Question regarding neutropenic patient...

  1. Hi all,
    I'm PRN at two places, both oncology/med surg floors. Well, I worked last nite, had an awful nite. I had a 43yr old pt that just got diagnosed with lung cancer with mets to brain, liver, and bone. Then I had two surgicals that nothing was done on, had to get consents signed, do preps, and start the surgical checklist and then had a lady all the way down at the end of the hall who "accidently pulled her IV out because she hit her bedside table". Then I also had an IV left for me that was bad, wasn't even taken out, but didn't flush. Okay, so my lady who was neutropenic, the aide didn't get the second set of vitals until way late like maybe 9:30pm...told me in passing she had a 101.1 fever. Didn't even relate her being neutropenic so just gave her Tylenol for the fever. Luckily her fever came down. But got a call from my manager this afternoon stating the doctor had a fit because he wasn't called. That she could have gone septic and died. And at my other place, the standards are not the same. Well, we have eight or nine pts so if someone is running a fever, I relay it to the charge RN who then will call the doc. She's considered our desk nurse and does all the calling of the docs. Does anyone else feel like every little thing we do wrong is picked out, but we don't get appreciated for anything? Plus they had a "code review" this afternoon regarding a code that happened involving a 53yr old pt whose now a vegetable because the husband is really upset, saying we didn't respond quick enough. I think I'm getting burnt out and I've only been a nurse for THREE years. Now my manager wants me to come in and read the policy book on cancer pts, which will take about two hours so I know the policies at their place. Like I'm just a crappy nurse. I do feel bad. I'm glad the pt is okay. But I don't need phone calls at home regarding this stuff. :angryfire :angryfire
    Amy
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  2. 20 Comments

  3. by   caroladybelle
    And your question is?
  4. by   AmyRN1227
    Was I really wrong not to call the doctor??? I'm trying to find out what everyone else's policy is regarding neutropenic pts. Because at my other place we wouldn't have called, just gave her the Tylenol and monitor her.
  5. by   caroladybelle
    I am a traveler and have been doing Onco/hem for 8 years.

    The ONS has suggested monitoring temp of neutropenic patients Q4 hours. The general guidelines are any temp greater than 100.4 on a neutropenic patient is cause for concern. If a fever work up (CXR/BCs/UCS)has not been done within 24 hours, the MD should be notified so that one may be done and or ABX initiated/altered.

    Hospitals that I have worked vary with between 100.4 and 101, and 38. metric as cause for concern. While the fevers are higher with non-neutropenic patients may have little concern, for a neutropenic patient to be sick enough to produce any fever at all, they are pretty severely ill just to get a low grade temp. And they can crash pretty rapidly after any temp spike.

    Surgeons will let the temps (101.5-102) get on up with surgical cases, but neutropenics have to have greater care.

    However, the manager could have told you when you came in. Calling you at home was a bit much. They also need to have a clue sheet for people that float in, stating some of these standards since many nurses would not be very familiar with the greater care taken regarding temps and neutropenic patients. Most Onco units that are that concerned with temp, usually have a BB post regarding theses issues to give you some standards to go by. No one has time to refer to those manuals (like you can find the info in them easily when you need it) ona regular basis.
  6. by   cannoli
    That's interesting info, will keep that in mind when I float to oncology or have that type of patient elsewhere.

    If they would only give us manageable, non-overwhelming assignments we'd be able to keep right on top of things like that, now wouldn't we?
  7. by   globalRN
    Yes, the 101 F fever should have been reported and the patient assessed and treated. Here are a few of my thoughts...

    Report should have been more thorough...how could the fact that the patient was neutropenic not been passed on? What assessment was done of the patient? The 'why questions' for a fever can often direct you to the correct action.

    A neutropenic patient could have crashed and burned.

    Having said that I just defended a family doctor of one of my patients:
    he was very unhappy with the care provided...the doctor had missed
    an early Broviac line tunnel infection and dismissed it as a skin allergy.
    When the patient saw me: I diagnosed and treated for a Broviac tunnel infection with IV Vancomycin which saved the line.
    The GP was actually very good(he followed the patient's HTN and I was
    impressed at the time he spent caring well for this man).
    I told the patient that IMHO the GP had taken good general care of him and that there is no need to throw the baby out with the bathwater. He may have missed the line infection because he is not as used to lines as we are nor as attuned to line complications...

    On med surg there are lots of different things to learn...chalk this up to learning...Cancer is one of the three biggest killers around....you will likely meet many neutropenic and thrombocytopenic patients in your career...so it is worthwhile to brush up on the care of these patients.
    All the best to you.
    Last edit by globalRN on Mar 12, '04
  8. by   Erin RN
    Wasn't the pt on Neutropenic precautions? Regardless of how busy you were, like a previous poster said a neutropenic pt can crash and burn in a big hurry so it is your responsibility to know what to watch for and what to do; a temp of 101 could have easily of went through the roof. I used to do Oncology and there is a lot to learn with the various transfusions, central lines, chemo and blood , hemolysis and neutropenia. I made cheet sheets which I put on my clipboard.
    Erin
  9. by   jemb
    Quote from AmyRN1227
    Was I really wrong not to call the doctor??? I'm trying to find out what everyone else's policy is regarding neutropenic pts. Because at my other place we wouldn't have called, just gave her the Tylenol and monitor her.
    I realize that you have gotten your answer by now-- yes, you should have called the doctor.

    But I realize, also, that you were hired into oncology as a fairly new nurse - about a year after you graduated. It is scary that you were not required to meet some basic oncology nursing knowledge requirements before you ended your preceptorship on the oncology floor. (Really makes me question the safety of a hospital whose policy, as you stated, is to give Tylenol and monitor a febrile neutropenic patient! Yikes!)

    Please take the time and effort to familiarize yourself with oncology nursing standards. Read your facilities' policies for oncology/neutropenia. Get info from ONS (Oncology Nursing Society).
    If one facility's policy truly is as you stated, please try to get the policy changed.

    Pass the info along to your co-workers, because they, too, may have simply gone along with an incorrect policy.
  10. by   nursemary9
    Just read you're note & I know others have answered you, but you are definitely wrong!!

    You need to read those policies!! A temp like this in a neutropenic pt. is an emergency & cultures need to be done!! I have seen people die within hours!
    Most of our hem/onc MD's don't even want tylenol given!!

    Sorry, I know things get hectic, but some things just have to be done!!

    This is one of my concerns, even in my hospital--Oncology nurses should be caring for oncology patients!! Too often floats, agency, registry are given these types of patients & they have no experience with them!! This puts the poor nurse in a very stressful situation.

    Sorry you were placed in this situation to begin with!!
  11. by   renerian
    Yes Amy I can see you now know about that type of client care. It is standard to call. Do you have standing orders for blood cultures/reporting/CXR or anything?

    I am always in favor of reading manuals. Everyone needs to do that. It is the basis of your care and if you follow them your in better coverage legally.

    renerian
  12. by   canoehead
    I worked one shift on an oncology unit, and know to watch for fevers in neutropenic patients and report them. Based on that I would say that taking your manager up on the opportunity to sit and read up on what you need to know would be a good idea.
  13. by   ProfRN4
    Unfortunately, in our profession, we learn things the hard way. And there is usually little room for error. This should have been made absolutely clear to you, while you were being trained. I was actually on the receiving end of a similar situation at the beginning of my onc. career- The previous RN didn't culture, call the MD and get the vanco started- the attending had a fit- but during her fit explained why, and how quickly a gram neg septic pt. can crash. At the time, I did not realize the rationale, but hoped I would have done the right thing had it been me. Don't beat yourself up over it. KNOWLEDGE IS POWER!! The is a world of educational opportunities in Oncology. Hook yourself up, even if your instituion is not proactive in cont. ed.
  14. by   julieK
    I can understand if the temp was something like 100.6 and you didn't report it b/c on other floors the policy is usually to report over 101. But with neutropenic pts, we report 100.4 and above. Any patient with >101 should have been reported, neutropenic or not.

    Don't worry, though. It will make you a better nurse. I got my head handed to me yesterday because I didn't make blood slips for cultures (something that the clerk should have done but didn't and it is of course the RN's responsibility to follow up) so the cultures weren't done in a timely manner and the doc threw a fit.

    -Julie

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