new grad-advice on when to call doc for febrile pt

[kbear1729]

Hi all, I'm new to allnurses.com, and a new nurse working nights on a med-surg floor with only 2 months experience. I was hoping to get some advice. I had a patient who was admitted with pneumonia yesterday morning and had a temp of 100 on admission. Around midnight when I started he was up to 103. All other VS stable, being treated with IV antibiotics, and doc had ordered blood culture on his admission, awaiting results. He was c/o a headache, so my thought was to give him Percocet as was ordered prn for pain and that would bring his temp down. I went to one of my colleagues, as I am still on orientation, and explained the situation and my reasoning. She advised me not to wake the doc for his temp bc he was running temps when he came in, cultures were ordered, and standing order for perc. This made sense to me-as a temp w/ pneumonia is expected and really what else could he have ordered? I administered the perc and his temp was down to 101 within an hour. I know everyone has different practices about calling a doc in the middle of the night, but I just wanted to get some feedback on whether this should warrant a call to the MD. Pt was comfortable, not diaphoretic, taking PO fluids. Any feedback is appreciated.

[ckh23, BSN, RN]

She made it pretty clear that the dr had already ordered blood cultures, iv antibiotics, and percocet prn.

Yeah nothing about tylenol or motrin. IV abx do nothing to reduce a fever and there is a possibility they are doing nothing at all until the c&s comes back. Last time I checked Percocet is not the drug of choice for a fever.

[kanzi monkey]

If the night float is going to sign off to someone in the morning, she is going to want that information. Since the pt has a diagnosis, had cultures drawn, and is getting antibiotics, what you did was appropriate--you assessed your patient and made him comfortable. You gave an anti-pyretic and then you re-checked the temp, which had come down. At that point, you could have FYI paged the doc. You could also page when you first get the temp, give a brief assessment, and tell your plan (to give percocet). Leave a call back # in case there are any follow up questions.

In this scenario, you are not paging the doc before thinking through or performing your nursing interventions. You ARE, however, communicating critical info about the patient which most covering clinicians would be grateful for. If the patient had already received abx and spiked a temp that high, I'd worry that the antibiotic might not have broad enough coverage, or that something had been missed in the initial eval and plan.

[Horseshoe, BSN, RN]

Yeah nothing about tylenol or motrin. IV abx do nothing to reduce a fever and there is a possibility they are doing nothing at all until the c&s comes back. Last time I checked Percocet is not the drug of choice for a fever.

True, but the Percocet does contain Tylenol (acetaminophen), so with his c/o headache, she was killing two birds with one stone by giving the Percocet.

I don't think she would be making a huge mistake by calling the doc, but neither did she show bad judgment by handling the situation with the orders she already had.

[rkitty198, BSN, RN]

I agree with Horseshoe...

In regards to Percocet...since when was tylenol not the choice for a fever?

You did a good job here OP!

[HeartsOpenWide, RN]

NO med surg here, but I agree on what some others say; depends on the doc. Most of the docs do not want us to call for decel that we can correct with nursing intervention. I work with one doc that wants to know ANY decel or even a single variable on the EFM and will rip you a new one if she hears you did not call about it.

[DuluthMike]

We generally culture above 38.5.

[kanzi monkey]

Most of the docs do not want us to call for decel that we can correct with nursing intervention.

But this is a different clinical scenario. A nurse cannot "correct" the underlying condition that causes a temp to rise to 103 with nursing interventions. Tylenol can bring the fever down thus making the patient more comfortable, but it does nothing to fix the cause. That's a high temp. Believe me, the doc wants to know about it.

A temp of 103 likely indicates that the patient needs further assessment, especially if they are already receiving abx. I think a good rule is to send an FYI with any temp >101.5. No one will fault you for this.

[ckh23, BSN, RN]

I agree with Horseshoe...

In regards to Percocet...since when was tylenol not the choice for a fever?

You did a good job here OP!

Tylenol is the choice for fevers not percocet. Why would you give narcotics for a simple headache. This is why there are RR for people not breathing because of narcotics. This person would have to get 10mg of oxycodone to get the 650mg of Tylenol. It's not that the op did anything wrong but more the fact you should the correct order for the proper teatment and if it involves waking up someone to get it than so be it. The point I'm trying to make is nurses shouldn't have to walk on eggshells about waking up a doctor for anything regardless of how small it may be.

[kbear1729]

I appreciate all the good feedback here. I think this is one of the most frustrating things about being new is that there is different advice depending on who you ask. I just need to learn to operate "in the grey" and I think next time I will just play it safe and give the doc a heads up.

[kanzi monkey]

I appreciate all the good feedback here. I think this is one of the most frustrating things about being new is that there is different advice depending on who you ask. I just need to learn to operate "in the grey" and I think next time I will just play it safe and give the doc a heads up.

I think that's a really good idea. As a surgical NP I get pages from nurses all the time, and believe me, at least half of them are unnecessary. But I don't fault nurses for this. I get paged for many reasons--different patients, different scenarios. But the one thing I STRONGLY believe is that nurses page me when they are concerned about a patient--and for that, they can't be faulted. Sometimes the nurse is new, or not confident in his or her skills and maybe needs some reassurance. Sometimes our patient is sick, and the nurse is alerting me to the first stages of a pt's decline. While I wish I could only get paged for important reasons, there are VERY few pages that I get that actually upset me or make me feel that a nurse is totally incapable. I've had a few situations where I've felt a nurse is paging too much. If I have the time, I will approach her and try to establish the root of her concern and hopefully empower her to feel more confident in her decision making. If I don't have time, I might ignore a page or 2 (which I try NEVER to do), and get back to her when I have a moment.

I may have a little advice to help you feel more confident though. When you have an abnormal vital sign, if you are not totally familiar with the patient's current state, go check on them, see if the clinical appearance makes the abnormal sign more worrisome (this is exactly what you did). Then, go back and look at at least 24 hours of vital signs. If the temp is 101.7, and the patient has been above 101 for 24 hours, check the chart really quick and see if the primary team has left a note of what they plan to do about the temps. If there's no note, you're in a grey area--but it's probably safe to say that the primary team knows the pt's been febrile, so you probably don't need additional orders (though they SHOULD comment on that in the chart). If your patient's abnormal vital sign is really off, make sure you recheck it, then call the covering person with other vital signs and your assessment in hand.

So, check your patient, check your chart. If at that point, you are still unsure and you have other things to be doing (which you do), just send the page. I would rather get 50 pages in a day than 0 if one disaster can be avoided.

[ZippyGBR, BSN, RN]

We generally culture above 38.5.

even if there is a recent set ( or pair of sets ) of culture not yet reported ?

[CCL RN, RN]

even if there is a recent set ( or pair of sets ) of culture not yet reported ?

Yes, even if a set was done yesterday. We culture if temps >38.5 also.

I would have called. It sucks working nights, but this is one of the MAIN reasons why Drs don't leave standing orders for Tylenol, PRN. They want to know, and NEED to know that the pt spiked a fever. They expect you to call, especially if this is a teaching hospital. I had a cardiologist refuse to order 12 ekg with chest pain. I informed him it was a standing order and he crossed it out. He said if he checked that box nurses would just give the meds, or do the ekg without calling..

In the ICU, a temp that high gets pan cultures all over again...