Evaluate this situation. What did I miss?

[Billy_Ruben]

Several nights back I admitted a patient that had a temp of 105. Blood cultures were drawn and they were positive. The patient was put on IV vanc. They also removed his port-cath two days ago because it was infected. The patient had been plodding along doing relatively well. No more high temps, white count 12. Last night his temp shot up to 103. This occurred around 4 am. I treated the fever with Tylenol and it was down to 99 by 6 am.

The doctor was furious enough with me for not calling that he went to the nursing director. I had to explain to her my rationale for not calling which was blood cultures had already been drawn and he's been on vanc. I'm not sure what else would have been done at this point. She told me to always call the doctor in a situation like that. But this wasn't a new thing. He came in with very high fever. I feel like if I had called at 4 am the doctor would have said, "He's been on vanc and we've already done cultures. Why are you calling and waking me up with this?"

Is my like of thinking wrong? I feel like I am never for sure when to call in situations like this is the middle of the night.

Also, I forgot to mention. This am his white count had jumped from 12 to 16. However, that info wasn't available to me on my shift. Labs came in right at the tail end.

[monkeybug]

A slightly different tack: You're not 'bothering' them - IT'S THEIR JOB!

I learned long ago from a gruff old surgeon- the doc works for the patient, not the other way around.

Always call.

My favorite doc in the whole world would handle what he perceived as unnecessary phone calls this way, "Okay, you told me, thanks, consider your a** covered." He didn't see a problem, but wasn't going to get angry about me doing my job.

[OCRN3]

Or "MD aware" on the words of another old time doc! :)

Sent from my iPhone using allnurses.com

[RNOTODAY, BSN, RN]

Yes you most deffinitely should have called. and I am so far removed from floor nursing its not even funny. (OR)

[BostonFNP, APRN]

I would have expected a call for that if I was on call.

You made a judgment call. It is not outright incorrect and hindsight is 20/20.

When was next dose of vanc? Did you have a vanc trough draw on file?

[HyperSaurus, RN, BSN]

I would have called. I actually recently had a pt with temps 99-101, but one night he spiked up to 103.3. I called the doc at home for it (at midnight). He appreciated the call. They had recently changed his antibiotics but this told him what they were doing wasn't the right track. Our unit has a policy to call for any new temp 101 or higher (if they had been afebrile for a day or two, that would have counted)

[Esme12, ASN, BSN, RN]

I would have called.....you said....

The patient had been plodding along doing relatively well. No more high temps, white count 12.

then the patient developed a change

Last night his temp shot up to 103.

The MD needed to know so they can possibly make a change in care. If he/she didn't like it...too bad ......my job is to call with changes ...is their job to hear me.

I'd rather the MD be angry I called than sued by the patient for delay of treatment because I didn't.

[KelRN215, BSN, RN]

I would have called. It's always been the expectation to call for temps > 38.5 C (101.3 F) in any job I've had and that's what we instructed parents when we sent them home too.

[canoehead, BSN, RN]

I would call with any temp spike with greater than 24h since the last blood culture, order or not.

[edimo]

I would have called solely based on the fact that it had been several days from the last blood culture draw. Repeat cultures should have been taken (typically, our sets are good for 72 hours where I work; if patient spikes post 72 hours from last cultures, they are repeated) and another antibiotic introduced or started.

It never hurts to call the doctor; even if their action may be to do nothing, you can at least chart something along the lines of "patient x had temp of 103 at 0400; no chills or rigors, patient appears comfortable. Currently on vancomycin xmg q12, last blood cultures taken oct 28. MD on call notified and advised to continue with current treatment plan. Will re-evaluate vitals in one hour"

[canesdukegirl, BSN, RN]

CALL. THE. DOC.

[jadelpn, LPN, EMT-B]

Thanks for the replies. I guess my reasoning wasn't too far off base but I probably should have called. I hate making poor judgement calls. It makes me feel so dumb.

Ah, but if the MD wrote clearer orders, then this would not be a position you would have had to be put in. If they are gonna order Tylenol for a temp greater than whatever, then it takes what, 2.2 seconds to continue with "call MD for temp greater than 101"?

That the MD is apparently second guessing is not your concern. When the MD trudges themselves to the unit to look at the whole picture, orders a theraputic dose of vanco or adds other antibiotics or whatever the MD is going to do, perhaps it would be prudent to add an order regarding calling him for a temperature spike.

[Billy_Ruben]

I would call with any temp spike with greater than 24h since the last blood culture, order or not.

I think that's the key thing I missed here. I mistakenly thought since we had cultures a call wasn't necessarily needed. It's a mistake I won't make again. I feel pretty bad about it.