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?

@ bjaeram....

I have been sued. Not over anything with medication, and bottom line, the renal failure that was not treated with dialysis was what killed the woman.... but myself, the DON, administrator, and weekend charge nurse were sued. It boiled down to charting a few I & Os. The company settled, which made me mad. I was ready to go to court and face the family member who never showed up when grandma was alive, but was all over us like white on rice when she croaked.

It also had a LOT to do with a doc who refused to return faxes and phone calls re: a skin issue (that I will NOT to this day call a pressure ulcer....it looked NOTHING like a decub; I did treatments and skin checks for years.....the closest this came was reactive hyperemia- it blanched- , and a bit of sheet burn from poor protein levels, poor mobility, and actively deteriorating d/t the renal failure).

It really inhaled sharply with pursed lips (:D). And the ibuprofen thing was after the lawsuit.

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oxygen is a drug. i would never, ever have put a visitor on oxygen. as far as leaving the motrin in the room -- if it were clearly labeled, i might have left it near the sink. it was, after all, sent up for the nurse's personal use. doubt i would have suggested to the father that he take it, though.

that's why my wording was very specific. :) "i can't do much if you find some". i did not tell him i'd left it, or to take it .... he may have actually seen me put it down, or found them later. (i had my back to him when i was documenting, and put the tablets on the sink). to this day, i don't know. on purpose :)

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Your damned if you do and damned if you don't ....depending on the NONpatients outcome.

We were told ...you don't treat anyone but your patient. If in doubt send them down to the ER.

My question is....should you take that bp....where would you document your findings...they don't have a chart and it doesn't belong in your actual patients either.?

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Specializes in School Nursing/Med-Surg.

I get that it would be a good idea to direct any visitors to the ED for liability reasons and because it isn't in an RN's scope to diagnose. But my question is, wouldn't the good samaritan act protect a nurse in the examples above? It seems ridiculous for anyone to get angry at a nurse for taking a visitor's VITAL SIGNS. It is crazy for anyone to get in trouble over this - its one of the reasons I'm so sick of the hospital setting. 

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Specializes in Psychiatry, Community, Nurse Manager, hospice.
On 10/17/2011 at 12:01 PM, nerdtonurse? said:

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."

You did the right thing. No good deed goes unpunished.

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Specializes in Psychiatry, Community, Nurse Manager, hospice.

I was visiting my psych patient in her home when her son came in and said he was dying. He was pacing, diaphoretic. I used my pulse oximeter.  His heart rate was around 150 and his SPO2 was normal and he confessed that he had just done meth. He let me call him an ambulance and I stayed with him until they came. 

No bad consequences for me and I have no regrets. But I worked for a community mental health agency that wasn't constantly attacking honest employees.

My philosophy is to do the best you can for everyone, and if you get sued, you can say you did the best you could in the circumstance. 

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On 10/17/2011 at 5:15 PM, AJPV said:

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?

This thread is semi-ancient ? Any way.. When I read this I’m happy that I do my nursing in a country where I don’t feel I have to base my decisions on fear (of being sued). This entire matter should in my opinion be allowed to be handled with common sense and sound nursing judgement. I know that the only way I’d get in trouble as a nurse in this situation, would be if I placed an individual in a wheelchair and carted them off to the ER against their wishes. That would be kidnapping, something I do my best to steer clear off ?

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