hypertensive emergency?

CrunchRN, ADN, RN · Jan 26, 2012

I totally disagree. Your only duty is to tell her that her BP is abnormally high and that she needs to report it immediately to her physician.

It is up to her as a competent adult to do that and it is up to her MD to give medical advice.

She is not your child, your ward, or incompetent.

If she asks if she should go to urgent care or ER say sure that is a good idea.

When people blur the lines is when they get into trouble.

Scarlette Wings · Jan 26, 2012

">today i had a student i was teaching who had a bp of 188/124. what would you have done in this situation? she says she recently saw the doctor and had a normal b.p., but is having problems with anxiety and has been prescribed med for anxiety, which she hasn't started yet and doesn't have with her. also that she's being treated now for uti. she said she had no symptoms with her b.p. except for feeling anxious and flushed. i was alarmed, and suggested she go home and either go to urgent care or call her doctor, but she wanted to stay till the end of the day. she didn't want to get her b.p. taken again at all, because it made her more anxious to do that. at the end of the day, i told her if it were me i'd either go some place that could take my b.p. or call my doctor. and i hinted that it could lead to a stroke. every time i brought up the subject, though, she said i was making the anxiety worse. what approach would you have used, and do you think it's something a phone call to the m.d. or a trip to urgent care could've taken care of?

for me there are a great many variables in the situation. these are my thoughts. one is that hypertension often has no symptoms and that is why it is called the silent killer. (that needs to be conveyed since there is mention of no s/s with her blood pressure.) second, i wonder why she allowed the b/p to be taken in the first place to know it was up... but then didn't want any follow up? i keep thinking what is the reason for all the anxiety and why would have it checked again increase that fear? is there more reason to fear getting checked than stroking out?

i also do not understand the relationship of you and the student. are you the school nurse? or a nursing instructor? is the student a minor or adult? what is the relationship and responsibility here? a school nurse has a different responsibility to intervene whereas a teacher with a student may not. just curious i guess as to why the student was so fearful and anxious. my mind wanders to possible abuse or threats.

i know too that patients that tend to run extremely high pressures tolerate higher readings more than if was an acute onset. did the blood pressure cuff fit right? was the equipment calibrated correctly? a uti can cause renal insufficiency and that create a hypertensive crisis. i seem to only have more questions. lol. sorry folks.

trauma_lama, BSN · Jan 26, 2012

I think she's a grownup and can decide what to do with her own health. That said, the s+s assoc with severe HTN and the potential complications make her a liability with patients. I would have said "you don't have to go to the doc but you can't stay here!" and she can't come back until she has some sort of improvement and/or doctor note. It's one thing if she strokes out while writing up her pt in her cli paperwork, but if she strokes out while ambulating a weak pt, THAT is a serious problem. I don't mean to sound cold, but people make their own choices. It's just not alright when they impact other people.

brownbook · Jan 27, 2012

I am certain the elevated BP was accurate, but I hate to see people intervene from one BP reading. I would have asked the student to somehow try to relax. Go to a quiet place, sit for 15 -30 minutes, have a glass of water or juice. Or even get distracted, watch some TV. Then taken another BP. I would have gotten at a minimum 2, and ideally 3 to 4 BP's over 30 to 40 minutes. If they all remained elevated I am not sure what I would do next. As I said, it just isn't good to intervene on the basis of one reading!

KelRN215, BSN, RN · Jan 27, 2012

That would be a good trick, to call the paramedics. But I'm not sure if that would violate the students' rights to call 911 without her permission? Another thing I could've done, since I was in the nursing home, would have been to talk it over with one of the other R.N.s there and see if the student would give permission for that R.N. to give her professional advice (maybe with a scary story thrown in about how a resident had a stroke with a high B.P. like that?), if my advice was being taken lightly and if I couldn't require her to go home. I'm still wondering, though, whether anyone could answer whether an urgent care center can handle such problems, or would they just send such a person straight to the E.R.?

You can call 911 whenever you deem it appropriate. But, anyone over the age of 18 (provided they are conscious and not obviously under the influence of anything) can refuse medical attention when the paramedics arrive and sign a release saying that they refused to be transported to the hospital.

loriangel14, RN · Jan 27, 2012

She is an adult. Really her BP is none of your business.You can give her advice but after that it is up her.

conscientiousnurse · Jan 27, 2012

"i also do not understand the relationship of you and the student. are you the school nurse? or a nursing instructor? is the student a minor or adult? what is the relationship and responsibility here? a school nurse has a different responsibility to intervene whereas a teacher with a student may not. just curious i guess as to why the student was so fearful and anxious. my mind wanders to possible abuse or threats.

i know too that patients that tend to run extremely high pressures tolerate higher readings more than if was an acute onset. did the blood pressure cuff fit right? was the equipment calibrated correctly? "

i am the instructor for these nursing assistant students, and she is an adult. as far as being normally high, she stated the contrary, that her b.p. is normal and was normal at last doctor visit, and that's she's not on b.p. meds.

the cuff may have been slightly small for her, though i didn't measure it to her arm. i have no idea when the cuff was last calibrated, but it was one being used on the unit.

another poster asked about intervening with only one reading. in this case, it was impossible to obtain any further readings, because she refused.

i guess i'm tense about it because i am the teacher there and take care of her in every other way while she's there, so i would feel responsible somehow if she had a stroke or something and i hadn't done the right thing, such as giving her proper info on the reason why it's so important to contact a doctor, or insisting she go home, etc. what is the legal liability, i wonder, in such a situation? and would you recommend writing up some kind of report about this incident to put in her student records?

GM2RN · Jan 27, 2012

Those say that you have no responsibility or that her BP is not your business are being short-sighted. While this might be true if the patient was just your neighbor, for example, it is likely NOT true while you are acting as an agent of the school. I couldn't agree more with the post that counseled you to find out the school's policy and adhere to it strictly, as you may be putting them in a position of liability if you don't. The only thing I would add to that is to get the school's policy in writing so as to cover your own behind if it becomes necessary. I wouldn't rely on anything told to me verbally.

CrunchRN, ADN, RN · Jan 27, 2012

Liability is exactly why you have her report it to the doctor. Then it is out of your hands and into theirs. You could tell her she requires MD clearance to return to school.

I once worked for a hospital risk management lawyer and i learned a lot. Very eye opening. The more you do the deeper you are in and the more liability you are getting yourself into.

All that other stuff like repeat measurements and other advice is just establishing yourself as a care provider which you are not and do not want to do!

GM2RN · Jan 27, 2012

The op can recommend that she report to the doctor, but she can't force her to. However, the op can require that she leave if the school's policy allows it. That's why she needs to find out what the policy is.

Altra, BSN, RN · Jan 27, 2012

That would be a good trick, to call the paramedics. But I'm not sure if that would violate the students' rights to call 911 without her permission? Another thing I could've done, since I was in the nursing home, would have been to talk it over with one of the other R.N.s there and see if the student would give permission for that R.N. to give her professional advice (maybe with a scary story thrown in about how a resident had a stroke with a high B.P. like that

I find this unsettling ... this talk of calling 911 as a "trick" to get the student to get immediate medical attention. But probably not as unsettling as the idea of asking an RN at the facility where these clinicals are being held to assume care of the student. This is completely inappropriate.

You are this student's academic instructor. Period.

I was just reading something about this subject, and it made me think. It says that acute renal failure can be a cause or effect of elevated blood pressure. She says she has a UTI now which has been hard to treat. Hmm...could it be that something wrong with her kidneys now is causing her body to be unable to regulate B.P. and react so strongly to anxiety?
I also still wonder whether it's appropriate in this case to send her to urgent care, or would they immediately send her to E.R.?

It is unfortunate that the student felt the need to share other personal medical information with you. You have no business to know that. And as an adult whose mental status is not currently compromised ... neither you nor anyone else can "send" her anywhere ... it is HER decision whether or not to seek medical attention.

I guess I'm tense about it because I am the teacher there and take care of her in every other way while she's there, so I would feel responsible somehow if she had a stroke or something and I hadn't done the right thing, such as giving her proper info on the reason why it's so important to contact a doctor, or insisting she go home, etc. What is the legal liability, I wonder, in such a situation? And would you recommend writing up some kind of report about this incident to put in her student records?

I wholeheartedly disagree with your perception of your role being to "take care of her in every other way while she's there". You are her instructor. Your relationship extends no further than the instructor-student exchange of information and evaluation of the student's learning process.

As an instructor, what report of an incidental finding of an elevated BP would you like to add to this student's academic record?

If you felt strongly about the BP you could have sent the student home, if it is in accordance with your school's policies to do so, as might be the case if a student was vomiting or febrile, for example. The school might have required medical clearance from the student's physician to be allowed to return, if it is their policy.

NurseOnAMotorcycle, ASN, RN · Jan 27, 2012

I agree with most of what Altra said about the student's choice being her own.

As an instructor, you are acting almost as her NM/supervisor. Could you have sent her to employee health or something similar?

Or as a teacher, set her down in a quiet office with a hot cup of tea for a while?

Sticky business for sure. How far as a teacher should you go, how far as a medical professional? Certainly as a group of nursing instructors, explaining to her family why she went from school to the ED with an aneurysm would be a nightmare in itself.

Either way I'd document the heck out of it and bring the situation up to the higher ups. My friends and I will be arguing this one for days.