PNA, elevated temp and potential for D/C

[opossum]

I was working on a med-surg floor the other night and one of my pts was an 85yo male with PNA who had been there for a few days, can't remember if he had abx during his course of tx but I believe he did.

Anyway, my shift started at 2300, listened to report (we use voice recorded report system), where I heard he had a fever (102.0) during day shift but was expected to D/C the next day. I took his temp at beginning of my shift, it was 100.0. He slept for most of my shift, and things got busy so I didn't get to his 0400 vitals...when I recorded report for day shift, I mentioned he had a fever during day shift and that for me, his temp was 100.0 but that I had heard he might be going home, etc.

When I go to give the day shift nurse updates, she says "So you think they're going to send him home with a fever?" I told her that while it was elevated, his temp was more borderline fever (orders are to give Tyl for temp >101) and that...well...I don't know, that's just what I heard from day shift and MD progress notes. She insisted that we wouldn't send people home with a fever.

I was just passing along what I heard, but also giving my objective description of his temp. I suppose any anticipation for D/C would change if his AM temp was back to 102, or other vitals were a bit off. I guess I was looking at it like this - he's 85, he had PNA, his temp is going down...his PNA wasn't totally resolved in that he still had a wet cough (though not very productive). But why wouldn't we D/C him to recover at home if his vitals are stable and any abx are finished?

I'm a new nurse (less than 1 yr) and I'm already self-conscious about my nursing judgment (and I know giving orders to D/C are out of my scope of practice ) but...am I wrong to think this guy should stay longer because his temp was 100? Am I being lazy and dangerous here??

[Esme12, ASN, BSN, RN]

i wouldn't say lazy or dangerous. i'd say new. if a patient admitted for pna better have had antibiotics during their hospital stay. does core measures ring a bell?

pneumonia measures

november 2, 2011

in may 2001, the joint commission announced four initial core measurement areas for hospitals, which included pneumonia (pn). the joint commission collaborates with the centers for medicare and medicaid services (cms) as well as the infectious disease society of america (idsa), the american thoracic society (ats), the american society of emergency room physicians (aqsep), and the centers for disease control and prevention (cdc) with respect to the performance measures for patients with pneumonia.

in addition, the joint commission and cms are advised on the pneumonia measures by a technical expert panel (tep). these groups have provided hours of technical expertise and resources to ensure the pneumonia measures are fully supported by evidence-based research. currently there are 5 measures in the pn measure set.

the pn measures can be found in the specification manual for national hospital inpatient quality measures.

http://www.jointcommission.org/pneumonia/

that being said, the temp of 102 on days should have been reported to the md. were there any blood cultures done? was the md notified? if the temp was 102 on days and 100 at night.....that would be a vital sign that i would not miss for that patient. a temp of 102 can delay a discharge. just because antibiotics were given doesn't mean they worked and tha thte patient hasn't recovered enought to go home.

i do think with new reimbursement guideline that a patient can't be readmitted for the same diagnosis within a designated amt of time (i can't remember now what that is) it will delay discharge where as before if they were out of the facility for 24 hours and readmitted it was another set of new days to be paid for.

[MassED, BSN, RN]

we send stable patients home with Pneumonia diagnosis all the time. Low grade fevers are not the issue.

I would think for floor d/c: were walking oxygen sats ok, not desatting with walking would be my concern. Alert/oriented, independent, not SOB would be my issues. I'm sure antibiotics were on board starting in the ER, as that is the pneumonia pathway... Blood cultures x2 are always initiated in an ER prior to antibiotic delivery - usually first antibiotic is at least started in ER prior to admission to the floor.

I would continue to expect low grade fevers with Pneumonia, that is not a concern at all. No need to repeat Blood cultures for a low grade fever... if the patient then started to spike higher (and back to previous) then I might call the doc, but still wouldn't scream a need to remain admitted unless the patient decompensated in any other way (increased RR, decreased ambulatory sats, etc.)

[leslie :-D]

i just wish more people/dr's knew that any temp in an elderly person, is usually indicative of advanced disease.

many, many elderly have uti's/uri's and are afebrile.

it's not until infection has advanced, that they present with 'classic' s/s.

a 100 temp at night, with an 85yo person, bears close monitoring.

leslie

[Been there,done that, ASN, RN]

Temperature is one aspect of vital signs. Your focus on that has limited you in the full assessment of the patient.

I would not discharge him until his saturation level is 92% on room air , with a respiratory rate less than 18.

That needs to be while ambulating.

Think about how this person will manage... at home.. without oxygen.

[MassED, BSN, RN]

Leslie,

I agree.... would need more info on the patient's specifics...

[DixieRedHead, ASN, RN]

If you have to stay late to chart, or you have to miss lunch, or you have to hold your bladder until your eyes turn yellow, never miss vital signs. They are called vital signs because THEY ARE VITAL.

[nurseprnRN, BSN, RN]

" i guess i was looking at it like this - he's 85, he had pna, his temp is going down...his pna wasn't totally resolved in that he still had a wet cough (though not very productive). but why wouldn't we d/c him to recover at home if his vitals are stable and any abx are finished?"

ok, he's 85, so we know he can't generate much of a fever as well as a younger person. his chest is still wet (you don't mention having listened to breath sounds...you did, right?) you should have a good idea about what his home situation is and his ability to walk, get up and down, cook for himself, dress himself...i don't see any mention of anybody assessing any of that, but an old guy with a wet chest who goes home and lies down will be back in

don't ever send anyone at risk for self-care deficit and inadequate breathing out of your sight until he has a clear cxr (did you check that? no mention) and no fever at all. just because the medical plan of care says vs qshift and doesn't mention better overall assessment doesn't mean an intelligent, forward-thinking rn can't check them more often on a fragile elder. we are responsible for safety-- that's the nursing plan of care.

[opossum]

Thank you for the replies :)

Esme12 - You're absolutely right - this particular pt's 0400 vitals should not have been the sacrificial lamb.

DixieRedHead - I see your point...one of my biggest problems is time mgmt and I think I got caught up with my other patient who was a post-op with low BP and elevated temp during day shift...she was VS q2. I had 5 pts that night...not an excuse to miss vital signs, but still...this is one of the many reasons I despise med surg.

I realize now I did not include a lot of other pertinent info in my original post, such as CXR, etc.and I dug out my brain sheet and see that his O2 sats were 93% RA, stationary....jeez, I really missed the mark on this one.

[opossum]

If you have to stay late to chart, or you have to miss lunch, or you have to hold your bladder until your eyes turn yellow, never miss vital signs. They are called vital signs because THEY ARE VITAL.

...this seems to be the scenario every time I work med surg...I don't know how other nurses manage to get it all done and out of there by 0730.

(The first part of your statement, that is...I almost always do my 0400 VS)

[LongislandRN23]

Vital signs and assessment are important as well as calling the MD with any changes in the pt condition. As far as the oncoming nurse asking you if you think we are going to discharge him with a fever I would have responded : "not my call to make MD notified his decision".

[Esme12, ASN, BSN, RN]

Thank you for the replies :)

Esme12 - You're absolutely right - this particular pt's 0400 vitals should not have been the sacrificial lamb.

DixieRedHead - I see your point...one of my biggest problems is time mgmt and I think I got caught up with my other patient who was a post-op with low BP and elevated temp during day shift...she was VS q2. I had 5 pts that night...not an excuse to miss vital signs, but still...this is one of the many reasons I despise med surg.

I realize now I did not include a lot of other pertinent info in my original post, such as CXR, etc.and I dug out my brain sheet and see that his O2 sats were 93% RA, stationary....jeez, I really missed the mark on this one.

There see.....now you learned for the next time. It's so easy to get over whelmed and when you are new....difficult to sort out. A CNA couls have grabbed the temp or you could have grabbed it a little later. The day nurse you gave report to should have been kinder to you and explained to you how to differently view this patients case instead of snapping.

By the way.......it's the biggest reason I left med surg all those year ago 6 months into nursing and NEVER went back......