acceptable methods of payment include Visa, MasterCard, Visa debit, money order or debit (in person at the CLPNM office). Cheques and cash are not accepted. Registration renewal applications will not be approved until the required funds have been received by the CLPNM. Any dishonored payments will be subject to an administrative fee. If you are enrolled in the PPP, are in good standing and renew your registration online before October 15, 2015, further payment will not be required. It is the registrant s responsibility to remain informed of any outstanding payment requirements. Receipt Information You can access your receipt for income tax purposes by logging into your profile on the CLPNM website and clicking on the receipts tab. How to Access the Online Registration Renewal System A step-by-step renewal guide will be available on the CLPNM website when the registration year opens August 15, To renew your registration, go to and login using your User ID (registration number) and your password, which remains the same as last year unless you have changed it. If you have been selected for the CCP audit, you will be notified when you login to the online registration renewal system. If you have any questions about renewing your 2016 registration, please contact the CLPNM at (204) , toll free at , or by at 2017 PREAUTHORIZED PAYMENT PLAN Pay your 2017 fees in advance through the College of Licensed Practical Nurses of Manitoba s (CLPNM s) Preauthorized Payment Plan (PPP). This option is available to active practising registrants who wish to pay for upcoming registration fees through automatic bank debit. Automatic withdrawals for 2017 fees will be ten equal payments of $38.85 based on the current annual fee. The payments will begin November 15, 2015 and are withdrawn monthly up to and including August 15, If you are already enrolled in the plan and wish to continue there is nothing you need to do. If you wish to join, a PPP application must be completed and submitted to the CLPNM office in person, by mail to 463 St. Anne s Road, Winnipeg, MB R2M 3C9 or by fax (204) The completed application may also be ed to Application forms are available on the Fee Schedule page of the College website at If you have any questions regarding the PPP, please contact Barbara Palz, Business Manager at ca or (204)
10 /2016 FEE SCHEDULE Amount GST Total Active Practicing Registration Renewal Fee (by Oct 15) $ $18.50 $ Oct 16 - Nov 30 (add late filing administration fee ) $ $23.50 $ Dec 1 - Dec 15 (add default re-activation fee ) $ $29.75 $ After December 15 cancelled (add re-instatement fee ) $ $37.25 $ Application for Enrolment, Active Practising Registration $ $23.50 $ Includes Practising fee of and Initial Enrolment of Graduate Registration Fee $ $5.00 $ Graduate Registration Renewal Fee $ $5.00 $ Student Registration Fee $50.00 $2.50 $52.50 Student Registration Renewal Fee (2nd year) $50.00 $2.50 $52.50 Late filing administrative fee - Grad and student $50.00 $2.50 $52.50 Exam Fee (CPNRE) $ $20.00 $ Late Filing Administrative Fee - Exam $50.00 $2.50 $52.50 DNW - Did Not Write $75.00 $3.75 $78.75 Re-scoring Exam Fee $75.00 $3.75 $78.75 Credential Assessment IEN Credential Assessment $ $21.00 $ Re-assessment fee $ $7.50 $ File extension fee $ $7.50 $ Endorsement (currently registered in another province) $ $15.00 $ Educational Session (required by order of Investigation/Discipline) $ $15.00 $ Unauthorized Practice Penalty $ $25.00 $ Non-Negotiable Transaction Fee $50.00 $0.00 $50.00 Administrative Fees Processing Fee $75.00 $3.75 $78.75 Verifications $75.00 $3.75 $78.75 Appeal of Registration decision $ $10.00 $ Payment options: Visa, MasterCard, Debit, Money Order Pre-authorized Payment Plan (PPP) 10 payments of $38.85 on the 15th of each month from Nov/15 - Aug/16
12 12 LEGAL ISSUES IN NURSING: ASSESSMENT This article was originally published in CARE Magazine, Fall 2014 issue, by the College of Licensed Practical Nurses of Alberta (www.clpna.com). Reprinted with permission. Article written by: Chris Rokosh, RN, PNC(C), Legal Nurse Consultant and president of CanLNC Incorporated; he is a popular speaker on legal issues in nursing across Canada and in the US. The first article in this series (CLPNM PN Journal, April 2015) included a case study about a medical malpractice lawsuit involving a lack of communication. You may recall 17-yearold Will Johnston whose right tibia was fractured when he was hit by a car. The tibia was successfully repaired, but post-operatively Will developed severe pain in his leg and became confused and irritable. The nurses caring for him documented signs of weakness and changes to the colour, warmth, sensation and movement in his right foot, but they failed to communicate this information to the doctor. Will was ultimately diagnosed with compartment syndrome, had a below-the-knee amputation, and filed a multimillion dollar lawsuit, suing both the nurses and doctors for the loss of his leg. When the nursing care was examined, it was determined that the nurses had failed to meet the standard of care in two key areas: by not communicating important clinical information to the doctor and by not assessing Will s leg according to hospital policy. This article will focus on the issue of nursing assessments; more specifically, medical malpractice lawsuits claiming that the nurse performed inadequate assessments. All nurses are tasked with the responsibility of providing safe, ethical and competent care. We are also responsible and accountable to ensure that our practice meets both professional standards and legal requirements. This requires that patient assessments are done according to doctors orders, current standards of care, best practice guidelines, facility policy, and most importantly according to each patient s individual condition. The court s view is that nurses have a specialized body of knowledge and that they are expected to use critical thinking to respond appropriately to information obtained through their assessments. In some situations, nurses are required to assess patients without the assistance of subjective information, such as during periods of sleep, recovery from anesthesia, in pediatric care or when working with unconscious or mentally compromised patients. But in all situations, the expectation is that if the patient s condition changes, so will the detail and frequency of nursing assessments. This means that you may need to assess patients more frequently if they become unstable or develop complications. Seems pretty straightforward, doesn t it? Many medical malpractice lawsuits include allegations that the nurse did not assess the patient often enough or that they didn t assess them at all. You may be familiar with the saying nothing written, nothing done. Many nurses are. This saying comes from a 1974 Supreme Court of Canada case called Kolesar vs. Jeffries. Although it is often used in reference to a lack of nursing documentation, it s really based on a lack of nursing assessment. The case involved a young man who had a spinal fusion and was returned to the surgical unit in satisfactory condition. The next morning he was found dead. There were no written entries in the medical record between 10 p.m. and 5 a.m. on the morning when his death was discovered. The nurse testified in court that she had measured pulse and respiration rates every half hour over night, and that they were always normal. She just hadn t written anything down. But the absence of documentation led the judge to believe that nothing was charted because nothing was done. This highlights both the importance of performing assessments according to the standards of care, and the necessity of documenting that you have done so. Let s learn more about this issue by examining a case study involving the assessment of a patient on a medical unit. CASE STUDY At 2:30 p.m., a 47-year-old woman named Margaret arrived in the emergency department complaining of a sudden onset of upper abdominal pain, nausea and vomiting. She came to the hospital directly from the airport after spending two weeks at an allinclusive resort in Mexico. Her medical history was significant for hypertension and chronic back pain. She was a smoker and admitted to occasional heavy alcohol use, especially in the past two weeks. Surgical history included a tonsillectomy many years ago, a hysterectomy 6 years ago and dental surgery. Current medications included vitamins, hormone replacement therapy, Tylenol #3 (for back pain), and Labetalol (to control blood pressure). Her vital signs on admission were temperature 37.8 degrees, BP 176/88 mmhg, pulse 90 beats per minute and respirations
13 13 24 breaths per minute. Laboratory tests revealed an elevated white blood cell count and an elevated serum amylase. Her abdomen was tender and slightly rigid. Margaret was diagnosed with acute pancreatitis and admitted to the medical unit. The doctor provided orders for IV fluids, antibiotics, additional lab and diagnostic testing, and consultation with an internist. Margaret was to remain NPO overnight and provided with medication orders to control pain and nausea. Vital signs were ordered as per protocol. At 8:45 p.m., Margaret arrived on the medical unit and was assigned to LPN Amy who was working a 12 hour night shift. Nurse Amy performed an initial physical assessment and completed the admission paperwork. Margaret denied having any pain or nausea. Temperature remained at 37.8 degrees. BP was 168/90 mmhg, pulse was 84 beats per minute and respirations were 22 breaths per minute. Nurse Amy oriented Margaret to her room, reminded her that she was NPO and showed her how to use the call bell. She also gave Margaret a warm blanket, settled her into bed and encouraged her to get some sleep. At 10:20 p.m., Nurse Amy returned to Margaret s room to change her IV bag and check her vital signs. Temperature was now 37.0 degrees, BP was 102/58 mmhg and pulse was 116 beats per minute. Respirations were not measured. Margaret again denied having pain or nausea, but complained of feeling cold. Nurse Amy gave her another warm blanket and encouraged Margaret to use her call bell if she needed anything during the night. Between 11:00 p.m. and 6:00 a.m., Nurse Amy documented that she performed Q1H rounds and that Margaret appeared to be sleeping with quiet, easy respirations. She also noted that the IV was infusing as ordered. Margaret did not ring her call bell or get up to use the bathroom overnight. At 6:15 a.m., Nurse Amy entered Margaret s room to check her vital signs. When Nurse Amy touched Margaret s arm, she noted that her skin felt cool to the touch. Although Margaret opened her eyes when she was spoken to, she did not respond to the questions Nurse Amy asked her. Nurse Amy was unable to obtain a blood pressure or temperature and the pulse felt weak. Respirations were shallow and Margaret was breathing at a rate of 6 breaths per minute. Nurse Amy left the room to get another blood pressure monitor, thinking that the one she had wasn t working right. But she wasn t able to obtain a reading on the second machine either. She then rang the call bell and asked the charge nurse to come to the room. By the time the charge nurse arrived, Margaret had lost consciousness and stopped breathing. At 6:27 a.m., a Code Blue was called. Margaret was resuscitated, intubated and taken to the ICU. Her remaining hospital stay was long and complicated, and included a diagnosis of sepsis, three laparotomies to remove sections of ischemic bowel, pneumonia and a brain injury due to prolonged hypoxia. Fifteen months after her hospitalization, she was still unable to return to work as an accountant and had developed insulin-dependent diabetes. It was uncertain that she would ever be able to return to full-time employment. Margaret filed a lawsuit against the hospital claiming, among other things, that Nurse Amy had failed to assess her vital signs properly during the first night of her admission. Margaret claimed that Nurse Amy was expected to know that a decrease in BP accompanied by a rise in the pulse rate can indicate the onset of shock in a patient with pancreatitis. She also claimed that Nurse Amy was required to communicate the 10:20 p.m. vital signs to the charge nurse or the doctor, alleging that earlier medical intervention could have prevented, or lessened, her injuries. Do you think Nurse Amy met the standard of care? Pancreatitis is an inflammation of the pancreas, the large gland behind the stomach that is responsible for the release of digestive enzymes into the small intestine and the release of insulin or glucagon into the bloodstream. Pancreatic inflammation happens when the digestive enzymes are activated before they are released into the intestine and begin attacking the pancreas itself. The most common causes are gall stones and chronic alcohol use. There are two forms of pancreatitis: acute and chronic. Acute pancreatitis affects approximately one per cent of the population (Lam and Lombard, 1999) and about 70 per cent of attacks are mild. However, of those individuals who develop severe forms of the disease, one in four will die (Forrest et al, 1995). The main symptom of pancreatitis is a sudden onset of abdominal pain in the epigastric region that may radiate to the back and be associated with nausea and vomiting (Alexander et al, 2000). A serum amylase more than four times the upper limit is diagnostic of pancreatitis. Physically, the patient may appear acutely unwell with signs of shock, abdominal tenderness and guarding or rigidity (Henry and Thompson, 2001). The nursing plan of care includes the administration of analgesia, antibiotics and anti-nausea medications, IV fluids, accurate measurement of intake and output, and regular observation of vital signs. In the acute stage, it may be necessary to take the patient s blood pressure, pulse, temperature and respirations every hour and respond to the results accordingly. Signs and symptoms of septic or hypovolemic shock, such as falling BP, rising pulse, lack of urinary output and decreased temperature must be reported immediately due to the risk of injury to the patient. The lawyer representing Margaret in the lawsuit retained a nursing