Question regarding patient refusal of vital signs & blood pressure meds.

[TheKyleRC]

I work in an environment with mentally ill patients that often refuse to have their vital signs taken for their scheduled blood pressure medication.

These are not elderly petients, however they are adults.

I am curious what the legal policy is behind this idea - I am in California.

As an LVN would you be allowed to give blood pressure medication to a patient when the physican has a specific order stating "Give blood pressure medication even if patient refuses vital signs, notify MD so the patient can be assessed."

The MD is essentially stating to give the blood pressure medication regardless if the patient refuses vital signs or not - This specific patient has refused vitals for 2 weeks in a row now and is still recieving Atenolol.

Is there a legal policy regarding this? As an LVN should I still continue to give the medication? Would any liability fall on to the LVN in this situation, or would the MD take all responsibility by making a order stating to give regardless of v/s? What would you do in this situation?

Thanks for your input!

[AngelicDarkness]

The order specifically says ""Give blood pressure medication even if patient refuses vital signs, notify MD so the patient can be assessed.""? I'm not sure the legal standing on this for California, but I'd educate the pt on taking vitals, if they refuse give the medication and document that they refused vital signs. Then notify the dr per order, and document again.

[Anna Flaxis, BSN, RN]

I would think you'd be covered to a certain extent. In the absence of clinical signs of poor perfusion, I think you'd be safe under your doctor's order.

Vital signs are not the only indicators of poor perfusion. Think about what other things you might notice if a person's blood pressure or heart rate are too low.

You might notice a change in level of consciousness, weakness, dyspnea, and/or complaints of chest discomfort.

If you see any s/s of poor perfusion, then you should hold the med and call the doctor. If the person is functioning at their baseline and s/s of poor perfusion are absent, then it seems to me that it would be safe to follow the doctor's order.

[Anna Flaxis, BSN, RN]

Also remember that there is a reason this person has been prescribed atenolol. The patient will not receive the benefit of the medication if they are not taking it. Lots of people take beta blockers like atenolol and do not check their blood pressure before taking it.

Another thing to consider is rebound hypertension. Now, I'm not sure if this is a concern with atenolol so much, but I have seen it with metoprolol. Rebound hypertension occurs when a person who has been on a beta blocker for a long time stops taking it (maybe they're vomiting and can't keep anything down, or they have trouble getting to the pharmacy for their refill, or any number of things that happen in the real world), and their blood pressure increases rapidly to dangerous levels as a result.

So basically, the doctor has determined that the benefit of taking the atenolol outweighs the risk of not checking BP prior to administration. As the nurse, it's your job to put on your thinking cap and assess the patient, with or without vital signs, for any s/s that might put administering the med into question. In the absence of any of those s/s, you follow the doctor's order. You should be covered as long as your rationale is defensible.

[netglow, ASN, RN]

You say these patients are DX mental health issues. This then would be something that seems to have been addressed in the med orders for this patient. Doc being aware of tendency for refusals, and as others have said thinks it important enough to note. Should the patient become combative, etc spitting out etc that warrants more documentation and another look at the situation by the doc.

What sucks is if nurses weren't so over obligated, we'd have time for a little trust building. Sometimes that's all it takes - mental illness or not.

[shawon]

I think you don't be confused about the patients management. I do assume that the patients is already experienced by Hypertension. So, the doctor advised to give blood pressure medication undoubtedly. If the patients will deteriorated then he/doctor advice to notify MD.

I can not understand one thing that is, you said the patient was mentally ill but why he refused to take BP but how he/she eager to take medication willingly? You too better motivate the patient at your high approach.

[wooh, BSN, RN]

The patient, if not for their psych diagnosis, would be at home taking their bp med. And most patients on bp meds don't check their bp everytime they take their medication. I certainly don't!

Agree with the above, the risk of skipping a dose is greater than the risk of giving it without getting a bp first.

[matilda123]

A patient has the right to refuse medication and/or treatment. It doesn't matter that it is mental health, to force a med against their will is against the law.

[vampiregirl, BSN, RN]

I'm not sure about the legal particulars in California. I just wanted to chime in to encourage you to make sure you've adequately documented - not only that the patient refused, how many times you attempted to take the bp, any reason(s) they offer for their refusal, what education you provided, their response to the education, that (how and when) you contacted the doctor, and if any additional orders were given.

[TheKyleRC]

A patient has the right to refuse medication and/or treatment. It doesn't matter that it is mental health, to force a med against their will is against the law.

This particular patient is on legal Keyhea - he doesn't have a choice on taking the medication because he is not mentally capable of making that decision. He does have the right to refuse vital signs, however.

Thanks for the input guys - Just wanted to make sure my license wouldn't be on the line for being a sheep and following orders blindly.

Makes sense!

[netglow, ASN, RN]

I'll support the OP on that. Those too quick to say illegal need to review psych if you did not have a experience in a true psych facility. You need to review voluntary vs involuntary admission and all the aspects of both. But it still is always going to be a complex issue legally. OP I've ways been interested in psych, but I enjoy reading about it more. Dealing with this pop exhausts me.

[Fribblet]

Often beta blockers are prescribed to help with anxiety.

Not sure if this is the case with this patient, but the dose is often low enough to have a noticeable effect on the heart rate without causing significant changes in the blood pressure.