MunoRN 33,285 Views
Joined Nov 18, '10.
Posts: 7,640 (69% Liked)
This used to be common, then went away, now is making a comeback. Would you rather deal with a combative, belligerent, paranoid, agitated, seizing DT patient or the hassle of giving someone a drink of whiskey?
One thing that raises a potential red flag for me as a legal nurse consultant is documentation that may be viewed as "defensive" documentation that appears to place blame on the patient. For example, a patient in a long term care facility frequently refuses to take his/her medications or to allow wound dressing changes to be performed. Simply charting said refusals took place is insufficient, making the charting appear to shift the blame to the patient for complications that may have resulted from said refusals. Be sure to document interventions attempted in order to try and achieve the patient's compliance. Were vital signs taken to evaluate if the patient may have been ill? Was the patient in need of pain medication prior to the prescribed times for dressing changes? Did the nurse return to the bedside at another time, say 10 minutes later and present the meds to the patient? Was the care plan changed to indicate patient's medication refusals? Psych eval for possible depression? In essence, why was the patient refusing to comply? Nurses no longer can simply say the patient chose not to comply without documenting attempts made to gain compliance from the patient. Is there documentation that the physician was notified? Were changes made in the patient's care plan and were those changes in the care plan actually initiated? In short, document sufficiently to cover your actions should an adverse situation or litigation present itself months or years down the road. You will find those interventions you may well have attempted have departed from your memory.
But let's say in a doctor's office setting usually doctors won't give pt anything for the 'pelvic pain" for example.. they send the pt to get a pelvic ultrasound and the pt f/u after that. So no action to stop the pain is taking until the results from the ultrasound are back..
A patient with a temp of 101.4 doesn't necessarily benefit from interventions to bring the temp down, such as tylenol. If the temp is due to infection, a fever is actually an important part of fighting the infection since many bacteria and viruses do not flourish at temps above 100, so you might be doing more harm than good by artificially altering what the body is trying to do.
In post-acute rehab the most common source of fever outside of neuro injury is lung congestion, so the best way to treat a temp in those patients is usually pulmonary exercises.
It can also occur at that time of day since it's not unusual for rehab patient to be on vicoden or percocet during the day which contains tylenol and might be hiding a persistent fever which becomes more apparent when the patient has been taking less tylenol-containing meds.
Personally I would hold off giving it, particularly if there is no order, and get another reading to establish a trend (if you check it again and it's >39 then call, if it's 37.8 on the recheck then there's less to worry about), and try other interventions first; passive cooling, pulmonary toilet, etc.
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