Taking blood pressure on an agitated patient

[nurselove757]

I'm a new nurse working at a psychiatric facility. One day, an agitated patient refused to get his blood pressure taken. He had 2 blood pressure medications scheduled at 8 pm. I tried 3 times altogether to take his blood pressure, and the charge nurse saw all this happen. I told him that I was putting Refuse in the MAR, and he agreed.The next day when I came back to work, the nurse that took over my patient overnight had a discussion with me. She told me that because this patient had 2 blood pressure medication due, it was extremely necessary for me to take his blood pressure. I told her that I tried several time, but the patient refused his blood pressure to be taken, and I did not want to give him the blood pressure medication because I was worried that I would put him in to a hypotensive state. She told me that in this situation, I should have given a PRN Haldol or Ativan, and when he is more relaxed, then I should have taken his blood pressure.I did not give this patient a PRN because even though he was refusing for me to take his blood pressure, he was not agitated to the point where he was a threat to himself or others. He just wanted to be left alone. Keep in mind that this is a high functioning psychiatric geriatric unit.So my question is this: should I have given him a PRN Ativan or Haldol so I could take his blood pressure? Like I said, I'm a new nurse. I just want to learn. Please tell me what you usually do in this situation in your Psych unit.

[Sammy Mendez]

I know how tough it can be just getting V.S. with psychiatric patients, I to worked in a Psych ward. I found it easier for me to get a pulse, and then do an apical pulse, prior to B/P so if they were noncompliant I would document what I was successful in getting, also I would fax the Psychiatrist and note this in my documentation. It dosen't work all the time, psychiatric patients are very touchy at times. I agree with you on not giving the prn. Patient refusing not to take a B/P w/o s/s of being agitated dosen't mean you have to resolve to this level of care. You stated that you are a new nurse in the ward, perhaps patient isn't comfortable with you yet, and just needs a little more time. Good luck to you.

[Meriwhen, ASN, BSN, MSN, RN]

Many nurses (and I'm not referring to you) tend to forget that psychiatric patients have the same rights as any medical patient. This includes the right to refuse treatment and medications...and yes, this right is there even if the patient is being involuntarily held.

It would take a specific court order or the patient being an immediate danger to himself or others to force treatment or medication on a patient. Being agitated or ticked off alone does not meet criteria for danger to self/others. If the patient is assaultive and throwing chairs at staff, THEN you can give PRNs against their will. If they have a history of HTN and are angry but otherwise no threat, no.

If a patient is competent and refuses VS, you can educate them on why you need to take them and the consequences (i.e., not getting their HTN meds, risks of untreated HTN, whatever) if they don't allow you to. If they still refuse, document all this thoroughly EVERY TIME it happens, and let your charge RN as well as the physician know.

I tell patients that they have the right to refuse but that it is part of my job to continue to come around at the appointed time and offer said treatment/meds, and they can continue refusing if they wish. That way they don't feel as much like I'm nagging them, and I've done the CYA bit. Eventually most thaw after they've refused a few times.

Keep in mind that one thing many inpatient psych patients feel, even voluntary ones, is a loss of control. They're in unfamiliar and restrictive surroundings, with a lot of the little things that they've taken for granted in life limited or not allowed. Sometimes all patients want is to feel like they have some control or say in the situation. Often knowing they have the right to refuse helps with that.

[marshmallowstar, BSN, RN]

Along the lines of helping them feel in control is asking which side he wants the bp on. So then the choices aren't yes or no to "Can I do your vitals?" but left or right to "I need to do your vitals, which side do you perfer?" I would also explore why he doesn't want his vitals done. I've had patients that it triggers restraint memories or trauma survivors that it triggers flashbacks. Is it a form of suicidality by not attending to medical needs or do they just want to finish watching their tv show and would agree to them later?

[MrChicagoRN, RN]

All good advice. Also, sometimes it's the approach. The patient may be objecting to someone rushing up, wrapping a cuff, and pumping it up hard. It may not be what is being done, but it's how it feels to the patient. Sometimes it works to use distraction, sit down & chat for a moment, all the while counting their resp and discreetly checking their point. After that maybe they'll be relaxed enough to let you get a quick BP

[mikenmim]

No harm in asking, "would you like something to help you relax?" The patient still has the option of refusing the PRN. he does not have to present a danger to self or others for you to offer. If he accepts, the PRN med ma help to lower his BP until he is willing to submit to BP checks.

[nurselove757]

You have clarified my issue. Thank you so much.

[nurselove757]

Along the lines of helping them feel in control is asking which side he wants the bp on. So then the choices aren't yes or no to "Can I do your vitals?" but left or right to "I need to do your vitals, which side do you perfer?" I would also explore why he doesn't want his vitals done. I've had patients that it triggers restraint memories or trauma survivors that it triggers flashbacks. Is it a form of suicidality by not attending to medical needs or do they just want to finish watching their tv show and would agree to them later?

I will definitely try that and see how it works out.

[nurselove757]

Many nurses (and I'm not referring to you) tend to forget that psychiatric patients have the same rights as any medical patient. This includes the right to refuse treatment and medications...and yes, this right is there even if the patient is being involuntarily held.

It would take a specific court order or the patient being an immediate danger to himself or others to force treatment or medication on a patient. Being agitated or ticked off alone does not meet criteria for danger to self/others. If the patient is assaultive and throwing chairs at staff, THEN you can give PRNs against their will. If they have a history of HTN and are angry but otherwise no threat, no.

If a patient is competent and refuses VS, you can educate them on why you need to take them and the consequences (i.e., not getting their HTN meds, risks of untreated HTN, whatever) if they don't allow you to. If they still refuse, document all this thoroughly EVERY TIME it happens, and let your charge RN as well as the physician know.

I tell patients that they have the right to refuse but that it is part of my job to continue to come around at the appointed time and offer said treatment/meds, and they can continue refusing if they wish. That way they don't feel as much like I'm nagging them, and I've done the CYA bit. Eventually most thaw after they've refused a few times.

Keep in mind that one thing many inpatient psych patients feel, even voluntary ones, is a loss of control. They're in unfamiliar and restrictive surroundings, with a lot of the little things that they've taken for granted in life limited or not allowed. Sometimes all patients want is to feel like they have some control or say in the situation. Often knowing they have the right to refuse helps with that.

You have given me great information and have clarified my thoughts. Thank you.

[loriangel14, RN]

I have this happen frequently with dementia patients. They can refuse to have their BP taken. That is their right.Unless they have a hx of hypotension I would give the BP med without checking the BP.

[302queen]

very good advice i am new to nursing and physch too thanks for the well written advice.

Along the lines of helping them feel in control is asking which side he wants the bp on. So then the choices aren't yes or no to "Can I do your vitals?" but left or right to "I need to do your vitals, which side do you perfer?" I would also explore why he doesn't want his vitals done. I've had patients that it triggers restraint memories or trauma survivors that it triggers flashbacks. Is it a form of suicidality by not attending to medical needs or do they just want to finish watching their tv show and would agree to them later?

[dashingdiva]

Along the lines of helping them feel in control is asking which side he wants the bp on. So then the choices aren't yes or no to "Can I do your vitals?" but left or right to "I need to do your vitals, which side do you perfer?" I would also explore why he doesn't want his vitals done. I've had patients that it triggers restraint memories or trauma survivors that it triggers flashbacks. Is it a form of suicidality by not attending to medical needs or do they just want to finish watching their tv show and would agree to them later?

Very good advice. :) Exploring by asking open ended questions would provide you with more useful cues regarding your patient's status and behavior. :)