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.

[CP2013]

My first thought is that the IC Vanc might not have been effective. If patient temp was previously stable, it could be new infection or may be that the current infection is resistant to current therapies. Most facilities have parameters like "call for pt temp greater than x" and most places I have worked the temp greater than 101.5 or 102 would be reason enough to call.

[Pangea Reunited, ASN, RN]

Aside from learning each physician's preferences, I don't see a solution. You're damned if you do and damned if you don't.

[madwife2002, BSN, RN]

I would have called the Doctor re elevated temp of 103 I would be worried about sepsis and the ineffective anti-biotic

[OCRN3]

I think your rationale for not calling was right. I don't think I would have called at 4 am either. There are doctors that have preferences and do get mad if you call or don't call. Just make sure you call this particular doctor for anything abnormal no matter what time it is from now on.

Sent from my iPhone using allnurses.com

[mluvsgnc]

It seems like the order would have been the answer. As cp2013 mentioned, almost every order has parameters for "a temperature greater than X" to call the physician. Then if the doctor got mad that you called him at 4am, you could state that you were following the (his) order. Also, you would give the doc your rationale for calling ("I'm concerned about sepsis" or "the infection might be resistant to the meds" etc.), which are both valid concerns.

[nurseprnRN, BSN, RN]

It seems like the order would have been the answer. As cp2013 mentioned, almost every order has parameters for "a temperature greater than X" to call the physician. Then if the doctor got mad that you called him at 4am, you could state that you were following the (his) order. Also, you would give the doc your rationale for calling ("I'm concerned about sepsis" or "the infection might be resistant to the meds" etc.), which are both valid concerns.

You would absolutely be within your scope of practice as an RN to say this, too, and don't let him or anyone else tell you otherwise.

[amoLucia]

I would have called the Doctor re elevated temp of 103 I would be worried about sepsis and the ineffective anti-biotic

Without a doubt, I would have called. While all your reasons seem plausible, I would consider this a significant change of status for a pt who was otherwise showing signs of improvement/recovery. This signals a setback as something else seems to be brewing and the MD needs to be notified in a timely fashion.

If this MD got her knickers bunched up because of the time, well then, so be it. Her problem. But when in doubt, I always try to err on the safe side. I'd have called, if nothing more than to CYA (mine).

[Billy_Ruben]

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.

[meanmaryjean, DNP, RN]

A slightly different tack: You're not 'bothering' them - IT'S THEIR JOB!

I learned long ago from a gruff old surgeon- the doc works for the patient, not the other way around.

Always call.

[LadyFree28, BSN, LPN, RN]

A slightly different tack: You're not 'bothering' them - IT'S THEIR JOB! I learned long ago from a gruff old surgeon- the doc works for the patient not the other way around. Always call.[/quote']

THIS...

I would've called.

And you are not dumb; you made a decision based on prior limited knowledge; know you know and are more prepared for next time. :)

[Guttercat, ASN, RN]

We ALL have moments of "feeling dumb" with those "should I call or shouldn't I call" moments. I know I've had my share.

Yes, calling the doc was entirely appropriate, as another poster mentioned-- it was a significant status change in a patient that had been humming along. Bacteremia/septicemia can be a very big deal.

Don't beat yourself up, though. It's all part of adding more knowledge and critical thinking to your quiver.