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.

[Esme12, ASN, BSN, RN]

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.

we learn as we go....I usually error on the side of caution and call them..or at least talk it over with other staff.

I'd rather be yelled at for bothering them then not calling. See you learned something. Many ID physicians believe further cultures are not necessary after antibiotics are started. It is a learning process in getting to know your physicians.

[OCNRN63, RN]

[/b]lly_Ruben;7593226]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.

Not dumb; it's just part of the learning process.

[wooh, BSN, RN]

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"?

If the MD has to write everything into an order that could/should be left to our nursing judgment, why have nurses? Why not just hire someone off the street that's capable of reading and following directions? The whole point of having nurses is that we should have the knowledge to make judgment calls.

One, important bit of info: Why did the patient have a port in the first place? That bit of history can make the huge difference between, "Not quite what I'd do but not necessarily wrong" and "Oh why oh why oh why did you not call?"

I think Esme made a very good point, and what tends to be what draws the line for me. Watch for CHANGES. Whenever you have a change that takes the patient in the wrong direction, that's when you need to do some serious thinking. Not just about, "What will fix this?" (tylenol) but also, "What on earth has caused THIS change?" (sepsis as just one possibility.)

When patient first arrives with infection, and the workup has been done, I'm going to give tylenol and be happy if/when the temp comes down and patient is more comfortable. If patient is doing well for a while, and THEN spikes a temp, I'm going to be wanting to know, "Why a temp NOW? Why is he no longer doing better?"

But live and learn. We've all had times we should have done something differently. As long as we learn from it, that's the best we can do. :)

[LadyFree28, BSN, LPN, RN]

If the MD has to write everything into an order that could/should be left to our nursing judgment why have nurses? Why not just hire someone off the street that's capable of reading and following directions? The whole point of having nurses is that we should have the knowledge to make judgment calls. One, important bit of info: Why did the patient have a port in the first place? That bit of history can make the huge difference between, "Not quite what I'd do but not necessarily wrong" and "Oh why oh why oh why did you not call?" I think Esme made a very good point, and what tends to be what draws the line for me. Watch for CHANGES. Whenever you have a change that takes the patient in the wrong direction, that's when you need to do some serious thinking. Not just about, "What will fix this?" (tylenol) but also, "What on earth has caused THIS change?" (sepsis as just one possibility.) When patient first arrives with infection, and the workup has been done, I'm going to give tylenol and be happy if/when the temp comes down and patient is more comfortable. If patient is doing well for a while, and THEN spikes a temp, I'm going to be wanting to know, "Why a temp NOW? Why is he no longer doing better?" But live and learn. We've all had times we should have done something differently. As long as we learn from it, that's the best we can do. :)[/quote']

Well said!

[klone, MSN, RN]

Wooh made a very valid point. The thought process behind it should have been "why is this person suddenly spiking a fever after several days of doing well?" When I read that you gave Tylenol to a 103 temp and went about your day, that kind of surprised me, actually. Your first thought should be not on the symptom, but looking at the big picture, and what's different, and what could be causing the change.

[MomaNurse]

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.

I agree that it was probably because the patient seemed to be responding well to treatment and then spiked a fever that the doc was upset. Early intervention could get control without too much trauma to the patient. But it's something to discuss with your director. I know you feel bad or you wouldn't be searching for answers. That's a sign of a really good nurse. Just don't beat yourself up. Learn what caused it and move on.

[jadelpn, LPN, EMT-B]

I am certainly not suggesting that we don't need nurses. Nor am I suggesting a call is not warranted. And yes, the OP has stated she has learned something. And I always say use your resources (your charge nurse, for instance). However, it often is a case of darn if you do, darn if you don't. Especially on nights. If an MD is going to order tylenol, for fever, then there is usually a parameter. There should also be a parameter of when they would like a call. If nurses are going to use judgement when giving tylenol, they would be called nurse practioners and do what they would like to as far as ordering a medication.

No need to be snarky, and lesson learned by the OP. But methinks that any nurse who has been in this business for any length of time would say that a call would have perhaps resulted in "Did you medicate with Tylenol?" "Yes" "Did the fever come down?" "Yes". "Do you have the CBC back?" "Doesn't get drawn until 7"....and on and on it would go.....doesn't make it right--but who else has been there? Many of us. Tylenol doesn't preclude drawing new cultures.

[OCRN3]

Jadelpn, I agree with you, I know that for me, a 4 am call when the doctor would probably come in at 6-7am is not warranted of the patients fever came down. Especially if I have no labs or nothing else to report at 4 am. Yes the doctor does need to know, but I work with really old school docs and they would chew my head off for that. In a side note the same situation working in a teaching facility with interns and residents, I would call then because they really want that info and probably won't give me orders untill the attending would do rounds, but that's just my experience.

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[LongislandRN23]

If the tylenol was ineffective and/or the pts symptoms worsened or new symptoms presented I would have called the md. I have seen plenty of septic pts have stabalized temps on iv vanco for two days and then suddenly have a temp spike that goea away so I wouldn't be overly worried. In your case I don't think you did anything wrong.

[Penelope_Pitstop, BSN, RN]

If it's been more than a couple of days since those cultures were drawn, then a new set would have been most likely warranted, and the best time to do that is during the temp spike. Also, a lactate just to be thorough.

Also, was the patient pan-cultured (urine, respiratory culture, et al?) How did the lungs sound? Could be atelectasis (kind of high for that, but possible) or pneumonia (quick stat chest x ray). Any chance of DVT? (Again, kind of high for that).

I don't think you are wrong. I just happen to work in an area that has sepsis beaten into me daily. I believe that if the patient had assessment changes or other vital sign issues you would have called. And chances are this was a fluke. But a call would have been the best choice...as in NCLEX, though...there is always more than one correct answer.

One of my rules of nursing (Jan made them a sticky ) is NEVER apologize for calling a doctor.

[Anna Flaxis, BSN, RN]

I would have called for a temp >/= 38.5, orders or no.