Losing sleep over this, need support from fellow RN's.
Had a patient last night that was hit by a car. He is quadriplegic and is ventilator dependent. He is 19 years old and has been with us for a while.
He is to be discharged home with home care nurse/mother and girlfriend doing cares. Because his mom does not yet have a vehicle that can transport him, we had to arrange a ride. Well this ride can only pick him up at 10am. Pretty early for a discharge! So it is 3am the morning of his discharge (today this am) and the PCT comes to be and says he has a temp of 100.4 (axillary). I went him, asked him how he was feeling he said fine but a little warm. I set him up with a fan and pulled off the blankets leaving him with just a sheet as he requested. I had to go back in at 5am for a lab draw they needed. So i waited until 5am to get another temperature, thinking maybe he was just warm. I went in at 5am, and i got a temperature of 99.1 oral. A little feverish, but better than before. I looked on the MAR and didn't see anything i could give for a temperature. So i left it and would report it off to the morning shift at 6:30am so they could report it off to the doctors on their morning rounds at 7am.
Ok, so it's 6:30 exactly and the doctor, a new resident actually, came up to me and the oncoming nurse as we are doing report and he was like "did you notice he had a temperature of 100.4 last night?" i told him the situation and he rolled his eyes and said to me like i'm stupid "Why didn't you call someone to get an order for something?"
He seemed very annoyed and he was like "Now i have to deal with this and decide what to do before 10am. you really should have paged the on-call" then he walked away not saying a word after that.
i'm like losing sleep over it, what did i do wrong?? he was feeling ok, didn't feel feverish. i really felt it could have waited until morning rounds. And besides, if i wold have given Tylenol (which i didn't have an order for, but would have gotten) then it would just mask the fact that he has a fever. It's not like the tyelnol i going to "cure" whatever is causing his "fever." given, we don't even know if it is a true fever because he is very warm blooded and is always complaining of being hot.
Was i in the wrong?? i'm loosing sleep over it, and i have to go back in for 2 more nights of a night shift this week.
Specializes in Infectious Disease, Neuro, Research.
"Maybe." I would have bumped the 0500 CBC to a STAT, and correlated the result to the past 24-48*. He's been with you "awhile" so I assume his post-trauma WBCs have pretty well stabilised. If his 0500 wbc was moving up, yeah, it would have been worth a call(but that could really wait for morning rounds, for my group). Check breath sounds & wounds for consolidation & new/purulent drainage, so that you'd have some positive/negative findings to report.
I'm ass-u-ming you didn't see any of that, since you don't mention it, so you're simply cursed with a whiney resident.
If he's working on something vent-acquired, honestly, he's probably better off at home, with discharge antibiotics and a 14 day follow-up.
"Maybe." I would have bumped the 0500 CBC to a STAT, and correlated the result to the past 24-48*. He's been with you "awhile" so I assume his post-trauma WBCs have pretty well stabilised. If his 0500 wbc was moving up, yeah, it would have been worth a call(but that could really wait for morning rounds, for my group). Check breath sounds & wounds for consolidation & new/purulent drainage, so that you'd have some positive/negative findings to report.
I'm ass-u-ming you didn't see any of that, since you don't mention it, so you're simply cursed with a whiney resident.
If he's working on something vent-acquired, honestly, he's probably better off at home, with discharge antibiotics and a 14 day follow-up.
does have wounds from being hit by a car. No abnormal drainage, just the normal serousangenous we had been getting all the time he had been with us. "a while" to me, for clarification is about a month or so. WBC have all been normal, wasn't around to see the 5am wbc count, but i got it!! I agree, something for fever should have been ordered, but i never even bothered to look because he has never needed it. Given his situation, i'm surprised it wasn't ordered either. considering it seems like it is almost a standing order unless they have some hepatic issues, even then i can give something to them.
it just makes me angry, because you can never make these people happy. they want you to call with this, but when you do they get annoyed. and if you don't call they get annoyed. You just lose either way.
From now on, for this doc, call his happy a** for anything other than textbook normal :) AND ask him for parameters on vs- regardless of shift. Some docs like stuff called in sooner (with this guy being a quad, he's at risk for a lot of stuff- could be part of why he was miffed).
Most of the docs I've worked with don't medicate for a temp under 101.0....AT 101, they want APAP, and a follow-up temp in an hour or so, then if there's an issue, call them. My 'favorite' docs left parameters for UAs and blood cultures/CBCs for temps in some of their patients- I liked those....I could go ahead and get things going. :) It also depended on any concomitant disorders they had.
If in doubt, call- if they get grouchy, remember you didn't hold a gun to their head and force them into med school - not your problem he/she is on call..... If you're doing what YOU feel is in the best interest of the patient and can back it up, blow off any hot-aired MD, who is going to whine no matter what you do :) If he/she makes a valid point- learn from it and move on. There will ALWAYS be a jerk in the bunch....and if you're newer at this than the resident, well, sh*^ rolls down hill :)
Find a good movie, get some popcorn, and think of this guy being reamed by the attending for something
Second, and MOST important, his repeat temp was 99 - NOT febrile by any stretch of the imagination.
Third, you need to speak up and state what his repeat temp was, not one earlier in the night. And further more, you don't need to call for an order for a temp UNDER 100 in any place I've ever worked.
You acted totally appropriately. Who gives a med for 100.4??? Taking off the covers was the best thing to do. And his temp came down, anyway. 99.1 is NOT a fever if oral. Nothing to worry about.
The doc is a toad. If you had called him at 3 AM he would have been annoyed. I am surprised that there weren't any prn orders for fever.
I do have one question - - why Axillary temp one time, then Oral temp at another time? Consistency is important.
oh, what power! Now that nurse needs to call THIS resident (I'm sure she remembers his or her name!!!) at 0300 the next time there's some inane request.
If you lost sleep over every negative comment a doc said to you....you get the idea?
Don't sweat the small stuff. Typically, if the patient's temp is > 100.5 at my hospital, we are to report it and/or give Tylenol. Then probably panculture etc, etc. So, I kind of do agree with you and the MD. If the patient was brewing some sort if infection, then the more quickly you identify it, the easier it is to treat.
You also wrote that your next temp was 99.1 ORAL. Axillary is much more accurate, and your repeat should have been from the same source IMO. What have his temps been over the past 24-48 hours?
Please try to get some rest. I hope this helps.
no, axillary is not more accurate than oral.
"The most commonly used site is the sublingual area. It is considered a fairly accurate site due to its close proximity to the lingual and external carotid arteries (DiBenedetto, 1993). However, on average it runs lower than core temperature by approximately 0.8° F (0.5° C). Correct placement of the oral thermometer is important for accuracy. Differences in readings can vary by as much as 1.7° F (0.95° C) from the rear sublingual pocket to beneath the frenum in front of the floor of the mouth (Erickson, 1976). "
does have wounds from being hit by a car. No abnormal drainage, just the normal serousangenous we had been getting all the time he had been with us. "a while" to me, for clarification is about a month or so. WBC have all been normal, wasn't around to see the 5am wbc count, but i got it!! I agree, something for fever should have been ordered, but i never even bothered to look because he has never needed it. Given his situation, i'm surprised it wasn't ordered either. considering it seems like it is almost a standing order unless they have some hepatic issues, even then i can give something to them.
it just makes me angry, because you can never make these people happy. they want you to call with this, but when you do they get annoyed. and if you don't call they get annoyed. You just lose either way.
really, don't sweat the small stuff. It's ALL small stuff when someone is breathing down your neck over something so trivial. Save that energy.
NO idea. I still don't know when to page for "temps" I almost always page if it is above 100.5. some drs culture everyone for anything, some get annoyed at being paged. i don't care anymore. I just let someone know. If you page about 100.9 to one he/she will say" why are you paging me, that is not a fever!" If you don't page about 100.3 to another he/she will think you are an incompetent fool...........
oh, what power! Now that nurse needs to call THIS resident (I'm sure she remembers his or her name!!!) at 0300 the next time there's some inane request.
I definitely would have called ... I work with quads and paras so it is different for them. A maybe not so high temp for a quad can mean a plethora a things. Nurses need to familiarize themselves with AD and other things that can happen from an innocent temp.
Rob72, ASN, RN
685 Posts
"Maybe." I would have bumped the 0500 CBC to a STAT, and correlated the result to the past 24-48*. He's been with you "awhile" so I assume his post-trauma WBCs have pretty well stabilised. If his 0500 wbc was moving up, yeah, it would have been worth a call(but that could really wait for morning rounds, for my group). Check breath sounds & wounds for consolidation & new/purulent drainage, so that you'd have some positive/negative findings to report.
I'm ass-u-ming you didn't see any of that, since you don't mention it, so you're simply cursed with a whiney resident.
If he's working on something vent-acquired, honestly, he's probably better off at home, with discharge antibiotics and a 14 day follow-up.