Is there any truth to this?

Susie2310 · Apr 14, 2013

But there is where I get hung up. If there IS something brewing, Tylenol is simply going to mask it and delay treatment. I can promise that no doc I work with is going to order blood cultures for 98.6, no matter what their baseline is.

not.done.yet, would the doctors you work with not order blood cultures for signs/symptoms of possible sepsis even if the patient's temperature was not significantly elevated, as it may not be in elderly patients who have sepsis, or in patients who are immunocompromised due to chemotherapy?

UTVOL3 · Apr 14, 2013

I wouldn't ask for a sepsis work-up if a patient told me this and had no other symptoms. If they said this and were otherwise feeling unwell, I'd pass that along to the doc. If they wanted tylenol, and it was ordered for the symptoms the patient was complaining of, I'd give it and document why. There is no harm in doing a little education about how tylenol is not without side effects.

I also run a low normal throughout the day, and I am quite miserable at 99.1. I medicate myself when I am uncomfortable and I would assume the patient does the same when they're at home.

kanzi monkey · Apr 14, 2013

I always go by symptoms. If the fever is less than 101 (and depending on other factors such as recent surgery) and the patient "feels like crap"--specifically malaise, sweats, or rigors--they will get at least a partial workup. Temp >102 generally buys a full workup (though there are outliers).

I'm on the fence about holding Tylenol. In my experience, for the folks that are spiking from an actual infection, it is a drug of mercy. If u have rigors and a temp

But yeah, if there is a gray area, I go with how a patient is feeling. If a patient truly feels "feverish", there is generally an underlying cause.

allnurses Guide · Apr 14, 2013

Interestingly our docs do at times seem to have trouble with the drop in temp that can signify sepsis. They struggle at times with AMS indicating possible UTI also. Generally there can be some stubbornness with a few of them. Frustrating.

Most of the time the patients with a rise from baseline temp to "up" but not "technically" feverish are asymptomatic other than anxiety about it. I did have one who did not have rigors, sweats, chills, cough etc. but in general looked very unwell. Sunken eyes, dark rings, malaise. That was the one that made me begin to wonder if a "fever" is more a percentage of change from baseline rather than an actual number from the thermometer. This person was acutely ill.

I have been unable to find any studies or evidence indicating one way or the other but have found lots of opinions, rather like this thread. By and large it seems most folks I have talked to find it unalarming at least and a symptom of hypochondria or attention seeking at worst. But in terms of EBP I have found very little out there on the subject. Conventional wisdom seems to be that 100.4 is the benchmark for a fever indicating infection but I can't seem to find a firm establishment of either why that is true or why it is not true. I am nodding my head a lot at the " treat the patient not the thermometer reading" responses.

MomRN0913 · Apr 14, 2013

I'll bet if you asked those annoying patients (mostly female) that they also went through infertility and monitoring the temp is, or was, one of the first things they were told to do even before getting OOB was to take their temp, track it and record it...so yes they KNOW their temp is 96.5! So then yes they probably feel like crap at 99.5......just like you feel like crap if your temp is 101.5.
We all inwardly roll our eyes but that doesn't make them any less sick or have less valid complaints. AND it is true a person who is septic can have a lower temp

I would be one of those patients in both respects. Early in the infertility battle, I took my temp every day to monitor for ovulation. I am baseline 96.5. My peak was 98.6.

I will be feeling like crap, achy all over, with the chills even, take my temp and find it to be 99.6. I reach 101 and then I can barely get out of bed and reach 102 and above I am actually delirious. True story.

So I believe we should combine symptoms with what the patient is saying regarding their temp. I would say if their baseline is low and they have a 99 something but feel just fine, I wouldn't worry too much. But if they are symptomatic, then it's time to look a bit further into what might be cooking.

marydc · Apr 14, 2013

I'll bet if you asked those annoying patients (mostly female) that they also went through infertility and monitoring the temp is, or was, one of the first things they were told to do even before getting OOB was to take their temp, track it and record it...so yes they KNOW their temp is 96.5! So then yes they probably feel like crap at 99.5......just like you feel like crap if your temp is 101.5.
We all inwardly roll our eyes but that doesn't make them any less sick or have less valid complaints. AND it is true a person who is septic can have a lower temp

Thankfully never been hospitalized with an illness but I'm one of those annoying people. :) My basal temp was usually even lower than the graph went. I also get symptomatic at a lower threshold. I agree with others. Go by the reading and symptoms.

NurseOnAMotorcycle, ASN, RN · Apr 14, 2013

You have people who's bp is 70/50 all the time? Walking around with no radial pulse?

Yes, people with artificial hearts (LVAD)have no radial pulses and no measurable diastolic r/t the way the pump runs their blood continuously rather than pumping it in bursts as a real heart does.

blondy2061h, MSN, RN · Apr 14, 2013

Yes, I'm aware of that. The context of my post was healthy people walking around with BPs of 70/50 due to their athleticism. 90/60 I've seen in athletes, but not SBPs below 80 in a healthy setting.

wooh, BSN, RN · Apr 14, 2013

I didn't say the 70/50 were "healthy." But had lots of those in the nursing home. (And since I usually got their pulse radially, yep, they had a radial pulse.) And if they suddenly had a "normal" BP, that would be worrisome.

People have a wide range of what is "normal" for them. Temps are no different. Ignoring what's high for a patient just because it's WNL is classic treating of numbers rather than treating the patient.

SwansonRN · Apr 14, 2013

I'm on the fence about this one! I agree that sometimes even low grade temps feel pretty awful. But 98.6? I really can't see myself giving acetaminophen in that instance. I may put a cool rag on their forehead and otherwise try to alleviate their symptoms, but giving PRN Tylenol that's ordered for a fever higher than 101.3 to someone who isn't that febrile could get you into trouble. I would have them modify the order to PRN for pain/discomfort if anything.

Someone should research this because now I'm really curious. Can a large change in vital signs, even if technically they are WNL, be just as detrimental for someone who is low at baseline?

redhead_NURSE98!, ADN, BSN · Apr 14, 2013

I have the guilty family members who show up on day 4 of admission and come to the desk screeching "MY DAD HAS A FEVER!!!!" an hour after morning vitals.

"Uh, his temperature at 7:45 was 98.2. Did someone come in and take his temperature again?"

"NO BUT HE FEELS ALL HOT AND SWEATY!"

"Okay, I'll go actually take his temperature again."

[guilty family member exits stage right, to elevator and out the door for another 4 days]

*takes temp*

97.5

Lather, rinse, repeat....

nurseprnRN, BSN, RN · Apr 14, 2013

I sometimes have people insist they are feverish when they aren't based on what they state their baseline temp is. "Well, I usually am 96.5 so YOU may not think 98.6 is a fever but for me it is". I have only ever had females make this type of statement and to be honest it has always been a patient who is difficult to care for in other ways. I do not want to dismiss it out off hand but my gut reaction is pretty much an inward eye roll. Is there any basis for this claim that anyone knows of?

I can tell you are not going to like this answer, but you are mistaken, and you're committing the error of not listening to a valid concern from your patients to boot.

A bit of history: Who says that 98.6 degF is normal temperature? Where did that come from? It came from the late 1800s in what was then the golden age of physiology research, when new technologies were being invented or transformed into bedside tools. EKGs were invented then (remember Einthoven?) There were a lot more Germans in this business, and one decided to determine patient temperatures. HE took a lot of them with his spandy new clinical thermometer (and we know now that any clinical instrument may need calibration from time to time, but then? ), averaged them, and declared with Teutonic certainty that 98.6 was IT. That has been part of medical mythology ever since. And you have bought it hook, line, and sinker. And you would be wrong.

Now, if you give it a moment's critical thought you would know perfectly well that it's completely impossible for the result of an individual metabolism to be so precisely uniform across the entire human race of all ages and both sexes at all times, Germanic certainty or not.

It is, as a matter of fact, the truth that many people's basal temperature is lower than 98.6. (Some are higher, too.) And when they have an infection or other source of inflammation, they increase their body temperatures, just like you do. It's just that because they started at a lower baseline, their fever is not as high as yours. However, it no less "valid," means no less than any elevated temperature does, and is not a figment of their imagination.

So if someone tells you that 98.6 is a fever for her, you'd be well-advised to listen to her...and to maintain a higher level of suspicion for other indicators of infection (look for left shifts in the diff, for example). Doing otherwise is acting from a position of ignorance.