How do YOU handle these situations?

calivianya, BSN, RN · Oct 16, 2015

I work in a hospital, but my facility follows the rules pretty strictly, too. We have to have the specific indication we're using a med for as the reason to give it. Even if we have Tylenol ordered for pain, we cannot give it for fever.

I just put a fan on the patient. Some of the intensivists get a little bit of a 'tude if I call about a fever in the middle of the night. Easier just t throw a fan on the patient and make day shift aware, so they can address the fever when a physician actually rounds. I would not call someone in the middle of the night unless the fever is climbing and significantly high, like 102/103.

Bob Loblaw · Oct 16, 2015

Obviously at that facility the docs want to be called for everything otherwise they would leave specific standing orders for fever, headache, nausea, stomach upset, insomnia etc with instructions for thresholds for notification. Our overnight pts have a plethora of PRN meds with dosage schedules and limits. I think the main thing is to be able to look @ your entire pt and make a judgement call- is this pt sick (they're in the hospital for something, yes?) or is this pt really really sick (downward spiral)- otherwise RN's become simple pill passers. I think a tremendous help has been the EMR where one can do trend analysis of vitals, I/O etc.

Our Sepsis Protocol Ruleout has several factors besides temp- H/R, BP, Res, age

SleeepyRN · Oct 16, 2015

It's amazing how much time you waste wringing your hands, and asking every other nurse on the unit what they think.
I'm including myself in the above.

What do mean asking other nurses on the unit? I didn't ask anybody at work.

SleeepyRN · Oct 16, 2015

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'm very aware of this, but thank you. I'm not concerned about sepsis as she has no s/s of such right now, I was just stating that we do care for patients recovering from sepsis as you mentioned the difference between sepsis screening and sepsis workup. We do either based on our assessment.

My bet: cellulitis, will be on zosyn today when I go to work.

RainMom · Oct 16, 2015

It's amazing how much time you waste wringing your hands, and asking every other nurse on the unit what they think.
I'm including myself in the above.

What do mean asking other nurses on the unit? I didn't ask anybody at work.

I think imintrouble just means that for a lot of us nurses, especially on nocs, when a situation isn't cut & dry, we tend to ask a lot of opinions & worry over it for a time before taking action. Then we worry about it some more & second guess ourselves.

Oh'Ello, BSN, RN · Oct 16, 2015

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 guess it depends on the language of your particular algorithm. Positive screen > Workup and Positive Workup > Treatment. Our work up does in no way shape or form include central line placement. Positive screen comes from Vitals and physical assessment findings, And the work up is diagnostics. A positive screen where I work, earns you Blood Cultures x2, Urine cultures, UA/CS, chest x-ray, CBC/Diff and Lactate.

canigraduate · Oct 16, 2015

A lot of the time, an early morning temp is a sign of congestion. Have the patient sit up and cough. I've dropped a few temps that way.

If it's a recurring temp, in my experience, it's often due to an underlying infection, usually a UTI.

I'll go along with the flow and say that 6AM is a perfectly fine time to call a doc. That's when I usually call for non-emergent reasons.

Anna Flaxis, BSN, RN · Oct 16, 2015

I would follow the nursing process and recheck a full set of VS personally, do a head to toe assessment, and depending on my observations, I would

A) Try nursing interventions such as pulmonary toileting and recheck VS in one hour, or

B) Call the provider,

or

C) Both A & B

regardless of time of day.

Assessment: Gather VS, do head to toe

Diagnosis: Elevated body temp or not? Obvious source or not?

Planning: Nursing interventions (pulmonary toileting, adjusting room temperature or bed linens, cool cloth to forehead, etc)

Intervention: Do one/some of the above

Evaluation: Did it work? Go back to step 1-Assessment

SleeepyRN · Oct 17, 2015

I think imintrouble just means that for a lot of us nurses, especially on nocs, when a situation isn't cut & dry, we tend to ask a lot of opinions & worry over it for a time before taking action. Then we worry about it some more & second guess ourselves.

Ahhhh definitely lol.

SleeepyRN · Oct 17, 2015

One thing that has always bothered me about interpreting temps is not taking into account the route. If rectal is one of the most accurate routes, using the rubric, my patient's oral temp of 101.4 would really be a true body temp of about 102.3.

SleeepyRN · Oct 17, 2015

I would follow the nursing process and recheck a full set of VS personally, do a head to toe assessment, and depending on my observations, I would
A) Try nursing interventions such as pulmonary toileting and recheck VS in one hour, or
B) Call the provider,
or
C) Both A & B
regardless of time of day.
Assessment: Gather VS, do head to toe
Diagnosis: Elevated body temp or not? Obvious source or not?
Planning: Nursing interventions (pulmonary toileting, adjusting room temperature or bed linens, cool cloth to forehead, etc)
Intervention: Do one/some of the above
Evaluation: Did it work? Go back to step 1-Assessment

If it were another time of day, I'd agree. This was one hour before change of shift, smack dab in the middle of med pass, accuchecks giving insulin.... I'd keep my assessment focused in this particular area from now on and notify MD at 6am and get back to my med pass. The rest is on day shift.

whisperingsage · Oct 18, 2015

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 :-/

Lucky me, my facilities had tylenol and several other things (cough drops, robitussin, etc) as SOP orders and it wasn't an issue. You might want to ask your DON or other responsible admin to make certain things part of the SOP standing orders.