treating a visitor of your pt? reprimanded for not doing it....

[rehab nurse]

am i right or wrong here? just fyi, i work in a subacute rehab attached to ltc.

during report, had a nurse manager come in, tell me pt "had fainting spell" and to go see her. i get up, go in the pt's room, ready to do VS and assess, etc. four family members in the room with pt, one of whom is lying in bed next to pt. i say "what happened?", pt sitting up, a/o, no c/o. i go to take a BP on her, and another family member says "no, it's not her, it's my sister". sister laying in bed, says she has a "heart problem" and is vague with her symptoms. i say "sorry, i am not allowed to take your VS, but i will call an ambulance for you". rest of the family says, "no thanks, she's been complaining for the last hour, but we don't know why the nurses can't just give her a BP pill and check her VS every so often.":uhoh3: offer again to call ambulance, declined offer. so i go to nurse manager who's supervising building for the weekend, who goes to talk to family, and then writes me up for not taking the woman's vs. :stone

am i completely wrong here?

[Daytonite, BSN, RN]

No one (RN, LPN, CNA) is ever wrong to suggest a patient be seen by a physician. That is how you protect yourself in situations like this. And, then document what has happened and what you have done on an incident report so it is memorialized in case there is trouble later. These kinds of things are incidents. Whether the incident report goes to the safety committee or the executive committee, it is one way to force adminstration to take note of these kinds of incidences and formulate policy. Incident reports do not get chucked into the trash. They are read and reviewed by administration. When some situation raises red flags then administration takes action. That is part of their function. Since the OP has talked with the DON I would suggest that she now move up the chain of command and ask to discuss this situation with the administrator of the facility. I would recommend that she point out that the manager was directing her to take on a visitor as a patient which she was taught in nursing school is improper procedure. She should ask why there is no facility policy covering this kind of situation and don't they think there should be one so that everyone's responsibility in a situation like this is defined in writing. The problem I have with her being written up is that I don't see where she has violated her duties as a staff nurse. Re-read your job description and see if it mentions anything about attending to the illnesses of visitors. If it's not there, then the write up is bogus and needs to be rescinded. My feeling is the manager needs to be written up.

My biggest problem with the situation being discussed here is the actions of the nursing manager, not the OP. I am bothered that a nurse manager deliberately involved a staff nurse in this situation when it was clearly within the manager's scope of duty to follow through on this situation as it involved a visitor and not a patient. I was a supervisor and manager for many years and had several situations involving visitors needing to be moved to the ER for some reason or another (falls, injuries, seizures, low blood sugar). Each time there was always an incident report generated. (We also had administrative incident report forms.) Someone has to take responsibility for people other than patients who get ill in the facility. In all the facilities I worked in that responsiblity moved up the line of supervision and was not delagated to the staff nurses. The highest ranking nurse who is present in a facility respresents not only the nurses, but administration, as well, if no one from administration is on the premises. Someone has to be concerned about a visitor who may be complaining of an illness whether faked or real or the facility could end up in some real hot water.

I do not think these kinds of discussions occur in acute hospitals at the staff nurse level as much as they do in LTC and rehab facilities. Nurses who take supervision and management jobs need to understand that they have many hats to wear and they need to step up and take responsibility when it is called for and not inappropriately delate administrative duties to staff nurses.

[Ruby Vee, BSN]

okay i may rock the boat here by having a different opinion i'm not saying you did the wrong thing but i dont think it would of hurt just to take her b/p but of course you can not administer medication to someone who is not your pt. but, we've had a few ppl come in from off the streets c/o dizziness and asking for us to take there b/p and i dont see a problem with that. just my opinion.

who has time to take blood pressures on visitors?

if she had taken the blood pressure, then what? if it's high or low, she's not going to treat it. the only thing she could do is stay by the visitor and wait for an ambulance while her legitimate patients lie in stool, complain of thirst and don't get their meds.

if it's normal, and she tells them that, they may decide not to get treatment. then if there is something wrong, they may decide to sue her.

there's no upside to taking the blood pressure of visitors, but a helluva lot of down sides.

ruby

[UM Review RN, ASN, RN]

if it's normal, and she tells them that, they may decide not to get treatment. then if there is something wrong, they may decide to sue her.

there's no upside to taking the blood pressure of visitors, but a helluva lot of down sides.

ruby

especially with a person who has a known cardiac history and is c/o "feeling faint". do you know how many things could be wrong with her? could range from a low blood glucose, to orthstatic hypotension, to a complete heart block, to taking one of her bp meds inappropriately to an ami--none of which are going to be proven with a simple, one-time bp.

she needed to go to the er for a workup, not play coy and try to self-diagnose.

[DusktilDawn]

who has time to take blood pressures on visitors?

if she had taken the blood pressure, then what? if it's high or low, she's not going to treat it. the only thing she could do is stay by the visitor and wait for an ambulance while her legitimate patients lie in stool, complain of thirst and don't get their meds.

if it's normal, and she tells them that, they may decide not to get treatment. then if there is something wrong, they may decide to sue her.

there's no upside to taking the blood pressure of visitors, but a helluva lot of down sides.

ruby

exactly ruby,

the bp could have been normal, but it would only have been one piece of data collected. there could be any number of things going on with this visitor in the original post that would not have been reflected in a bp reading. it was appropriate to offer to call an ambulance, it was also their right to refuse. the bottom line: document.

the visitor probably didn't want to wait in er, wanted her bp taken and medication given. a lot of visitors don't understand why we cannot give them even a simple tylenol, they don't understand that it is against our scope of practice to prescribe treatment, which would include giving tylenol for even a c/o headache.

daytonite: i do not think these kinds of discussions occur in acute hospitals at the staff nurse level as much as they do in ltc and rehab facilities.

yep they do. i've worked outpatients, clinics, and med-surg. in all areas i have had visitors/family members who will ask for bps, vs, for medication, etc. outpatients was really bad in regards to visitors asking to have their bps taken, most asked out of curiosity, not because they thought something was wrong. simply they were just curious as to what their bp was.

when visitors approach us with health related concerns, we have to walk a fine line. we can be held accountable in regards to health information we provide. if they are being followed by a doctor in regards to any condition, that is who they need to speak with, not the staff nurse taking care of their spouse/family member.

[Daytonite, BSN, RN]

who has time to take blood pressures on visitors? . .if she had taken the blood pressure, then what? if it's high or low, she's not going to treat it. . .if it's normal, and she tells them that, they may decide not to get treatment. then if there is something wrong, they may decide to sue her. . .there's no upside to taking the blood pressure of visitors, but a helluva lot of down sides.

this is why if anyone does decide to take that step to take a blood pressure, listen to a heart, take a pulse, etc., you need to cya by documenting what you have done. just because you don't have a chart in front of you for a visitor doesn't mean that you don't record what you did with them. the easiest thing is to grab an incident report form and fill it out, particularly because it often asks the important information needed. however, any blank piece of paper works.

what concerns me is if a visitor falls to the ground in front of a staff nurse, you just can't step over them and go about your job, which is the tone i'm picking up from reading everyone's replies to this. you have to do something, even if it's to pick up the phone and call for help. you can talk about the establishment of the nurse-patient relationship all you want, but as a human and as a citizen you have a minimal duty to do something for a person who is asking for help. some of the posts here sound like people would just turn around and walk away from a situation like that without giving it another thought. you can't do that, and i refuse to believe that you would despite what some of you have written. when a patient tells you they have some little ache or pain you are obligated to investigate those statements and take some kind of action even if the action is to end up doing nothing. what i'm saying is that when a visitor gives you some information that you know could very well play out to a bad scenario, you better do something--anything, to get the ball rolling on it or you are going to look very, very bad and have some explaining to do if things end up going terribly wrong! better safe than sorry. this is what makes us professionals and not just workers.

[DusktilDawn]

Have had visitors faint, develop SOB, c/o chest pain, vomiting, etc. Yes they are taken care of appropriately and incident reports were done. Yes it was the staff nurses who took care of these people. It was also the staff nurses who brought them down to ER to be further evaluated by a physician. That is how it is handled. Supervisor... where? Oh we'll see them long after the person has been taken care of.

I don't think anyone has said "walk over" the visitor that obviously needs treatment.

[nurse_clown]

did you ask your manager why she didn't take the vitals of the family member? managers are funny that way. we have one that likes to bend over backwards for the families and winds up having to do the tasks herself because the requests are "risky". i wont sacrafice my licence for someone who really doesn't care about me.

your manager should know better than to order you to do something like that. if she wanted it done, then she should have done it herself and taken the risk herself. she would have the right to write you up if she ended up having to do it herself. that's something you could say in your complaint. and i would definately complain about this.

you were right to offer the ambulance. i also would have encouraged the rest of the family to take this person home or to the doc right away! turn the responsibility right back at them!! :rotfl:

makes me laugh when people think that nurses should do everything. small note: i had a friend who was coughing on a peice of orange. definately not choking. then pointed at me and said "you're a nurse!" when i said, your mother should have taught you how to eat. how am i responsible for that??

[Ruby Vee, BSN]

what concerns me is if a visitor falls to the ground in front of a staff nurse, you just can't step over them and go about your job, which is the tone i'm picking up from reading everyone's replies to this. you have to do something, even if it's to pick up the phone and call for help.

i don't think anyone was advocating just stepping over a prostrate visitor. clearly, if they're down, we have an obligation to do something -- calling 911 comes to mind! it's those little grey areas -- you know you wouldn't just pop a catapress if your visitor has a high blood pressure, but what do you do? i think not even opening up the possibility is a good start. what the original poster did was absolutely right.

when i worked at a large teaching hospital on the west coast, there was a clearly stated policy that if the visitor goes down on the nursing unit, you stabilize them enough to get them to the er. if they refuse, you document. if they go down in a non-nursing unit (elevator, cafeteria, front lobby) you call a code and let the code team deal with them. and if they go down in the parking lot or the sidewalk in front of the hospital, you call 911. maybe not the ideal policy, but at least it was written in black and white.

ruby (who hopes not to have to deal with a visitor going down again.)

[canoehead, BSN, RN]

I work in an ER. If a visitor complains of physical symptoms they are encouraged to sign in for treatment. If they decline they have made their own choice. If they are sick enough to lie down or interfere with care they are asked to step into the waiting area or sign in to be treated as visitors must be able to take care of themselves for patient safety reasons and cannot be lying on the other beds or taking up RN time with out being signed in. If they actually pass out then it is an emergency in the sense that we can assess them (signed in as a patient of course) without consent.

So bringing that policy to a LTC situation- if the woman declined an ambulance then she was saying she was well enough to get up off the bed, and be escorted to a waiting area for a rest. If she was not well enough to care for herself then staff was obligated to call 911 to have her assessed, and start whatever protocol you have for on site visitor injuries.

[Daytonite, BSN, RN]

I don't think anyone has said "walk over" the visitor that obviously needs treatment.

I should have been clearer. I meant it in a metaphorical way, not literally. Sorry. I'm sure no one would actually do something like that. I was trying to get attention.

Honestly, this whole thread brings up a very serious subject. Something that isn't addressed in nursing school. As Ruby Vee stated in her post, the hospital she worked at had a policy on this. It would be a good idea for those of you reading this to check to see if your facilities have a policy. If not, push for one. It will CYA if this kind of situation ever comes up.

I was also thinking that it wouldn't be a bad idea to write to my state board and ask for an official position on this. They may already have addressed it for all I know. I'll have to check it out.

[UM Review RN, ASN, RN]

I should have been clearer. I meant it in a metaphorical way, not literally. Sorry. I'm sure no one would actually do something like that. I was trying to get attention.

Honestly, this whole thread brings up a very serious subject. Something that isn't addressed in nursing school. As Ruby Vee stated in her post, the hospital she worked at had a policy on this. It would be a good idea for those of you reading this to check to see if your facilities have a policy. If not, push for one. It will CYA if this kind of situation ever comes up.

I was also thinking that it wouldn't be a bad idea to write to my state board and ask for an official position on this. They may already have addressed it for all I know. I'll have to check it out.

I think it would fall under "patient abandonment" actually. Because once the nurse-patient relationship is established, the nurse who merely takes vitals and does not formally pass the patient on to the next caregiver, is open to lawsuit.

Remember, this was not clearly an emergent situation. You had an a/oX3 patient who was refusing the recommended treatment in favor of her own treatment, and all of the relatives agreeing with that instead of trying to insist that she go to the ER for a workup.

Taking vitals clearly establishes a nurse-patient relationship, IMHO. The supervisor who took the vitals, then let the patient leave the facility without further treatment, left herself and the facility wide open to a lawsuit if further treatment was warranted. Especially because there was no incident report filed, as others have said.

JMHO. I can't seem to find any direct legal cases on this, but if I do, I'll post the link.

[DusktilDawn]

Actually Daytonite, I realize you did not mean that literally. I just didn't feel anyone was condoning ignoring a visitor in obvious distress.

The point is we will be asked by visitors for evaluation and treatment. I don't think the general public realizes that when they visit in a facility the staff's primary function does not include being a clinic for them. I think most of us have had visitors engage us in conversation in regards to their health. As nurses we need to know what our responsibility and accountability is in these situations.

I agree that facilities should have policies in regards to this situation. I think that knowing where the SBON stands on this issue, the legalities involved, and the input of nurses needs to be included. On the thread medical advice seeker's (rant) one poster has written how their facility has implemented a policy that when someone calls the unit, even though they may not be under the care of any physician of that hospital, they are to be triaged and given advice. Now I am not in agreement with a policy such as this.