Checking visitor's vitals

Nurses General Nursing

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What would you do in this scenario? A nurse is in a hospital room doing vital signs. The mother of the patient is visiting along with a couple other family members. The mother of the patient comments that she (the mother) isn't feeling great (feeling weak & a little light-headed) and asks the nurse if she can take her BP. She comments that she takes a BP medication. The nurse checks her vitals and everything is A-okay. The nurse tells her the vitals but adds that if she is still not feeling right she should go get checked out by an MD right away. The nurse mentions that the mother could go to the ER, but the mother and family downplay the need for this. The nurse doesn't push the issue further.

Questions... Did the nurse put herself or her hospital at legal risk by her actions? Did the fact that she did not institute an official healthcare agency response (ie, insisting that she go to the ER now, placing her in a wheelchair and escorting her to the ER, or getting the charge nurse or an MD who happens to be on the floor) fall short of what she should have done? Should the nurse have completed an incident report?

Specializes in Cardiac.
I had a family member visiting a post MI patient, and I walked into the room, started my "Hi, I'm Nerd and I'll be your --- sir, do you feel okay?" Pt's son in law was about 300 pounds, smelled like tobacco, sweaty, out of breath, gray. He was saying he was going to drive back home and lay down -- wife asked me to take his BP, and I did, which was thru the roof. We got him into a wheelchair and to the ER, where he was found to be in the middle of a huge MI, and almost coded. Had he got in the car and tried to drive home (about 60 miles), I doubt he would have made it, and might have killed someone on the road with him. I got yelled at for doing vitals, "starting the nurse patient relationship" what if he'd left anyway, they could have sued, etc. I kept saying, "but the guy was having an MI" -- didn't matter. My charge nurse yelled at me, told me if something bad had happened, neither mine or the hospital's insurance would have covered me.

Now, if I saw that going on again, I'd tell the patient, "Okay, we're taking you to the ER to get checked out, get in the wheelchair right NOW."

BTW, the next night patient I was originally going in to see again, the wife (who was the patient's daughter) was there and she hugged me and said, "thanks for saving my husband's life."

Kind of crazy to get yelled at in this scenario. Much better to head off an issue then to have this man collapse in the middle of a patient's room and code. Also, I would think the liability would be high for a nurse to refuse taking some vitals.... if that patient did crash on his way home (etc), then I would think he could come back and sue the nurse for refusing to check.

Specializes in CDI Supervisor; Formerly NICU.
Is this a homework question?

What the heck difference does it make? If your world is shattered by people asking for homework answers, move on down the road to another thread. Getting old seeing all the old iron panty proselytizing about this. No one is trying to cheat you out of anything. And you're no better than a spammer when you answer the post as you did. Jebus, people.

OP: I think the nurse is definitely on shaky ground. I would not have taken the visitor under my care, and would have instead referred her to her MD or the ER.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Although this reeks of homework.:smokin:.....and you are in school...you should be looking this up yourself, with references....but I'll bite.....Here's the Deal.

There are a wide variety of responses here. All of these responses depend on the hospitals individual policy and the person requesting help. If they are ashen, diaphoretic, or dropped in front of you of course you will take their B/P. Many hospitals have "rapid response" teams and in the case that a visitor looks really bad or goes out in front of you, you wold do as for them as your would do for any one who drops dead in front of you.....Call the code/call 911 and begin BLS.....then fill out the code sheet and incident report to document the events up to the calling of the code.

When a patients visitor says they aren't "feeling well, could you please check my......" requires (or is best handled) that you notify someone in charge, at the very least, and filling out an incident/occurrence/variance report to document the incident. It is fine to check the patients B/P but you need to be able to document what you did and what the family member did and that they were advised to go to the ED. Being in the hospital give the facility the obligation of a "full medical screening" and some of the Emergency EMTALA laws apply. While you can't "force them" into a chair and push them to the ED.....there is an "understood" "obligation of treatment" and "medical screening exam" by the hospital to the patient to be. All these laws, rules, and regs will drive you crazy:uhoh3: that is what hospital (or LTC) policy is for....to tell you how to handle these type of situations.

Of course if your facility says that even when a visitor drops dead in front of you you are to escort them to their car.......you need to remember that as a medical professional you are at least obligated by morals if not law, to dial 911 and render BLS assistance. I know that there will be someone with an anecdotal story that their facility doesn't have such policies :icon_roll but they are there....somewhere, even if no one know they are..... and if they aren't......notify JACHO and find another job.

Facilities that I have worked require the notification of the supervisor, ADON, DON, charge nurse, AOC, etc....(whomever is in charge) on call so that if there are ramifications from the visitor they have been notified and you can get the necessary instructions on what to do. Most places I have worked in acute care state that unless the patient is in "immediate distress" the "visitor" is escorted to the ED where such assessment (vitals signs, glucose pulse) can take place. The patient can then be assessed by the triage nurse, registered then from triage can refuse to be seen. The triage process and refusal to be seen is with out charge (doesn't seem right to anyone who's worked triage which I affectionately call the "penalty box") to the patient and the LWBS (left with out being seen or refusal for treatment is signed and they patient is free to go.

If the facility allows bedside B/P's to be taken it usually is specified that some sort of "interaction" documentation occur usually in the form of an incident report to develop a paper trail of the interaction for liability reasons. If the visitor/patient is escorted to the ED for a medical emergency it is for liability reasons that they be escorted by hospital personnel with some medical training (depending on the situation) in case the visitor drops dead in the elevator. So, the not allowing of employees to transport as stated by SkylarW may be because they are a pharmacy tech/student and not a nurse and may be governed by a different set of policies. Once you initiate medical care, even by a B/P, begins the obligation of treatment and liability of the hospital/by the hospital to the patient/visitor and envoke a set of rules and regs that policy and procedures cover. http://www.nursingcenter.com/library/journalarticle.asp?article_id=423284

A complicated answer to a complex question. NUrses are obligated for their actions as well as their non actions which is why I ALWAYS recommend for ALL nurses to carry . For whatever it was worth....I hope this helps :D.

Seriously, it's not homework. But it is amusing seeing how many peoples' undergarments are getting contorted out of suspicion! :lol2: Has nursing education entirely done away with multiple choice tests and switched completely to scenario-based essay assignments?

Anyway, your feedback has been great. This really was based on personal observation and the questions it raised in my mind. Now I would definitely seek guidance from my charge nurse if this happened to me.

Specializes in Gerontology.
Many visitors are old & frail, and under emotional stress. I"ll check their BP, give them some juice and crackers if they're feeling a little weak (then direct them to the cafeteria), whatever.

Possible outcomes:

You check their vitals, WNL, write it down for them & say, "if you're still not feeling well, you may want to f/u with your MD. Don't discuss meds, diet, or anything else. They're fine, they're happy that the staff cares about someone even if they're not being paid to do so.

You check, BP elevated; recommend f/u with MD or ER, depending on severity. After that it's up to them, but at least they are making an informed decision. They say thank you, and make their decision

You don't check...patient and family decide the staff here are caring & unfriendly. Chilling effect on the way they interact with you during their stay. They say so in their surveys, to their friends and neighbors, and maybe on their FB page.

You don't check...30 minutes later family member collapses on the floor, maybe needs CPR. Deep down you wonder if this could have been avoided if that dangerous BP had been noted.

It's much simpler to just check the BP, provide the data and direction, and move on.

5th possible outcome - you check their BP and is it WNL. They are happy. They go home. They have a massive stroke unrelated to BP. The family says "the nurse checked their BP and said is was OK so we went home instead of ER like we planned. It is all her fault." If she hadn't said the BP was OK we would have gone to ER.

You are sued. The hospital is sued.

Specializes in Critical Care.

May I suggest you actually look up the policy at your facility? Your charge may not be aware of how to handle it as well

If you aren't my patient, I don't treat you or assess you or "just" take your BP. Not feeling well? What would you do at the store/bank/park if you didn't have me in the room with you? THAT's what you should do.

I'm a PCT.

I've done it before, maybe I shouldn't have but I have. I see myself doing it again in the future, especially if it's a situation like the one described above where the PT looks horrible and is actually having an MI.

I have a duty to myself to do what I consider the right thing, if in the course of doing the right thing I break a rule or get in trouble, so be it. If I ever got in trouble or fired for taking somebody's vital signs, I wouldn't want to work for that place to begin with. So the split up would be mutual.

I've walked into a pt's room before and there was way too many visitors in there and in the corner I see a kid struggling to breath. How nobody else saw him is beyond me. After some commotion, I'm carrying the kid in my arms and the family is following me. I brought the kid right into a trauma room in the ER, explained why, what, how, and who and after the ER team was working on him I left. I didn't get in trouble, and I'd do it again without hesitating.

For those curious, kid ate a chocolate covered peanut not realizing it was a peanut. Had an allergy.

Yes, I have wanted to choke a visitor :smokin:

Oops, I just re-read it and there is nothing about choking - only checking. Oops!

Specializes in Hospice.

I suspect that the legal question hinges on whether simply taking a bp creates a provider-patient relationship, with all the obligations that go along with it.

If it does, you're twisting in the wind, working without any information about chronic conditions, allergies, medications, etc, that would be contained in a chart.

Question needs to be answered by legal or risk management, I think.

Personally, I decline these requests but question the asker to see if they need to be seen in the ER and make sure they get there if they do.

I agree that it is prudent to look at the possible legal risks. That is the reality of our society. But I also think that is a very sad reality! Why is it that the same visitor can walk into Wal Mart and take their BP on the free automatic machine at the pharmacy and there are no "patient-provider" obligations that magically occur?

1 Votes

When you go to Walmart you are going to a store, not a healthcare institution. You are also choosing to check your own BP - no healthcare "provider" is involved.

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