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 :-/
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
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.
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!
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.
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!
I'm interpreting this as, "I have anxiety because it is very early in the morning and I'm afraid to get negative feedback from a provider." It is the on-call providers job to handle these situations, obviously you should call them.
I'm interpreting this as, "I have anxiety because it is very early in the morning and I'm afraid to get negative feedback from a provider." It is the on-call providers job to handle these situations, obviously you should call them.
Yep, that was half of it. I truly wasnt certain though, if it being so close to 7 if it was appropriate to call just yet. Now I know many nurses call at 6am, and that that is perfectly acceptable.
The other half was anxiety about being chewed out by oncoming shift for still having some meds to pass. (Like last week's disaster of 6 ABTs I hung that all wanted to beep and beep, keeping me from getting done on time and pissing off oncoming shift.) I was like, really? Of the dozens and dozens of times I've used these pumps, they all wanted to create problems for me at once. Sigh...
(I'm relatively new at this facility and trying to get over caring about people being annoyed with me.)
NOCs is not my usual shift, its quite new to me. I am learning new things about overnights week by week as I pick up a NOC about once a week.
Ordinarily, with this particular patient, I would have assessed:
- her not new surgical site (I did see the site when I gave her insulin in her thigh - no s/s of infection
- her lower extremeties d/t lymphedema and hx of cellulitis
Specializes in Psych, Addictions, SOL (Student of Life).
Way back in the day when I was a new grad working L & D on noc I called a doctor to report a temp of 101.5 on a fresh C-section patient. The doctor said to me (over the phone) "Have you never learned about a normal Inflammatory response after surgery? Don't call me back unless it gets to 102.0" Still most of the good physicians I have worked with over the years always had a set of standing admission orders.
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!
Temperature would only be a small part of the overall picture that could potentially warrant being really worried about a patient, and by itself a temp of 101 is rather meaningless. If you're concerned about sepsis you would be looking for signs of impaired perfusion; is the BP below the patient's normal range and/or is the HR above normal range? Is their RR above normal range and/or O2 sats below normal range? Are there signs of organ hypoperfusion etc.? The more you know about a patient and can establish is normal vs abnormal, the less anxiety you'll likely feel about a situation.
I would check previous labs, symptoms, other vital signs/changes, also check facility policy manual on their specific criteria for calls. I have worked sub acute many years ago and they had specific rules as when we were to call the Physician for non emergency issues.
SleeepyRN
1,076 Posts
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.