Fever or pyrexia is a condition where the internal body temperature could be considered to be greatly above what is normal (that is 37 degrees Celsius or 98.6 degrees Fahrenheit) (Silicon & Enbli, 2000). This condition occurs often in sick patients. However, the effective management of fever has continued to pose a challenge to nurses.
Effectiveness of nursing interventions used to reduce fever
Nurses are usually challenged with the best method by which a patient could be cooled during a fever attack. They are also tasked with cooling a patient or not. Therefore, nurses play a huge role in the management of a patient’s fever. A nurse should have higher problem-solving abilities using specialized knowledge regarding the patient’s response to fever. The nursing process when dealing with fever requires quick decision-making and problem-solving. As professional people, nurses need to provide effective medical care based on the best facts available relating to successful fever management. Nurses use a number of methods to cool down patients who have a fever. These methods include the use of Sponge baths, light blankets, electric fans, ice packs, cool room temperature, cooling blankets, alcohol sponging, and hydration (Hogstel, 2004)
Sponge baths reduce the body temperature because the skin is covered with a thin layer of water that evaporates and cools down the body as a result of this. When the body is cooled during the bath, the fever drops below that which is pre-set and as a result, it will begin to work towards reaching the high-preset temperature by shivering and vasoconstriction (Judd, 2000). However, the negative side of applying this method is that the patient will feel cold and uncomfortable. As a result, nurses usually avoid using this method to reduce the temperature in a patient. On the other hand, in some patients, external cooling may produce heat loss but may also activate conservation of heat and heat-producing mechanisms for example shivering and goosebumps (Judd, 2000)
Nurses manage fever by allowing heat to escape by applying bed sheets and a thin blanket over patients with fever. They avoid rapid removal of clothes because this may cause chilling which is not good for patients as it may worsen their condition. However, thermosensory nerve endings for heat loss are not uniformly distributed over the body (Krupp, 2003)
The use of an electric fan as a way of reducing the fever is not effective because it can cause vasoconstriction with shivering (Judd, 2000) and a further increase in temperature thus nurses usually avoid using this method to cool down a patient who has a fever.
Ice packs are used by nurses although they engulf the patient’s warming resistance and a good quantity of heat is lost but at a great cost of metabolic energy to the patient (Krupp, 2003)
The nurses also ensure that the patient is in a room with a cool temperature. They also use cooling blankets but they usually reserve them for patients whose core temperature is uncontrollable as these blankets can overwhelm the patient’s warming defenses as heat is lost but at a great expense of metabolic energy to the patient (Judd, 2000)
According to (Krupp, 2003) nurses also use alcohol sponges to reduce fevers in patients although they avoid using them often because alcohol evaporates very fast hence it causes vasoconstriction and shivering. The fumes can be lethal if the patient inhales them.
According to (Hogstel, 2004) nurses replace the fluid in patients to improve hydration and ion balance and this affects the hypothalamic set point. Dehydration can raise the set point of the hypothalamus and this induces fever. In most cases, nurses consider aantipyretictherapy for febrile patients with preexisting cardiac or pulmonary insufficiency because fever in most cases increases the body’s oxygen demands (Hogstel, 2004)
Conversely, a nurse is usually responsible for administering medicine as approved by a doctor. Therefore, it is important for a nurse to have the necessary facts regarding pharmacological content, dosages, effects, side effects, and contraindications of medication that he or she is administering to the patient (Judd, 2000) for instance, in most cases nurses administer aspirin in three to four doses in twenty-four hours to manage fever.
According to Marshall (2008), he states that nurses normally apply critical thinking and evidence-based nursing when managing fever as critical care nursing requires an ability to deal with crucial situations rapidly and with utmost care. Critical thinking is a process that is purposeful, systematic, and reasonable. A nurse should apply critical thinking when dealing with fever because of thermoregulation. A nurse needs the following scientific knowledge about normal and altered thermoregulation in order to guide their nursing actions based on evidence (Marshall, 2008)
- Knowledge of thermoregulation adjustment in order for a nurse to effectively predict a patient’s thermal responses. The nurse has to understand the dynamics of the febrile response (Marshall, 2008)
- Knowledge about a patient’s physiological status, if the nurse understands the physiological compensation mechanisms the nurse can then plan actions that enhance, replace, suppress or avoid thermal responses (Marshall, 2008)
- Knowledge to critically assess the nursing outcomes to evaluate his or her actions for efficacy (Marshall, 2008)
Consequently, the nurses need to carefully review the patients with fever and decide if cooling methods may be needed. It is important for nurses to set procedures to efficiently treat fever in patients.
Best practice report
According to Ignatavicius, Worlman, and Mishler (2008) fever can be present in the post-operative period for infectious reasons. It is therefore essential for nurses to be very cautious and check the patient for any underlying conditions not easily detectable using the normal eye. For example, collagen vascular accounts for many fevers and an infectious process is present in less than half of the febrile post-operative patients (Marshall, 2008). In this practice sheet, the term observation refers to a patient’s observation while vital signs are used in reference to fever.
The different body areas that nurses have used for the measurement of body temperature in reference to fever are the mouth, axilla, tympanic membrane, rectum, skin surface, pulmonary artery, nose, groin, esophagus, trachea, urinary bladder, and urine (Judd, 2005). Nurses also use a wide assortment of medical instruments to check for high temperatures in patients. These include:
- Electronic thermometers
- Pulmonary artery catheters
- Glass mercury thermometers
- Tympanic thermometers
- Urinary catheter with temperature probe
- Endotracheal tube with temperature probe
- Liquid crystal thermometer strip disposable thermometers
According to Ignatavicius, Worlman, and Mishler (2008), the largest volume of research addresses various aspects of temperature measurement in relation to fever and it highlights the large range of methods and different parts of the body that nurse’s use to measure temperature. I will address the aspects of oral, rectal axillary, and tympanic temperatures.
Either study evaluating measurements from the different areas of the mouth recommended using the right or left posterior sublingual pocket, as these result in higher recorded temperatures (Krupp, 2003). Evaluation of the impact of oxygen therapy on oral temperatures has reported contradictory results regarding its statistical significance. However, no study has reported a clinically noteworthy effect. Equally, dissimilar rates of oxygen flow from two liters to six liters per minute and warmed or cooled inspired gas were found not to have an influence on oral temperature measurements (Krupp, 2003). However, some studies have found that rapid respiratory rates had a small influence on oral temperature measurements, but these results have been contradicted by another study that found neither rapid nor deep breathing whether alone or in combination, did not have any impact on oral temperatures (Krupp, 2003). A wide range of studies has shown that consuming hot or cold water could have a major blow on oral temperatures. Therefore, it is wise for patients to wait for a while after taking drinks to ensure true temperature readings. Many researchers have evaluated the time required for mercury thermometers to accurately record the patient’s oral temperature. According to Hogstel (2004), one study has found that with healthy adults, using a two-minute insertion time resulted in twenty-seven percent of the temperature readings having an error at zero degree degrees centigrade. The study also assessed the thermometer insertion time in a febrile adult suggested a six-minute insertion time as a compromise between optimal time and clinical practicality while another recommended a seven-minute insertion time to ensure the majority of temperatures are correctly recorded (Hogstel, 2004). However, a survey of nurses showed that most nurses left the mercury thermometer in the mouth for less than three minutes (Hogstel, 2004)
Research conducted by Hogstel (2004), indicates that there has been considerable research addressing tympanic temperature measurements ranging from the influence of infection and cerumen on measurement accuracy to optimal technique. Many studies have reported a statistically noteworthy dissimilarity in tympanic temperatures between ears in patients with unilateral otitis media, the difference in temperature was small (Hogstel, 2004).
The presence of cerumen has a great influence on the tympanic temperature readings. Studies evaluating practice suggest an ear tug should be used during the measurement of tympanic temperature, as this is reported to straighten the external auditory canal (Hogstel, 2004) Failure to use the ear tug means infrared thermometers are only partially directed at the tympanic membrane. Hogstel (2004) has described the tug technique in adults, as pulling the auricle of the ear in an upward and backward direction. Evaluations of the impact of ambient temperatures on tympanic temperature imply that while a hot environment can noticeably affect readings, a cold environment has a small outcome. After analyzing costs of the different measurement methods, infrared measurements may be the most cost-effective despite the greater initial costs (Hogstel, 2004)
According to Berger and Williams (2009), many studies have compared the different methods of temperature measurement and rectal temperatures are the most commonly used as the standard comparison. The most familiar reported issue related to rectal temperature is that of rectal perforation, which appears to be a risk and with the advent of tympanic thermometers, this risk will be less common (Berger and Williams, 2009)
Document for bedside use
The document will guide the nurse in effectively monitoring the patient. The nurse has to tick the following as a yes or no:
- Assessment: Was the patient assessed as having fever or having the potential of developing one? In this case, the nurse will assess the patient for fever and see if there is a possibility of one developing.
- Nursing Diagnosis: Was a nursing diagnosis written down over the temperature at which the patient is? It is the duty of the nurse has to personally jot down the conclusion he or she came to after taking the patient’s fever.
- Outcomes identification: Was an outcome acknowledged relating to the patient’s body temperature?
- Planning: Did the nurse plan for the healing of fever or the possibility of one breaking out?
- Implementing: Did the nurse document the execution of the management of fever?
- Evaluation: Did the nurse assess the effect of the method used to cool down the patient or did he or she assess the patient’s temperature again?
The interventions stated above would be a great help at the hospital. However, there is a need for nurses to determine the role of patient observation to ensure:
- That the study is right as determined by the status of the patient
- Technologies used are applied in the correct manner to harmonize effective methods of patient observation.
- Observations that are inappropriate and which are based on habit rather than need should be greatly minimized.
Issues identified that have an impact on clinical practice are:
- The nurses should not check the rectum as the first choice for the measurement of temperature.
- The term observation should be used in reference to vital signs as it reflects when monitoring the patient.
- There are many factors that influence the accuracy of the different methods used to check the fever, therefore nurses should support a standardized method for all measurements(Berger & William, 2009)
However, when nurses are evaluating a patient with post-operative fever, they should ask questions like:
- When did the patient have surgery?
- What type of operation was performed on the patient?
- When did the symptoms commence?
- Were there any symptoms present before the surgery?
- Was there a surgery complication?
The above questions can be a great help to the nurses and it will aid them in successfully getting rid of fever in postoperative patients.
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