Had family visiting a patient last shift, and when I walked in to do my initial assessment, etc, did a double take at one of the visitors. Before I could even open my mouth, he said, "I don't feel well, can you take my blood pressure? I've got the worst headache I've every had." Guy weighs at least 400 pounds, is sweating, grey in the face, and is just setting off all my "oh crap" alarms. I took his bp and his temp, since he was hot to the touch. Sky high bp, pulse so fast I can't count it, and temp 102.1. EEEEK! I told him to go to the ER, which he did. He was admitted, and I know his weight was over 400 because when they admitted him, he had to be put on an ICU bed in a med surg wing because he was over our equipment's weight limit.
Now, after he wheels down to the ER, my charge nurse tells me I should have never touched the guy, never told him to do anything, just referred him to his family physician. All I could think was, well, it would have looked real good at trial when the wife and patient/father says, "he said he didn't feel well, had a history of hypertension, and that nurse didn't do anything and he died from a stroke on the way home." Not to mention it's not going to help my post-MI patient if his son-in-law codes in his room.
How does your hospital handle this sort of thing? I'm still so new I practically squeak, and I've referred plenty of sore throat/look at this mole requests to "visit you physician of choice," but if you see a visitor who looks like he could be in real trouble, are you still supposed to wait until he hits the ground at your facility?
Specializes in Cardiac stepdown Unit & Pediatrics.
Kudos to you because you did the right thing! I had to call a "code" on a visitor who came nonresponsive (although breathing and pulses were fine) and started vomiting last week. She just wouldnt wake up. I knew I could either call the rapid response team or a code blue. I knew I needed people FAST so I called the code. You better believe they got her on oxygen, got an IV in her, drew blood samples, and then got her to the ER in less than 10 minutes. The charge nurse said I did fine because I didnt know WHAT I was walking into--no clue of a medical history. All I knew is she was projectile vomiting, unresponsive, and looked a dusky shade of grey/blue.
If ever in doubt, call the rapid response team. Heaven forbid you would've just instructed that man to go to the ER and he had an accident walking downstairs. For that, you might have been sued and where would you license be then?!
Great job for doing the right thing in this situation! I agree that taking VS is an assessment, not a treatment. And as nurses, we make assessments all the time without even laying our hands on people...whether they are our patients or not. What if this had been a fellow employee who was experiencing these symptoms? Would you have told them to just go to the ER or would you have taken a couple extra (and possibly life-saving) minutes to take VS? At our hospital, we can call a "Code Assist" for any non-patient (visitor, employee, etc.) who, if they were an inpatient, would need a rapid response or code blue called.
Now, after he wheels down to the ER, my charge nurse tells me I should have never touched the guy, never told him to do anything, just referred him to his family physician. All I could think was, well, it would have looked real good at trial when the wife and patient/father says, "he said he didn't feel well, had a history of hypertension, and that nurse didn't do anything and he died from a stroke on the way home." Not to mention it's not going to help my post-MI patient if his son-in-law codes in his room.
How does your hospital handle this sort of thing? I'm still so new I practically squeak, and I've referred plenty of sore throat/look at this mole requests to "visit you physician of choice," but if you see a visitor who looks like he could be in real trouble, are you still supposed to wait until he hits the ground at your facility?
Something similar happened recently in our facility. Nurse taking care of Patient X has a visitor in the room who complains of...stuff, and the nurse takes vitals. Guy is a mess. Refers to ER at that point, and visitor goes. Can't recall if admitted or not. But the nurse who took the vitals, made the phone calls, etc, got in to a bit of trouble for doing so. She was NOT taking care of her assigned patients by doing this, and she had no authority to enter into an agreement of care for the visitor.
Administration was quite clear on this: you as the nurse do NOT take vitals or ANYTHING on anyone who is not an assigned patient, period. If someone looks questionable, you are to refer him to the ER, that's it. Once in the ER, he can be assessed, history taken, etc. And yes, if the person drops on the way TO the ER, a code is called and it's handled like anyone who codes on their way into the ER. Doesn't matter if it's the hallway or the parking lot, they were on their way TO the ER. We were told that once you've taken vital signs, you've also established the intent to care for this patient, and that is the problem. He's not admitted, he's not been triaged, he's not even stated that he's seeking medical care (as he would if he were on his way into the ER, it's implied just in that step).
Me, I am not about to enter into a responsibility situation with the guy you just described for any amount of money. He's a liability waiting to happen. I'd look at him, tell him that if he feels poorly he should go to the ER now and be assessed by one of the emergency room nurses. He is not your patient, and you don't want him to become one under these circumstances!
I also think that checking VS is an assessment, not a treatment.
I was thinking the exact same thing. I mean, heck, people can go and get their VS taken at a fire station. And I agree with what the other posters said...had you not taken the VS, he might have thought you were just giving him the formula, CYA, response in just telling him to go to the ER.
Specializes in Jack of all trades, and still learning.
Not knowing your system, I know my comments may be inaccurate, or lacking in understanding. But I would have thought that as a nurse you are responsible for any person who is ill. If you are driving past on the road and find someone in a car crash, are you expected to stop because you are a nurse, or are you permitted to keep driving?
In Oz we are expected to stop. In the same vein then, I think you did exactly the right thing. After all, how did taking a blood pressure and other sets of vitals affect the hospital? Yet how important was it to the visitor, and to yourself legally?
You did exactly the right thing as far as I'm concerned. Sounds like your supervisor is being pedantic...
Thanks for all the replies, and sorry it took me so long to get back. I understand the hospital may have legal issues, and that my charge nurse was doing what she thought was right. I could have hung my rump out to dry...but...at the end of the day, I have to sleep with me, not the hospital's head of legal. Ewwwwww, mental image I just didn't need.....
Seriously, the guy was admitted with sepsis, CHF and fluid around the heart. The dad, who's still my patient, took my hand at the start of my next shift, and said, "thanks for saving my little girl's husband." I teared up and so did he.
Sometimes, this job really stinks, but this wasn't one of them. I LOVE BEING A NURSE!:heartbeat
I didn't read all the responses but I think you did the right thing. This may be a chance for you to change hospital policy though. In our hospital corporation we have an "Emergency Response Team." Basically its an ER nurse who is called to the scene to triage a person who is not a patient but is a visitor OR an employee. They are also called in the case of falls on the property, etc. Its kind of a catch all thing but it protects the nurse from liability of assessing someone who is not a patient and protects the facility from liability of not coming to the aid of a sick person on the property. Maybe you could suggest this to your facility and get a new policy put in place. I have used it before for a patient walking down the hall barely able to stand up, out of breath, legs looked like marshmallows. Pretty clear chf exacerbation but she needed to be seen. I did not get vitals or assess, just eyeballed and called. Hope that helps!
We don't "treat" a visitor that c/o sudden illness but assessing BP, HR, temp are things you can do for yourself at home or your local discount store. We have had family members code while visiting and they are treated just like any other code-let billing worry about thier admission status after we save thier life. It is always prudent to err on the side of caution and refer the family member to the E.R., even if everything looks OK, and by all means notify the supervisor so someone besides you and the family member can attest to the fact that they were advised to go to E.R.
I know this thread is old, but I had something like this happen once.
530 in the morning, a visitor was walking up the hall from the visitor restroom. Two of us are at the nurses' station. We hear "help me" kind of quiet from down the hall, then CRACK when her head hit the floor. We went booking down there, she was breathing but barely...kind of snoring resps. Not knowing what else to do, we called a code...we needed people there, and FAST. Took VS, blood sugar, put O2 on her, anything we could. They brought a stretcher up from ER and took her down.
Turns out she had bilateral PE's and was admitted to ICU. She had been there visiting her 16 year old daughter, who had just had an appy.
Code team arrived and kind of didn't know WHAT to do, but either way, we knew we needed help, bodies, whatever...and you have to respond appropriately to save a life. Sounds like the visitor in the OP was NOT far away from being unresponsive himself, and then the ball game would be totally different. I think the actions were spot on (coming from a charge nurse~!).
When you take the vitals of an ill family member in the hospital setting, you are crossing that fine line by establishing a nurse-patient relationship with someone about whom you know nothing (medical history, allergies, etc.) and someone whose future actions you have no control over. You begin to collect data, and you become obligated to see the person's care thru, whether or not you actually have the ability to do so. (You are not in the ER, you may or may not have the supplies, equipment and expertise necessary to properly care for the patient's condition, and you may not be able to persuade this person to obtain the follow-up s/he needs.)
While I agree with the overall point--we're better off recommending that someone call his/her primary or go to the ER, and not assess the person ourselves--I do have to point something out: we are NEVER in control of the future actions of others so we should not base decisions upon this idea. Even when a patient is formally seen in the ER, s/he may or may not follow up properly. We have no control over this.
The reason I would not recommend taking a visitor's vitals is because, as you said, you are establishing a nurse-patient relationship. Now, in this case the end result was a recommendation to go to the ER, so I don't think there is a problem. The problem could have come in if the nurse takes vitals and recommends a lower level of intervention--someone could then easily come back and say that the nurse should have recommended a higher level of intervention. Since the OP recommended the ER, she's covered--there's really nothing else she could have done, whether or not the patient refused.
merellis2009
73 Posts
Kudos to you because you did the right thing! I had to call a "code" on a visitor who came nonresponsive (although breathing and pulses were fine) and started vomiting last week. She just wouldnt wake up. I knew I could either call the rapid response team or a code blue. I knew I needed people FAST so I called the code. You better believe they got her on oxygen, got an IV in her, drew blood samples, and then got her to the ER in less than 10 minutes. The charge nurse said I did fine because I didnt know WHAT I was walking into--no clue of a medical history. All I knew is she was projectile vomiting, unresponsive, and looked a dusky shade of grey/blue.
If ever in doubt, call the rapid response team. Heaven forbid you would've just instructed that man to go to the ER and he had an accident walking downstairs. For that, you might have been sued and where would you license be then?!
You did a great job. Feel good about it.