Abnormal vital signs present major risks

In January 2009, an emergency nurse and the nurse's hospital were found negligent for not making appropriate reassessments and failing to detect a worsening condition in a patient with a femoral arterial blockage. A $2.4 million verdict was returned.

"While the patient was awaiting transfer to the surgical floor for approximately two hours, the ED nurse failed to make any assessments," says Teri J. Cox, RN, MS, CLNC, president and owner of Point Pleasant, NJ-based TCK Consulting and former director of emergency services at Bellevue Hospital/New York University Medical Center in New York City. "By the end of the two hours, the vascular surgeon found the right leg cold and pulseless. An above-the-knee amputation was necessary."

Cox says patients with abnormal vital signs present three potential liability risks for ED nurses: failing to recognize the abnormal vital signs, failing to communicate these to the appropriate person, and failing to take action or intervene accurately with a plan of care prior to discharge or transfer.

Patricia Ann Bemis, RN, CEN, author of the Emergency Nursing Bible, says, "When a nurse does not take the actions outlined in the hospital's policies and procedures for abnormal vital signs, or does not take the standard actions that would be expected from another nurse of like education and experience, the liability risk is increased."

Christine Macaulay, RN, MSN, CEN, nursing practice and safety specialist at The Children's Hospital of Philadelphia, says obtaining frequent vital signs "is particularly important if patients have other chronic medical problems. Most hospitals will say to do this minimally every hour, not only for patients inside, but also those in the waiting room."

What are you actually required to do if a patient has abnormal vital signs? "It's a touchy subject, as nurses will complain that they did their job by taking the signs and documenting such and will say that it's the physician's job to diagnose and treat the problem," says Elisabeth Ridgely, RN, LNCC, a Telford, PA-based emergency nurse and legal nurse consultant. "Technically, it's everybody's job."

She gives the example of a patient presents with hypotension and tachycardia with no overt signs of bleeding. You should assume that this patient might be dehydrated, says Ridgely.

"This might not be the problem or the only problem. However, it is not a large jump to assume this, and it could be fairly simple to correct," Ridgely says. "The nurse could hang a liter of fluid, after checking with the physician, to see if this helps the situation."

This action seems very basic, but the potential problems would arise in the subsequent hours, says Ridgely. For example, did the nurse follow up with vital signs? Did she document that the patient responded to the volume? Did the patient get worse? Who did the nurse report this change to?

"I would be hard-pressed to find a nurse out there who could not determine whether or not vital signs were normal or abnormal," says Ridgely. "The issue is in the follow-up and what the nurse does with the information."

Chart all you do to to assess vital signs

"Many of us will say: "I can look at a patient and know they are OK,' but 'I just knew the patient was OK,' is not an acceptable defense," says Teri J. Cox, RN, MS, CLNC, president and owner of Point Pleasant, NJ-based TCK Consulting and former director of emergency services at Bellevue Hospital/New York University Medical Center in New York City. "Many cases are settled in favor of the plaintiff because the medical record does not support the nurses' action."

Did your assessment include the patient's skin color, turgor, response to touch, evidence of cyanosis, pulse oximetry, blood pressure sitting up and lying down, and checking the pulse? Did you notice skipped beats, or was a rhythm strip attached but hard to find? Is the respiratory rate shallow, deep, and noisy? Is the patient's chest expanding on both sides?

"Document it in the chart," urges Cox.

Chart what interventions were done, whether they worked, whether the patient was noncompliant, whether you communicated specific vital signs to the physician, if the patient showed any distress, and whether there were witnesses to these interventions. "If your assessments and interventions are consistent with the accepted standards of care, you will not be found liable for unforeseen complications resulting from injury or unknown comorbidities, or unknown allergies or other circumstances," she says.