Postoperative Fever and Tachycardia
Mr. J is a 68-year-old male who is 48 hours post open cholecystectomy. He has a history of type 2 diabetes, hypertension, and obesity (BMI 34). His current vital signs are: temperature 38.3°C (101°F), heart rate 112 bpm, respiratory rate 22 breaths/min, blood pressure 128/76 mmHg, and oxygen saturation 94% on room air. He reports incisional pain rated 6/10 and says he feels 'chilly.' His white blood cell count is 14,000/mm³, and his blood glucose is 210 mg/dL. He has a Jackson-Pratt drain with serosanguineous output of 30 mL over the past 8 hours. The nurse notes that the surgical incision is approximated but has mild erythema at the edges. He is receiving cefazolin every 8 hours, insulin sliding scale, and acetaminophen as needed for pain.
1. What are the priority nursing assessments and interventions for Mr. J at this time? Provide rationale for each.
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Priority assessments include: 1) Monitor vital signs closely, especially temperature and heart rate, to detect sepsis or worsening infection. 2) Assess the surgical incision for signs of infection (increased redness, warmth, drainage, or separation). 3) Auscultate lung sounds and monitor oxygen saturation because atelectasis is a common cause of early postoperative fever and his SpO2 is 94%. 4) Assess pain level and characteristics; pain can contribute to tachycardia and shallow breathing. 5) Monitor blood glucose because hyperglycemia (210 mg/dL) impairs immune function and increases infection risk. 6) Inspect the drain site and note character of drainage. Interventions: Administer prescribed antibiotics (cefazolin) on time; provide supplemental oxygen if SpO2 falls below 92%; encourage incentive spirometry and coughing/deep breathing; administer acetaminophen for fever and pain as ordered; maintain strict aseptic technique for dressing changes; and collaborate with the provider regarding persistent fever and tachycardia. Rationale: Early detection of infection and prompt intervention prevent complications such as sepsis and promote recovery.
2. The provider orders a blood culture and prescribes acetaminophen 650 mg PO for fever. What is the nurse's responsibility regarding the blood culture and acetaminophen administration?
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The nurse should obtain the blood culture before administering acetaminophen because acetaminophen can mask a fever and potentially reduce the yield of blood cultures if the fever is suppressed. The nurse should draw the blood culture from a peripheral site, using sterile technique, and ensure adequate volume. After the culture is obtained, administer the acetaminophen as prescribed for fever and discomfort. The nurse should also document the time of culture collection and the antipyretic administration. Rationale: Blood cultures are most accurate when drawn during a fever spike and before antibiotics or antipyretics that might alter the clinical picture.