How do YOU handle these situations?

[SleeepyRN]

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 :-/

[SleeepyRN]

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.

Unfortunately, they won't. We even just discussed this at our jcaho training class, and it came up. Our facility will not have these standing orders. We have to ask the provider during an admit for any standing orders.

A admitted a pt a couple weeks ago and saw there was nothing ordered for fever. So when I called the NP to verify orders, I asked if I could get a PRN order for Tylenol in case of fever. I just *felt* he was going to need it. She said yes, no problem. But it's up to each provider/NP as to if they will give standing orders.

[dream'n, BSN, RN]

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.

It seems that many (and sometimes most) condition changes, etc. happen right before shift change. A change in a patient's condition is a priority over passing your 'regular' medications on time. Sorry I know it sucks to be caught up with everything and then the crap hits the fan right before your relief arrives, but I consider it MY responsibility because it happened on MY shift. I would never pass off a condition change to the next shift just so I could leave on time. No way. You needed to take the time to assess the patient more carefully and place the call to the Dr. A fever can be a late sign in the elderly of serious infection and your patient had recently been released from the hospital for sepsis. Not to mention that they recently also had PICC lines. Sepsis can progress very quickly and be very deadly.

My philosophy is that I'd rather break a facility rule, then provide substandard nursing care. If I felt the Dr should be called, I would call them; I'd rather find another job then having to answer to the BON for bad care. If the patient had a bad outcome, the BON wouldn't care less that the facility didn't want the Dr disturbed or the patient sent to the hospital.

[SleeepyRN]

It seems that many (and sometimes most) condition changes, etc. happen right before shift change. A change in a patient's condition is a priority over passing your 'regular' medications on time. Sorry I know it sucks to be caught up with everything and then the crap hits the fan right before your relief arrives, but I consider it MY responsibility because it happened on MY shift. I would never pass off a condition change to the next shift just so I could leave on time. No way. You needed to take the time to assess the patient more carefully and place the call to the Dr. A fever can be a late sign in the elderly of serious infection and your patient had recently been released from the hospital for sepsis. Not to mention that they recently also had PICC lines. Sepsis can progress very quickly and be very deadly.

My philosophy is that I'd rather break a facility rule, then provide substandard nursing care. If I felt the Dr should be called, I would call them; I'd rather find another job then having to answer to the BON for bad care. If the patient had a bad outcome, the BON wouldn't care less that the facility didn't want the Dr disturbed or the patient sent to the hospital.

I agree with most of what you said. I have already stated that I am kicking myself for how I handled the situation. However, I would not consider waiting 1 hour to call the NP dangerous. I placed a cool compress on her, and pulled the blanket down to have the sheet covering her. She had no chills nor discomfort.

It had NOTHING to do with getting out on time. While in an ideal world, I would like to go home to my family, I stay late quite often to continue providing care if a nurse needs help inserting an IV, foley, dressing change, charting....

It's also not just facility rules, it's law that meds must be passed within a 2 hour window.

She is not elderly. And I have stated that I learned my lesson with NOC shift and appropriate time to call.

Nursing is a 24 hour process. Endorsement has to happen, or we would never get out. I took your tone in writing as if I were flippant about the situation and WANTED to "pass it off" as if I simply didn't want to deal with it.

I would never have posted my question if I hadn't considered it an important matter and what to do next time it happens.

Thank you for your input.

[Garden,RN, ASN, RN]

I always felt there were too many ambiguities like this is our profession. So many of these things could be solved if they had standing orders and other resources.