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.
i haven't read the whole thread but it is important for you to look up and know your policies. when things go wrong it is the policies and acting within those policies that will save you. acting "outside" hospital policies and procedures no matter how mundane can cause you your job if the right circumstances occur. i only say this because i care and wouldn't want anything to happen..... and it's plain to see that you care or you wouldn't care about what that putz of the md said to you. if i had a dime for everytime a doc made a mountain out of a mole hill, or got p.o'd about something, i'd be richer than warren buffet.
that being said....i probably would have called. in quads the way they respond to small little changes can be quite dramatic especially in the presence of autonomic dysreflexia.
autonomic dysreflexia, "ad" also known as "autonomic hyperreflexia or hyperreflexia, is a potentially life threatening condition which can be considered a medical emergency requiring immediate attention. ad occurs most often in spinal cord-injured individuals with spinal lesions above the (t6) spinal cord level. acute ad is a reaction of the autonomic (involuntary) nervous system to overstimulation. it is characterised by severe paroxysmal hypertension (episodic high blood pressure) associated with throbbing headaches, profuse sweating, nasal stuffiness, flushing of the skin above the level of the lesion, bradycardia, apprehension and anxiety, which is sometimes accompanied by cognitive impairment. the sympathetic discharge that occurs is usually in association with spinal cord injury (sci) or disease (e.g. multiple sclerosis). ad is believed to be triggered by afferent stimuli (nerve signals that send messages back to the spinal cord and brain) which originate below the level of the spinal cord lesion. it is believed that these afferent stimuli trigger and maintain an increase in blood pressure via a sympathetically mediated vasoconstriction in muscle, skin and splanchnic (gut) vascular beds.
the diagnosis is usually not subtle, although asymptomatic events have been documented. autonomic dysreflexia differs from autonomic instability, a term used to describe the variety of modest cardiac and neurological changes that accompany a spinal cord injury, including bradycardia, orthostatic hypotension, and ambient temperature intolerance. in autonomic dysreflexia, patients will experience hypertension, sweating, and erythema (more likely in upper extremities) and may suffer from headaches and blurred vision. mortality is rare with ad, but morbidity such as stroke, retinal hemorrhage and pulmonary edema if left untreated can be quite severe. older patients with very incomplete spinal cord injuries and systolic hypertension without symptoms are usually experiencing essential hypertension, not autonomic dysreflexia. aggressive treatment of these elderly patients with rapidly acting antihypertensive medications can have disastrous results.
the risk is greatest with cervical spinal cord lesions and is rare with lesions below t6. it has rarely been reported in spinal cord lesions as low as t10. the first episode may occur weeks to years after spinal cord injury takes place, but most people at risk (80%) develop their first episode within the first year after injury.
this condition is distinct and usually episodic, with the patient experiencing remarkably high blood pressure (often with systolic readings over 200 mm. hg), intense headaches, profuse sweating, facial erythema, goosebumps, nasal stuffiness, and a "feeling of doom". an elevation of 40 mm. hg. over baseline systolic should be suspicious for dysreflexia.
proper treatment of autonomic dysreflexia involves administration of anti-hypertensives along with immediate determination and removal of the triggering stimuli. often, sitting the patient up and dangling legs over the bedside can reduce blood pressures below dangerous levels and provide partial symptom relief. tight clothing and stockings should be removed. catheterization of the bladder, or relief of a blocked urinary catheter tube may resolve the problem. the rectum should be cleared of stool impaction, using anaesthetic lubricating jelly. if the noxious precipitating trigger cannot be identified, drug treatment is needed to decrease elevating intracranial pressure until further studies can identify the cause.
drug treatment includes the rapidly acting vasodilators, including sublingual nitrates or oral clonidine. topical nitropaste is a convenient and safe treatment—an inch or two can be applied to the chest wall, and wiped off when blood pressures begin to normalize. autonomic dysreflexia is abolished temporarily by spinal or general anaesthesia. these treatment are used during obstetric delivery of a woman with autonomic dysreflexia.
autonomic dysreflexia can become chronic and recurrent, often in response to longstanding medical problems like soft tissue ulcers or hemorrhoids. long term therapy may include alpha blockers or calcium channel
blockers.
complications of severe acute hypertension can include seizures, pulmonary edema, myocardial infarction or cerebral hemorrhage.
the cause of autonomic dysreflexia itself can be life threatening, and must also be completely investigated and treated appropriately to prevent unnecessary morbidity and mortality. the consortium for spinal cord medicine has developed evidence-based clinical practice guidelines for the management of autonomic dysreflexia in adults, children, and pregnant women.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
from the information the OP provided, didn't sound like AD was the concern.... COULD have been later in the morning, but not with that 99 temp...
I agree, but early on (especially with a new quad) it needs to be apart of the differential. Their ability to temperature regulate is affected....her actions,uncovering the patient, were appropriate. I have found however that nurses that work the floor unaccustomed with quadraplegics......are unaware of AD, it's implications, indcations, actions, causes, and consequences......is why I posted the stuff about AD. Sounds like this kid is local and going to be seen at her facility.
The doctor was snippy. Write him a fools pass and realize you did fine.
One thing I did think about- how about his lungs? Quadraplegics are very prone to respiratory infections.
He has crackles, but it was no different than before. Doc's were aware, but he is unable to cough up his secretions. He tells us when he thinks he needs suctioning, it is maybe every hour-2 hours suctioning. He likes the cough assist as well.
We are required to report temps of 101 or above, and oral is the preferred route.. However, working in a large teaching hospital, I have the advantage of a resident who is always awake & routinely rounding at night. AD is definitely a concern but it sounds like that patient could've benefitted from a breathing treatment & some good old chest PT :)
Ignore the grumpy resident & move on.... I'm sure they'll be plenty more to come :)
I don't know, given the pt's diagnosis and the fact that he was to be discharged that day- I'd probably have called. 101.4 is a fever and there is a reason for it. Neuro patients can be fragile.
MassED, BSN, RN
2,636 Posts
from the information the op provided, didn't sound like ad was the concern.... could have been later in the morning, but not with that 99 temp...