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How do YOU handle these situations?

Posted

I'm admitting right off the bat that this, at the surface, sounds like a pretty silly question. But I'm asking anyway.

I work in a facility that follows rules pretty strictly. (Which is very refreshing.) I'm comparing this to a previous place of employment where everyone just gave certain meds without orders. Patient can't sleep? Here's a benadryl for you although there is no order for it.

My current situation is that it seems that within one to two hours before the end of my shift, there is suddenly a change in vital signs. Specifically....temperature.

I work Post-Acute Rehab. My main hours are 3-11. But, I pick up overnights about once a week.

It keeps happening that my patient's temperature is documented as normal when it's checked at 10-11pm by the oncoming overnight shift, then inevitably there is a patient with a fever all of a sudden at 6am. Patient is not on ABT. No dx of any infection, no orders for Tylenol for fever. Yesterday, 1 hour before end of shift, the 6am oncoming CNA tells me pt. has temp of 101.4

It's 6am. I REALLY REALLY don't want to call the provider at that time for Tylenol. Especially since they will be getting paged in a few hours with lab results anyway. Then paged again with a new admit. Then again for radiology results....etc. I know it's their job, but I still respect their time and want to cluster calls as much as possible. On the PM shift, we nurses always ask each other if we need to talk to a doctor/NP they are paging so as to minimize calls and respect the provider's time the best we can.

I, personally, when admitting patients, ask the providers for orders for Tylenol for fever and then notify them if I have to give it, specifically to avoid situations like this. In this scenario, I could just give the Tylenol, then day shift can notify the provider around 8am. (That's how long it takes for everyone to finally get report and start their work.) Or I can, if I'm still charting.

But if there are no orders for anything for fever and it's 6am in a post Acute rehab facility, what would you guys do in this situation?

When I first started there, I was in the habit of my previous place of employment, and about 10:50 pm a pt wanted Tylenol for pain. They had an order for Tylenol for fever. I just gave the Tylenol and reported it to the oncoming nurse, hoping to get an order for Tylenol for pain the next day. Bad habit, I know. I learned my lesson. She told me I better cover my butt and call and get an order. So at 11pm, I called and got the order.

So what to do. Call the MD/NP at 6, and give the Tylenol? Put a cool cloth on patients head til 8 when I can get an order? (But many patients start their PT as early as 6am :-/

Edited by SleeepyRN

Nicole5128, ADN, BSN, RN

Specializes in Emergency Medicine. Has 7 years experience.

I would just call. Although I dont routinely have to go through calling docs, at my place of work they say for us to wait until 6 am to start calling docs/consults unless it's life threatening/very important. I'd say 6 am is ok but that's just my opinion. And if the doc gets mad oh well. Just document document document :)

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

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.

I'd call. There's always the chance that the MD would want blood cultures, a urine culture, or chest X ray.

TheCommuter, BSN, RN

Specializes in Case mgmt., rehab, (CRRN), LTC & psych. Has 15 years experience.

I work Post-Acute Rehab.
I also work in post-acute rehab...

Our medical director is also the attending physician for all patients who are admitted. Since he's been the medical director for 20+ years and dislikes phone calls for non-emergent issues, every patient has an extensive list of standing orders initiated upon admission. The orders include Tylenol, Norco, Phenergan, Catapres, Dulcolax, Glucagon, Restoril, D50, etc.

Hence, he's created a system whereby there's no need to call him unless something emergent occurs (read: chest pain, respiratory distress, sudden unilateral weakness).

A patient with a temp of 101.4 doesn't necessarily benefit from interventions to bring the temp down, such as Tylenol.
Our facility protocol is to not administer Tylenol or other anti-pyretics unless the temperature is greater than 101.5 degrees.

iluvivt, BSN, RN

Specializes in Infusion Nursing, Home Health Infusion. Has 32 years experience.

Ok, If there is an indication for fever reduction because not all fevers need to be treated, then you need to call if the patient has a change in their condition. If there is no indication for fever reduction based upon your assessment then it can wait and you can get the order later just as a comfort measure.

For example, a few classes of medications are known to cause fevers and sometimes you do not want to reduce a fever as there is some evidence that suggests that antipyretics and cooling techniques may prolong the course of an illness.

But back to a general rule of nursing: You have a legal duty to report to the provider any significant change in condition of a patient. So even if you have an order already to treat a fever with Acetaminophen,you may still need to report it if it a new onset especially if notice other things such as an elevated WBC ct/ neutrophil count,cloudy urine or chills.

Been there,done that, ASN, RN

Has 33 years experience.

A temp of 101.4 requires notification. I would expect orders for a full sepsis work-up.

You should approach management and nursing education to obtain standing orders for OTC medications.

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.

I'm thinking more along the lines of what to do in the moment. I know a few reasons her temp might be up because I'm pretty familiar with her as a readmit. Im betting when I go back Friday, she will be on IV Zosyn.

However, I can't record a temp over 100.1 and place no intervention. Per facility policy. (Other nurses have rolled their eyes at me when coming on shift because I didn't give Tylenol for a temp of 99. Im thinking really, guys? Go back and review physiology please.)

So I completely agree with you on the body doing its job by raising the temperature. It creates an environment not conducive for infectious microorganisms. Our in house doctors treat fever above 100.1.

Without an order or putting a cool compress on her, there is nothing else I can do for her in that moment, being an hour away from end of shift and in the middle of med pass. I would endorse further interventions.

Ok, If there is an indication for fever reduction because not all fevers need to be treated, then you need to call if the patient has a change in their condition. If there is no indication for fever reduction based upon your assessment then it can wait and you can get the order later just as a comfort measure.

For example, a few classes of medications are known to cause fevers and sometimes you do not want to reduce a fever as there is some evidence that suggests that antipyretics and cooling techniques may prolong the course of an illness.

But back to a general rule of nursing: You have a legal duty to report to the provider any significant change in condition of a patient. So even if you have an order already to treat a fever with Acetaminophen,you may still need to report it if it a new onset especially if notice other things such as an elevated WBC ct/ neutrophil count,cloudy urine or chills.

True. I shouldn't have made tylenol the issue, but rather, ask others opinions on if I should call for the change in condition at 6 or endorse it being so close to 7am. Granted, endorsing anything, God forbid, would create an uproar.

Anyway, she wasn't exhibiting discomfort, while last week a patient was miserable with chills at only 101.3 or so.

Thanks everyone. I'm going to go ahead and make the call next time. Let the provider be irritated if he/she decides to be. I can leave knowing I advocated for my patient and did my job. :-) And in this case, if the NP wanted labs, the lab people were in the building right then, so I could have gotten labs done that morning instead of having to wait a day.

Oh, and she had been scheduled for a special case of being allowed to go out on pass later. It's normally not allowed for her. I'd hate for her temp to go up while she's out of the building and then end up getting chills and feeling miserable without any care.

iluvivt, BSN, RN

Specializes in Infusion Nursing, Home Health Infusion. Has 32 years experience.

Good plan! let the doctor or provider decide if this is a case in which they do not want to treat a fever based upon their knowledge of the patient and the assessment in which you will relay to them. You did your duty and reported a change in condition and no one can ever fault you for that!

For educational purposes ...look at what medications may cause a fever

Anticholinergics, e.g., antihistamines, benztropine, tricyclic anti-depressants

Hallucinogenic amphetamines, e.g., MDMA (a.k.a. ecstasy)

Monoamine oxidase inhibitors (MAOIs)

Salicylates

Selective serotonin re-uptake inhibitors (SSRIs), e.g., fluoxetine, paroxetine can cause the serotonin syndrome, which increases body temperature.

Sympathomimetics, e.g., amphetamine, cocaine, phencyclidine (PCP)

Thyroid medications, e.g., levothyroxine

A temp of 101.4 requires notification. I would expect orders for a full sepsis work-up.

You should approach management and nursing education to obtain standing orders for OTC medications.

We recently spoke of standing orders in a meeting, and apparently the reason we don't automatically have standing orders for everyone for OTC meds and some other meds is because unlike a hospital, we don't always have an MD in the building.

BUT, I can ask in individual cases like during a new admit.

Good plan! let the doctor or provider decide if this is a case in which they do not want to treat a fever based upon their knowledge of the patient and the assessment in which you will relay to them. You did your duty and reported a change in condition and no one can ever fault you for that!

For educational purposes ...look at what medications may cause a fever

Anticholinergics, e.g., antihistamines, benztropine, tricyclic anti-depressants

Hallucinogenic amphetamines, e.g., MDMA (a.k.a. ecstasy)

Monoamine oxidase inhibitors (MAOIs)

Salicylates

Selective serotonin re-uptake inhibitors (SSRIs), e.g., fluoxetine, paroxetine can cause the serotonin syndrome, which increases body temperature.

Sympathomimetics, e.g., amphetamine, cocaine, phencyclidine (PCP)

Thyroid medications, e.g., levothyroxine

Awesome! Thank you for the list! I appreciate it :-)

Since synthroid dosages are aways changing based off labs and symptoms, that makes complete sense. I honestly never thought to look for an increase in temp when synthroid was increased. Don't know why as it is obvious when I outright think about it lol.

BuckyBadgerRN, ASN, RN

Specializes in HH, Peds, Rehab, Clinical. Has 4 years experience.

Tylenol for fever, either PO or rectally is a standing order in my facility. It is on every admitting document for every patient, removed only if there is a reason for a resident not to have it. Push for this!

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

A temp of 101.4 requires notification. I would expect orders for a full sepsis work-up.

You should approach management and nursing education to obtain standing orders for OTC medications.

I would hope you mean a sepsis "screening" rather than a "full sepsis work-up". Only a sepsis screening is indicated for a temp of 101. Not every person with a temp of 101 requires things like central line placement for CVP and ScVO2, that should only be considered for a positive screening.

NRSKarenRN, BSN, RN

Specializes in Vents, Telemetry, Home Care, Home infusion. Has 44 years experience.

OP is working in POST ACUTE REHAB

Looking for interventions /advice for this practice setting. ;)

amoLucia

Specializes in LTC.

I usually made all my calls around 6a (excepting really emergent ones). I figured the provider was probably getting up about then and ready to start the day.

I freq gave Tylenol for lower temps (yeah, the order says 'greater than 101'). I assessed and would document administration for "GENERAL DISCOMFORT" which I interpreted as being jusssst a shade shy of being in "PAIN".

I realize I was splitting hairs. But personally, I become very uncomfortable with even minor temp elevations. I flush beet-red. I air-fluff my blankets, turn my pillow, I'll even shower. I become miserable, so I would treat.

I didn't take it lightly to be making phone calls during the nite shift for minor things. I wanted providers to recognize me and respect my judgment if I had to call during NOC. Like my message was for something important that really needed their intervention. And when I called, I wanted to be called back ASAP because I realllly needed them to call me back.

I guess that was a benefit of working NOCs. You learned how to differentiate & prioritorize situations. And that SBAR process was practiced to do so.

I would hope you mean a sepsis "screening" rather than a "full sepsis work-up". Only a sepsis screening is indicated for a temp of 101. Not every person with a temp of 101 requires things like central line placement for CVP and ScVO2, that should only be considered for a positive screening.

We get admits all the time coming from a brief hospital stay d/t sepsis. This particular patient is actually one of them and has had 2 piccs inserted and removed since her admit and readmit with us.

I'm interested to see tomorrow if she's back on ABT. I'm kicking myself for not looking at her legs

She has lymphedema to BLE, a hx of cellulitis, and DM.

I'll chalk it up to a learning experience for Nocs and try to not beat myself up over it. I didn't care for her the way I would have during my regular PM shift. I was too busy worrying about day shift being pissy if I weren't ready right at 7am for report, and rushing to beat the clock to get my 12 accuchecks and rest of med pass done. I won't make that mistake again!

Thanks so much, everyone!