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NURSING MANAGEMENT OF FEVER

IN CRITICALLY ILL PATIENTS

HESTER SOPHIA ELIZABETH BESTER


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IN CRITICALLY ILL PATIENTS

by

HESTER SOPHIA ELIZABETH BESTER

submitted in partial fulfillment of the requirements for the degree

MAGISTER TECHNOLOGIAE: NURSING

in the

Department of Nursing

FACULTY OF HEALTH SCIENCES

TECHNIKON PRETORIA

Supervisor: Dr. J E Bornman

Co-Supervisor: Dr. C van Belkum

October 2003


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I hereby declare that this dissertation submitted for the degree in M Tech: Nursing,

at Technikon Pretoria, is my own original work and has not previously been

submitted to any other institution of higher education. I further declare that all

sources cited or quoted are indicated and acknowledged by means of a

comprehensive list of references.

Signed: _______________

Student number: 200 107 217

Date: 31 October 2003

Copyright @ Technikon Pretoria 2003

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I dedicate this study with

love to

my husband Louis and

children, Wimpie and Marina

for their support and personal

sacrifices.

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ABSTRACT

The aim of the study was to determine how critical care nurses in critical care units

manage fever, and to determine their knowledge of fever and fever management.

The context of the study consisted of critical care nurses working in critical care

units.

The objectives of the study were:

To determine the critical care nurses knowledge concerning fever and the

management thereof.

To determine how knowledge concerning fever is implemented in practice.

To determine how critical care nurses management of fever compares to

suggestions contained in literature.

The treatment of fever in critically ill patients had been a long-standing and

controversial issue. Although fever may be troubling, research had shown improved

outcomes when fever was allowed to run its course. The metabolic consequences

of fever, however, may outweigh potential benefits in the compromised patient. It is

important for nurses to understand the physiology of thermoregulation and the

pathophysiology of fever, in order to manage fever correctly.

The main question arising was:

How critical care nurses in critical care units manage fever, and what is the

extent of their knowledge regarding fever and fever management?

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The following questions arose from the main research question:

What is the critical care nurses knowledge concerning fever and the

management thereof?

How is the knowledge regarding fever and fever management implemented in

practice?

How does the management of fever in practice compare to what literature

suggests?

Is the nursing process utilised when managing the patient with fever?

The aim of the study was reached by means of a quantitative design. The strategy

was descriptive and contextual.

There was controversy in the opinions of the respondents on the management of

fever. The management was not done scientifically or based on evidence from

research. The opinions of medical practitioners also seemed to have an effect on

the opinions of the respondents, as well on the way that they manage a fever.

The results obtained from the questionnaires included the respondents knowledge

on the physiology of thermoregulation, the pathophysiology of fever and the

management of fever. There was a lack of knowledge concerning the physiology of

thermoregulation, the pathophysiology of fever, as well as the nursing management

of fever. Lack of knowledge could affect the management of the critically ill patient

with fever.

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The results obtained from the checklists analysed the utilisation of the nursing

process in the nursing management of the critically ill patient with fever. The

nursing process provides the framework in which the critical care nurse uses her

knowledge and skills to nurse the critically ill patient with fever. The steps in the

nursing process are overlapping.

Critical care nurses did not utilise the steps of the nursing process in the

management of the critically ill patient with fever. The management of fever did not

always compare with what was suggested by the literature.

In order to manage fever effectively, further education in the multidisciplinary field is

necessary. Nurses need to develop their own decision-making and care

management skills, based on evidence.

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EKSERP

Die doel van die studie was om vas te stel hoe kritiekesorgverpleegkundiges koors

in kritiekesorgeenhede hanteer, en om te bepaal wat hul kennis aangaande koors

en die hantering daarvan is. Die konteks van die studie het bestaan uit kritiekesorg-

verpleegkundiges werksaam in kritiekesorgeenhede.

Die doelwitte van die studie was:

Om kritiekesorgverpleegkundiges se kennis aangaande koors en die hantering

daarvan te bepaal.

Om vas te stel hoe hul kennis aangaande koors en die hantering daarvan in die

praktyk geimplementeer word.

Om vas te stel hoe kritiekesorgverpleegkundiges se hantering van koors

vergelyk met wat deur die literatuur beskryf word.

Die hantering van kritieke siek pasinte met koors, is n langstaande en

kontroversile argument. Koors kan voordelig wees vir n pasint se uitkoms,

alhoewel koors as sulks kommerwekkend is. In n kritieke siek pasint, kan die

metaboliese effek van koors egter swaarder weeg as die potensile voordele

daarvan. Dit is belangrik dat verpleegkundiges die fisiologie van termoregulering en

die patofisiologie van koors verstaan, ten einde koors korrek te hanteer.

Die hoofvraag van die studie was:

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Hoe hanteer kritiekesorgverpleegkundiges koors, en wat is hul kennis

aangaande koors en die verpleegkundige hantering daarvan?

Die volgende vrae vorm deel van die hoofvraag:

Wat is die kritiekesorgverpleegkundige se kennis betreffende koors en die

hantering daarvan?

Hoe word die kennis toegepas in die praktyk?

Hoe vergelyk die toepassing van koorshantering met dit wat beskryf word in die

literatuur?

Word die verpleegproses toegepas in die hantering van die kritieke siek pasint

met koors?

Die doel van die studie was bereik deur gebruik te maak van n kwantitatiewe

navorsingsontwerp. Die strategie was beskrywend en kontekstueel.

Daar was meningsverskil by verpleegkundiges betreffende die hantering van koors.

Dit word nie wetenskaplik benader nie en ook nie gebasseer op bewyse nie. Die

opinies van geneeshere het ook n effek op die verpleegkundige se hantering van

koors.

Die resultate verkry vanuit die vraelyste het die respondente se kennis betreffende

die fisiologie van termoregulering, die patofisiologie van koors en die hantering van

koors ingesluit. Daar was n gebrek aan kennis betreffende die fisiologie van

termoregulering, die patofisiologie van koors en die hantering van koors. n Gebrek

aan kennis kan die hantering van die kritieke siek pasint met koors affekteer.

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Die resultate verkry vanuit die kontrolelyste het die benutting van die verpleegproses

tydens die hantering van die kritieke siek pasint met koors, geanaliseer. Die

verpleegproses verskaf n raamwerk waarbinne die kritiekesorgverpleegkundige

haar kennis en vaardighede toepas om die kritieke siek pasint met koors te

hanteer. Die stappe van die verpleegproses oorvleuel mekaar.

Kritiekesorgverpleegkundiges pas nie die stappe van die verpleegproses tydens die

hantering van die kritieke siek pasint met koors toe nie. Die hantering van koors

stem nie altyd ooreen met wat deur die literatuur voorgestel word nie.

Om koors doeltreffend te hanteer, is dit nodig dat verdere multidissiplinre opleiding

in die hantering van koors gegee moet word. Verpleegkundiges moet hul

besluitnemingsvaardighede ontwikkel en hul aksies basseer op wetenskaplike

bewyse.

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ACKNOWLEDGEMENTS

I praise my Heavenly Father for enabling me to

undertake and complete this study.

I acknowledge the following people:

My family, friends and colleagues for their

support and love.

The management who granted me permission to

conduct the study in the hospitals under their

management.

The respondents who agreed to participate in

the study without them this study couldnt

be possible.

Izak for helping me with the initial

statistics and development of the research

tools.

Sarah for endless patience with me and for the

language revision.

Elsabe for the final technical revision.

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Dr. Corrien van Belkum, my co-supervisor, for

sharing her expert knowledge with me; for

making me a firm believer of quality and for

not letting go.

My sincere gratitude to my supervisor, Dr.

Jakkie Bornman, for her encouragement,

support and assistance throughout the period

of study.

Abstract.. iv

Ekserp vii

Addenda xvi

List of Figures.. xvii

HAPTER 1

INDEX

PAGE

Acknowledgements. x

List of Tables xxi

C

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ORIENTATION TO THE STUDY

1.1. INTRODUCTION .. 1

1.2. THE RESEARCH PROBLEM. .2

1.3. AIM OF THE STUDY AND SPECIFIC OBJECTIVES4

1.4. ETHICAL CONSIDERATIONS. 5

1.5. DEFINITIONS . 6

1.6. DIVISION OF CHAPTERS 8

CHAPTER 2

A THEORETICAL PERSPECTIVE ON FEVER AND THE MANAGEMENT

THEREOF IN THE CRITICALLY ILL PATIENT

2.1. INTRODUCTION.. 9

2.2. THE ROLE AND COMPETENCES OF THE CRITICAL CARE NURSE

IN THE NURSING MANAGEMENT OF FEVER. 12

2.3. THERMOREGULATORY MECHANISMS AND THE DYNAMICS

OF FEVER IN THE CRITICALLY ILL PATIENT 14

2.3.1. Thermoregulatory mechanisms. 15

2.3.1.1.The mechanisms of heat gain 15

2.3.1.2.The mechanisms of heat loss 17

2.3.2. The components of feedback system for heat gain and loss. 19

2.3.2.1.Afferent input 21

2.3.2.2. Central regulation 21

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2.3.2.3. Efferent input. 21

2.3.3. Fever versus hyperthermia. 25

2.3.4. The febrile response 28

2.3.4.1.Phase 1: Chill phase. 28

2.3.4.2.Phase 2: Plateau phase.. 29

2.3.4.3.Phase 3: Defervescence phase 29

2.3.5. Causes of fever 31

2.3.6. The role of pyrogens in the induction of fever 32

2.3.6.1.The role of Interleukin-1 during the inflammatory process 33

2.3.6.2.The induction of fever by Interleukin-6. 33

2.3.6.3.The role of Interferon 34

2.3.6.4.The fever causing effect of tumor necrosis factor (TNF) 34

2.4. THE APPLICATION OF THE SCIENTIFIC NURSING PROCESS IN THE

NURSING MANAGEMENT OF FEVER IN THE CRITICALLY ILL

PATIENT36

2.4.1. Assessment.. 39

2.4.2. Nursing diagnosis 40

2.4.3. Outcomes identification.. 41

2.4.4. Planning 42

2.4.4.1.Cooling down methods and environmental management. 44

2.4.4.2.Pharmacological management.. 49

2.4.5. Implementation. 51

2.4.6. Evaluation.. 52

2.4.7. Documentation. 52

2.5. THE UTILSATION OF CRITICAL THINKING AND EVIDENCE BASED

NURSING DURING THE NURSING MANAGEMENT OF FEVER. 53

2.6. SUMMARY 55

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CHAPTER 3

RESEARCH METHODOLOGY

3.1. INTRODUCTION. 56

3.2. RESEARCH DESIGN . 56

3.3. RESEARCH METHODS. 58

3.3.1. Population and unit of analysis.. 58

3.3.2. Data gathering 61

3.3.2.1.Tools for data gathering.. 61

3.3.2.2.Pilot study.. 64

3.3.2.3.Method of data gathering 65

3.4. ANALYSIS OF DATA 67

3.4.1. Nursing documentation. 67

3.4.2. Questionnaires.. 68

3.5. VALIDITY AND RELIABILITY OF THE STUDY.. 68

3.6. SUMMARY. 70

CHAPTER 4

DATA ANALYSES AND RESULTS OF THE STUDY

4.1. INTRODUCTION.. 71

4.2. DATA GATHERED BY MEANS OF THE QUESTIONNAIRES. 71

4.2.1. Professional category of respondents.. 72

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4.2.2. Knowledge of the physiology of thermoregulation 74

4.2.3. Knowledge of the pathophysiology of fever.. 79

4.2.4. Knowledge of the management of fever 83

4.2.5. The respondents own opinions of the nursing management of fever.. 88

4.3. DATA GATHERED BY MEANS OF THE CHECKLIST. 96

4.4. SUMMARY.. 111

CHAPTER 5

JUSTIFICATION, RECOMMENDATIONS AND CONCLUSIONS

5.1. INTRODUCTION. .. 114

5.2. JUSTIFICATION 114

5.2.1. The aim and objectives of the study. 114

5.2.2. Literature review versus results of the study 115

5.3. EVALUATION . 117

5.3.1. Limitations of the study 117

5.3.2. Strengths of the study.. 118

5.4. RECOMMENDATIONS 119

5.4.1. Education in South Africa 120

5.4.2. Nursing practice. 120

5.4.3. Further research 121

5.5. CONCLUSIONS. 121

BIBLIOGRAPHY 123

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ADDENDA

ADDENDUM A Covering letter of questionnaire 128

ADDENDUM B Questionnaire130

ADDENDUM C Approval from ethics committee.135

ADDENDUM D Checklist 137

ADDENDUM E Example of a letter of consent from hospitals. 139

ADDENDUM F Results of questionnaires142

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LIST OF FIGURES

FIGURE 2.1: The role and competences of the critical care nurse in the

nursing management of fever.. 11

FIGURE 2.2: The mechanisms by which heat is gained and lost(Ganong:2000). 15

FIGURE 2.3: Negative feedback mechanisms that conserve heat and increase

heat production (Tortora & Grabowski,1996:811).. 20

FIGURE 2.4. The three phases of the febrile response(Holtzclaw &

Faan,1992:484). 28

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FIGURE 2.5: Role of cytokines in the fever cascade(Rowsey,1997:203). 35

FIGURE 2.6: The six overlapping phases of the nursing process (as adapted from

Kozier et al,1993:16a) .38

FIGURE 4.1: The respondents professional categories 73

FIGURE 4.2: The respondents knowledge concerning the physiology of

thermoregulation 74

FIGURE 4.3. A comparison between the total percentages answered correct or

wrong in terms of the respondents knowledge concerning the

physiology of thermoregulation 78

FIGURE 4.4: The respondents knowledge concerning the pathophysiology of

fever 79

FIGURE 4.5: A comparison between the total percentages answered correct or

wrong in terms of the respondents knowledge concerning the

pathophysiology of fever. 82

FIGURE 4.6: The respondents knowledge concerning the management of

fever.. 83

FIGURE 4.7: A comparison between the total percentages answered correct or

wrong in terms of management of fever in the critically ill patient 86

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FIGURE 4.8: The frequency of cooling down methods rated by registered nurses

as the best or the worst methods for managing a fever 87

FIGURE 4.9: The respondents opinions on how often patients with fever were

cooled down in the units where they worked .. 89

FIGURE 4.10: The respondents opinions on when they would start treating a

fever.. 91

FIGURE 4.11: The respondents opinions whether they felt comfortable with the

way fever was managed in the units where they were

working .93

FIGURE 4.12: The frequency of assessment of fever recorded by registered

nurses per hospital97

FIGURE 4.13: The frequency of nursing diagnosis concerning fever recorded by

registered nurses per hospital 98

FIGURE 4.14: The frequency of outcomes identification of fever recorded by


FIGURE 4.15: The frequency of planning for the management of fever recorded by


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FIGURE 4.16: The frequency of implementation of management of fever recorded

by registered nurses per hospital 102

FIGURE 4.17: The removal of blankets at certain temperatures. 103

FIGURE 4.18: The administration of medication at certain temperatures 104

FIGURE 4.19: The utilisation of an electrical fan at certain temperatures .105

FIGURE 4.20: The utilisation of no treatment at certain temperatures105

FIGURE 4.21: The utilisation of sponge baths at different temperatures106

FIGURE 4.22: The utilisation of other cooling down methods107

FIGURE 4.23: The frequency of evaluation of fever or the effect of the management

of fever recorded by registered nurses per hospital 109

FIGURE 4.24: A comparison between the utilisation of the steps in the nursing

process by the registered nurses in the different hospitals 110

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LIST OF TABLES

TABLE 2.1: Comparison of fever and hyperthermia

(Rowsey,1997:289).. 26

TABLE 4.1: Discussion of questions measuring the respondents knowledge

of the physiology of thermoregulation. 75

TABLE 4.2: Discussion of the questions measuring the respondent knowledge

of the pathophysiology of fever... 80

TABLE 4.3: Discussion of the questions measuring the respondents knowledge

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on the management of fever 84

TABLE 4.4: Respondents motivations on how often patients with fever were

cooled down in the units where they were working.. 90

TABLE 4.5: Respondents motivations on when they would start managing

a patient with fever 92

TABLE 4.6: Motivations why respondents felt comfortable or not comfortable

with the way fever was managed in the units where they were

working 94

TABLE 4.7. Respondents final comments.. 95

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CHAPTER 1

ORIENTATION TO THE STUDY

1.1. INTRODUCTION

Many nurses believe that fever portends negative outcomes, and that lowering the

fever, will improve the course of the illness (Holtzclaw & Faan, 1992:482). These

beliefs are particularly important when nursing critically ill patients. Critically ill patients

are immunocompromised, and both the pyrogenic response and the antipyretic

therapy, can be hazardous to the patient.

According to Tortora and Grabowski (1996:812) fever is a condition that occurs often in

sick patients. Fever can be beneficial, but the harmful effects of fever outweigh the

benefits thereof. The management of fever in critically ill patients will continue to

present a challenge to nurses. The use of critical thinking in nursing allows nurses to

provide safe and effective care. Rowsey (1997:206) stated how important it is that the

nurse understands the physiology of the fever cascade. There are many views on

whether to cool a patient or not, and what methods of cooling should be used. As a

professional person, the critical care nurse needs to provide clinically effective care,

based on the best evidence available concerning fever management.

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1.2. THE RESEARCH PROBLEM

The researcher is a unit manager in a critical care unit. It was detected, after studying

patients flow sheets, that critical care nurses working in the unit are inconsistent in

respect of, and appear to be, uncertain about the management of fever. These

management strategies also do not coincide with what the literature suggests.

During the audit of nursing documentation, several flow sheets were studied by the

researcher. Being immunocompromised, all these patients had the potential to develop

fever due to the immune/inflammatory response system of the body. None of the

critical care nurses addressed fever as a potential problem in their twelve (12) hourly

planning phase of the nursing process. One (1) of the patients had temperatures

ranging from 36C to 39,8C. Six (6) critical care nurses managed this patients fever

in different ways and at different stages of fever, over a period of six (6) days.

Examples of the different methods used are:

38,4C : Codis cocktail

39,4C : Codis cocktail

37,9C : Codis cocktail and electrical fan

37,8C : Largactil 12,5mg intravenously

37,8C : Electrical fan

38C : Codis cocktail

Only one (1) of the critical care nurses in above scenario, evaluated the effect of the

treatment given in her nursing plan.

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Phillips (2000) stated that if the patient is physically cooled without resetting the

temperature set point in the hypothalamus, the patient will generate heat, and the body

temperature will rise. The use of the electrical fan for lowering fever is thus

questionable. The value of cooling measures, such as tepid sponge baths and

electrical fans, is not supported by research (Wong,1999).

A study done by Sharber in 1997 and described by Wong (1999), explained that

external cooling may produce heat loss, but may also activate heat-conservation and

produce mechanisms that include shivering, vasoconstriction and goose bumps.

When a person shivers, friction from muscle contractions produces heat and drives the

body temperature up even higher (Holtzclaw,1998). Holtzclaw is sending a new

message to nurses by stating that: Cooling a patient who has a fever, is not a good

idea.

The management of a patient with fever continues to be controversial. Based on the

literature studied it is not clear to determine whether fever should be treated, and if

treated, at what temperature and with what method. Hence it may be stated that there

is a definite need for the conducting of further research with regard to the fever

management in critically ill patients. The gaps in the literature related to fever

assessment and management are a challenging frontier for nursing research

(Holtzclaw & Faan, 1992:499).

The main research question arising is:

How critical care nurses in critical care units manage fever, and what is the extent

of their knowledge regarding fever and fever management?

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The following sub-questions arose from the main research question:

What is the critical care nurses knowledge concerning fever and the management

thereof?

How is the knowledge regarding fever and fever management implemented in

practice?

How does the management of fever in practice compare to what literature

suggests?

Is the nursing process utilised when managing the patient with fever?

1.3. AIM OF THE STUDY AND SPECIFIC OBJECTIVES

The aim of this study was to determine how critical care nurses in critical care units,

manage fever, and to determine their knowledge of fever and fever management.

The objectives of the study were:

To determine the critical care nurses knowledge concerning fever and the

management of fever.

To determine how knowledge concerning the management of fever is implemented

in practice.

To determine how critical care nurses management of fever compares to

suggestions contained in literature.

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1.4. ETHICAL CONSIDERATIONS

According to De Vos (2000:23) the researcher will be accountable for the

consequences of his/her decisions. Ethical guidelines serve as standards. De Vos

(2000:24) defined ethics as: a set of moral principles which is suggested by an

individual or group, is subsequently widely accepted, and which offers rules and

behavioral expectations about the most correct conduct towards experimental subjects

and respondents, employers, sponsors, other researchers, assistants and students.

The researcher took into consideration the following ethical principles during the

study:

Informed consent means that participants have adequate information regarding the

research (Polit & Hungler, 1997:134). Written consent was obtained from hospital

managers/nursing services managers. A description of the study was given to the

hospital managers/nursing services managers (Refer Addendum E). Data was

gathered with the critical care nurses knowledge and approval (Refer Addendum A).

As cited in Polit and Hungler (1997:130) beneficence is an important ethical principle

in research. The researcher intended to do good and not to do harm to the

respondents. Polit and Hungler (1997:132) stated: the study focuses on a

significant topic that has the potential to improve patient care. This study has the

potential to improve the nursing management of critically ill patients with fever.

De Vos stated (2000:29) that all possible means of protecting the privacy of

respondents should be applied. The respondents privacy was respected and no

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names appeared on the questionnaires and the hospitals were coded. Questionnaires

were numbered. Anonymity and confidentiality were adhered to. Approval for the

study was granted by the Faculty Research Committee and the Ethics committee of

Technikon Pretoria (Refer Addendum C).

Scientific honesty means that the researcher will protect the integrity of scientific

knowledge. As cited in Brink (1999:47) reports must reflect what has actually been

done.

1.5. DEFINITIONS

The following definitions describe the most important concepts of the study:

Critical care nurse: The critical care nurse is a registered professional nurse

committed to ensuring that all critically ill patients receive optimal care (Thelan, Davie

& Urden, 2002:32).

Critically ill patient: The critical ill patient is characterized by the presence of real

or potential life-threatening health problems and by the requirement for continuous

observation and intervention to prevent complications and restore health (Thelan,

Davie & Urden, 2002:32).

Critical thinking: Critical thinking is the use of those cognitive skills or strategies that

increase the probability of a desirable outcome. It is used to describe thinking that is

purposeful, reasoned and goal directed (Fowler,1996).

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Evidence based nursing: An underlying assumption of evidence-based nursing is

that science-based evidence will tell us what the most successful and cost-effective

approaches to nursing care are (Closs & Cheater, 1998:11).

Fever: body temperature >(higher than) 37.8C orally or >(higher than) 38.2C

rectally, or simply an elevation of body temperature above the normal daily variation

(Beers & Berkow, 1997:1093).

Nursing Documentation: Nursing documentation should be a complete and accurate

record of the patients condition and treatment. It is the basis for evaluation of health

care operations and use of resources by providing research data (Turner,1995).

Nursing process: As cited by Hickley in Booyens (2001:206) the nursing process is a

problem solving technique that helps the nurse to identify the needs of a patient, and to

plan, render and evaluate nursing care in a scientific way. The nursing process is a

discipline-specific version of critical thinking (Leddy & Pepper, 1998:203). The steps in

the nursing process are interdependent, but each step is directed at the total patient.

Scientific knowledge: The process of knowledge development begins with the direct

observation. Then the observation is processed by logical testing. If the observation

meets all the requirements of the logical testing then it goes to the communication and

presentation of knowledge (Fall,1999).

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1.6. DIVISION OF CHAPTERS

The study was divided into the following chapters:

Chapter 1: Orientation to the study.

Chapter 2: A theoretical perspective on fever and the management thereof in the

critically ill patient

Chapter 3: Research methodology.

Chapter 4: Data analysis and results of the study.

Chapter 5: Justification, recommendations and conclusion.

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CHAPTER 2

A THEORETICAL PERSPECTIVE ON FEVER AND THE MANAGEMENT THEREOF

IN THE CRITICALLY ILL PATIENT

2.1 INTRODUCTION

The treatment of fever in critically ill patients is a long-standing and controversial issue.

Although fever may be troubling, research has shown improved outcomes when fever

is allowed to run its course (McKenzie,1998). Levy as cited in Begany (2000), stated

that there is no existing evidence to indicate that the treatment of fever improves

outcomes.

Holtzclaw and Faan (1992:482), stated that scientific evidence exists that higher body

temperatures facilitate several immunostimulant host responses, such as increased

leucocyte bacteriocidal activity and an enhanced immune/inflammatory response.

Normal body temperature displays a circadian rhythm, ranging from 36.1C or lower in

predawn hours to 37.4C or higher in the afternoon. The metabolic consequences of

fever, however, may outweigh potential benefits in the compromised patient

(McKenzie, 1998). These consequences include increased oxygen consumption,

increased tissue catabolism and dehydration (Phillips, 2000).

The aim of this chapter was to:

Describe the role and competences of the critical care nurse in the nursing

management of fever in critically ill patients.

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Describe the application of the scientific nursing process in the nursing

management of fever in the critically ill patient.

Identify the need to base nursing actions, concerning the nursing management of

fever on critical thinking and evidence based nursing.

Chapter two (2) had a descriptive design. National and international literature were

explored for the criteria for the management of fever. These findings were described.

The results of the study compared with national and international criteria. Information

for the literature study was collected by means of:

Textbooks

Articles in journals

South African Nursing Council Documentation.

Searches on the world wide web

CD ROM

Databases through the assistance of the Technikon Pretoria Library.

The aim of this chapter is visualised in Figure 2.1.

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THE CRITICAL CARE NURSE

THECRITICALLY

ILLATIENTWITH

P

FEVER

THESCIENTIFIC

NURSINGPROCESS

CRITICALTHINKING

ANDEVIDENCE

BASEDNURSING

FIGURE2.1: The role and competences of the critical care nurse in the nursing

management of fever.

Figure 2.1 explains the framework for this chapter. This framework incorporates the

critically ill patient with fever, the scientific nursing process, critical thinking and

evidence based nursing, into the role and competences of the critical care nurse in the

nursing management of fever.

Leddy and Pepper (1998:336) stated that it is expected of professional nurses to be

competent in their practice. It is imperative for the critical care nurse to have

knowledge of her/his scope of practice and her/his role in the management of the

critically ill patient.

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2.2 THE ROLE AND COMPETENCES OF THE CRITICAL CARE NURSE IN THE


The critical care nurse plays an important role in the nursing management of the

patient with fever. South African and various international nursing organisations

described the role and competences required from nurses.

Critical care nurses require advanced problem solving abilities using specialised

knowledge regarding the human responses to critical illness. The South African

Nursing Council (The SANC, 1998:8) regards nursing as a caring profession which

supports and assists the patient to achieve and maintain optimal health. Nel (1993:2)

pointed out that the critical care nurse is accountable for her/his acts and omissions

during the nursing care of a patient. This accountability is described in Regulation 387

of February 1985 as laid down by the South African Nursing Council (Searle,

2000:119).

The American Association of Critical Care Nurses (AACCN, 2000) defined critical care

nursing as: that specialty within nursing which deals specifically with human

responses to life-threatening problems. A critical care nurse is a licensed professional

nurse who is responsible for ensuring that all critically ill patients receive optimal care.

According to the AACCN (2000) the critical care nurse shall help the patient to obtain

necessary care and monitor and safeguard the quality of care the patient receives.

The Canadian Association of Critical Care Nurses(CACCN,1997), stated in their

philosophy that critical care nursing is a profession which exists to care for patients

who are experiencing life threatening illnesses.

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Nursing is a dynamic process that involves the application of knowledge, skills, values

and attitudes. The critical care nurse must provide a view of the patients health needs

which require collaboration with the health care team. Muller (1998:25) wrote that

nurses must provide in the health needs of their patients. They also need the

necessary theoretical knowledge and skills required for their practice.

According to Finocchio (1998) and the American Organisation of Nurse Executives

(1996), transformation of the health care system has resulted in more emphasis being

placed on the competences of registered nurses. There is also an increasing demand

for quality care and the nurses competence to provide this quality care.

The Manitoba Association of Registered Nurses (1999) defined competence as follows:

The ability of a registered nurse to integrate and apply knowledge, skills, judgement,

and intrapersonal attributes required to practice safely and ethically in a designated

role and setting. Personal attributes include attitudes, values and beliefs.

Eichelberger (1999) cited that both Alspach and Parry described competence as the

application of knowledge, skills and attitudes.

A critical care nurse requires knowledge of her/his scope of practice and the

regulations under which she/he may practice. The scope of nursing is defined by

regulations under the Nursing Act no.50 of 1978 (Searle, 2000:119). In the critically ill

patient with fever, the critical care nurse will be responsible for the following acts or

procedures:

The diagnosing of abnormalities in thermoregulation, and the prescribing, provision

and execution of a nursing regimen in order to manage the fever.

The administration of medication prescribed by a doctor.

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Monitoring of the patients vital signs, and in this case, the patients fever.

In Halloway (1993:3) the scope of the critical care nurse is defined as interaction

between the critical care nurse, the critically ill patient and the critical care environment,

and her/his goal is to ensure effective interaction of these three elements.

The question arose: Why does the critical care nurse need to be competent when

nursing the critically ill patient with fever? The answer is twofold:

Her/his attitude about fevers benefits needs to be positive. She/he should change

her/his view in order to see fever as a response to illness rather than the illness

itself.

She/he must have the knowledge of thermoregulatory mechanisms and the

dynamics of fever in order to manage fever skillfully (Holtzclaw & Faan, 1992: 482).

Thermoregulation mechanisms and the dynamics of fever will be discussed.

2.3 THERMOREGULATORY MECHANISMS AND THE DYNAMICS OF FEVER IN

THE CRITICALLY ILL PATIENT

Normal body temperature displays a circadian rhythm, ranging from 36.1C or lower in

predawn hours to 37.4C or higher in the afternoon. Body temperatures that exceed

the norm of 37C are often observed in healthy people.

Body temperature is the balance between the heat produced by the body and heat lost

from the body, in other words, the balance of heat loss/gain determines body

temperature. The mechanisms by which heat is gained and lost, can be visualised in

Figure 2.2.

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FIGURE 2.2: The mechanisms by which heat is gained and lost (Ganong, 2000)

2.3.1 Thermoregulatory mechanisms

Even though there are wide fluctuations in environmental temperature,

thermoregulatory mechanisms can maintain a normal range for the internal body

temperature. Body temperature is regulated by mechanisms that attempt to keep

heat production and heat loss in balance (Tortora & Grabowski, 1996:809). As can be

seen in Figure 2.2, heat production by the body and input from the environment equals

heat gain.

2.3.1.1 The mechanisms of heat gain

Heat production occurs when heat is released by metabolic reactions, or absorbed

from the environment.

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Heat input from environment

The sun, fire, and warm objects are examples of environmental factors that can

lead to heat input. Body temperature rises quickly in a hot and humidatmosphere

(Ganong,2000).

Heat released by metabolic reactions

Basal metabolism accounts for all the heat production in a neutral thermal

environment. At rest, major organs supply 50-60% of body heat and muscle

movement supplies 20%. Ingestion of food increases the basal metabolic rate, with

consequent heat production. The overall rate at which heat is produced is termed

the metabolic rate. Metabolic rate is influenced by many factors, and it is measured

under standard conditions designed to reduce these factors as much as possible.

According to Tortora and Grabowski (1996:809), these conditions of the body are

called the basal state. The measurement obtained is the basal metabolic rate.

Basal metabolic rate is expressed in kilocalories per square meter of body surface

area per hour (kcal/m/hr).

Voluntary and involuntary muscular activity can produce heat. Exercise is a voluntary

mechanism and can increase the basal metabolic rate and causes an increased heat

production up to 90%. Shivering is an involuntary mechanism. Shivering increases the

basal metabolic rate and can increase heat production as much as 400 500%.

Shivering can cause increased oxygen consumption, increased carbon dioxide

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production, increased ventilatory demand, increased myocardial work and decreased

arterial oxygen saturation (Gendelman,2000).

Endocrine activity such as thyroid activity with thyroxine output increases the rate of

cellular metabolism throughout the body. This effect is called chemical thermogenisis

(Kozier et al, 1993:160). Emotion/fear stimulates the sympathetic nervous system with

consequent hormonal effects. Epinephrine, norepinephrine and sympathetic stimulation

(vasoconstriction) increase the rate of cellular metabolism. Non shivering

thermogenesis takes place in brown adipose tissue, particularly in the newborn

(Ganong,2000). This occurs primarily through the metabolism of brown fat and is

mediated by norepinephrine. Fever increases the basal metabolic rate in cells. For

every 1C rise in temperature, 13% more chemical reactions take place (Kozier et al,

1993:160).

2.3.1.2 The mechanisms of heat loss

Heat is lost from the environment through four physical processes, namely radiation,

conduction, convection and evaporation. Heat generated in deeper parts of the body is

first conducted to the body surface; this depends on blood flow to the skin and

insulation of the body.

Radiation

Energy transfer via electromagnetic waves, no direct contact is needed. Radiant

losses can be responsible for up to 50% of heat loss. The body will lose heat by

direct contact with a stable medium, like water (Ganong,2000).

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Conduction

The transfer of heat by direct contact with a stable medium, like water.

Convection

According to Uys and Mulder (1995:114) convection is the movement of gas or liquid

molecules from one region with a higher temperature to a region with a lower

temperature. Natural convection occurs when heat is conducted from the skin to the

surrounding layer of air. At the outer surface of the air layer convection currents rise

and carry the warmer air upwards, and cooler air takes its place. In forced convection,

the warm layer of air surrounding the body is mixed with cold air by the movement of

air. In this way the body cools down.

Evaporation

Evaporation occurs primarily through perspiration, but can occur from the respiratory

tract and open body cavities. This is the main mechanism by which the body prevents

hyperthermia (Gendelman,2000).

Body temperature in human beings is controlled by the hypothalamus. Information

from receptors goes to the posterior hypothalamus for integration. The hypothalamus

is a region of the brain that controls an immense number of bodily functions. It is

located in the middle of the base of the brain, and encapsulates the ventral portion of

the third ventricle.

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The balance between heat production and loss is regulated by a complicated and

sensitive feedback system based on three components: afferent input, central

regulation and efferent responses (OH, 1998:630).

2.3.2 The components of feedback system for heat gain and loss:

If body temperature starts to decrease, changes occur that help conserve heat and

produce heat at a quicker pace. These changes are part of a negative feedback

system that attempts to raise body temperature to normal (Tortora & Grabowski, 1996:

810). This process is visualised in Figure 2.3.

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FIGURE 2.3: Negative feedback mechanisms that conserve heat and increase

heat production (Tortora & Grabowski, 1996: 811).

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The following components of the feedback system will be discussed:

2.3.2.1 Afferent input

Temperature is sensed by the cold and warm sensitive receptors found throughout the

body. These are naked nerve endings located in the dermis. Signals from these

sensors are conveyed to the central regulatory system, primarily the hypothalamus.

Thermal inputs are received from these sensors. The skin insulates the body against

heat and cold and helps regulate body temperature. It does this by producing sweat

when the body becomes too hot. Blood vessels in the skin contract to conserve body

heat during cold weather (Bunch,1999).

2.3.2.2 Central regulation

Integrated thermal responses from the skin and deep tissues are compared with the set

threshold temperature in the hypothalamus. The normal set point is at 37C and with a

range of 0,2C lower or higher than 37C. Within this range, no thermoregulatory

responses are triggered. Appropriate responses are activated when the thermal input

exceeds the inter -threshold range. The set point is a range of temperatures above or

below through which compensatory warming or cooling mechanisms are activated

(Holtzclaw & Faan, 1992:483).

2.3.2.3 Efferent input

Efferent input changes metabolic heat production or alters heat loss. Energy-efficient

effectors, such as vasoconstriction, are maximized before metabolically costly

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responses such as shivering are activated (OH, 1998:630). Compensatory responses

to correct deviations are initiated.

Both smooth and skeletal muscles play important roles in maintaining the bodys

thermal homeostasis. The main contribution of smooth muscle is in the regulation of

the blood vessel diameter. When smooth muscle in the walls of skin arterioles relaxes,

the arterioles dilate, and more blood flows to the skin. This permits greater transfer of

heat from warm blood through the skin to the environment. On the other hand, when

heat conservation is needed, smooth muscle in the blood vessels of the skin contracts.

As a result, the vessels constrict, less blood flows through the skin, and less heat is

lost.

During contraction of skeletal muscles, only a small amount of the energy stored in

body chemicals, is used for movement. As much as 85% is released as heat. A

portion of the released heat helps maintain a normal body temperature. Excess heat is

eliminated through the skin and lungs. If body temperature decreases, one result is

shivering, which causes involuntary thermogenesis. This increase in muscle tone can

raise heat production by several hundred percent. Shivering is initiated by the

hypothalamus. It acts via a negative feedback system to produce enough heat to raise

body temperature back to normal (Tortora & Grabowski, 1996:251).

It is important for nurses to be aware of the factors that can influence body

temperature, so that they can understand the importance of temperature deviations.

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The following factors that affect body temperature are described by Kozier, Erb, Blais

and Wilkinson (1995:62):

Age

Infants are greatly influenced by environmental temperatures and childrens

temperatures are more labile than those of adults. Elderly over 75 years of age are at

risk for hypothermia for reasons such as a lack of central heating, inadequate diet, loss

of subcutaneous fat, lack of activity and reduced thermoregulatory efficiency. The

metabolic rate of a child is about double that of an elderly person (Tortora &

Grabowski, 1996:810).

Diurnal variations

Body temperatures change throughout the day and can vary with 1C between early

morning and late afternoon.

Exercise

Exercise can increase body temperature. The metabolic rate may increase to as

much as 15 times the basal rate during exercise (Tortora & Grabowski, 1996:810).

Hormones

Progesterone secretion at the time of ovulation raises body temperature by about

0.35C above basal temperature. Increased levels of thyroid hormones increase the

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metabolic rate and this causes body temperature to rise (Tortora & Grabowski, 1996:

810).

Stress

Stimulation of the sympathetic nervous system can increase the production of

epinephrine and norepinephrine, thereby increasing metabolic activity (Tortora &

Graboski, 1996:810).

Environment

Extremes in environmental temperatures can affect a persons temperature regulation.

If the environmental temperature is higher than that of the body, heat is absorbed from

the environment by the body (Uys & Mulder, 1995:115).

Fever is a common problem in critically ill patients. These patients frequently have

multiple infections. Fever is a basic response to infection, is an important host

defense mechanism and does, in the majority of cases, not require treatment (Marik,

2000:855).

The terms fever and hyperthermia are confusing and critical care nurses tend to think

they are synonyms. Both conditions are associated with a high temperature, but the

pathophysiology differs. A distinction is made between fever and hyperthermia.

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2.3.3 Fever versus hyperthermia

There are two kinds of body temperature, namely core temperature and surface

temperature:

Core temperature is the temperature of the deep tissues of the body, such as

the cranium, thorax, abdominal cavity, and pelvic cavity (Kozier, Erb, Blais &

Wilkinson, 1995:425). The core temperature remains relatively constant at 36C to

37,5C (OH, 1998:630). The body tissues and cells function best within a relatively

narrow temperature range, between 36C and 38C, but no single temperature is

normal for all people (Perry & Potter, 1998:239).

The surface temperature is the temperature of the skin, the subcutaneous

tissue, and fat (Kozier, Erb, Blais & Wilkinson, 1995:425). The surface

temperature rises and falls in response to the environment, and can vary from 20C

to 40C.

Fever is the elevation of the temperature set point in the hypothalamus. With an

increase in set point, the hypothalamus sends out signals to increase body

temperature. The body responds by shivering and increasing basal metabolic rate

(Corwin, 2000:75). Beers and Berkow (1997:1093) defined fever as a body

temperature higher than 37.8C orally, or 38.2C rectally, or simply an elevation of body

temperature above the normal daily variation.

Hyperthermia involves dysfunction of thermoregulatory ability. Core temperature can

be as high as 40C and above. These high temperatures cause denaturation of

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protein, and to prevent this, aggressive cooling is necessary. Heat stroke may result if

rate of heat gain exceeds rate of heat loss and body temperature continues to rise

(Ganong, 2000). Table 2.1 compares the differences between fever and hyperthermia,

using the physiological-, temperature-, cytokines-, symptoms- and environmental

factors.

Table 2.1: Comparison of fever and hyperthermia (Rowsey, 1997:289).

Factor Fever Hyperthermia

Physiology Prostaglandin

mediated rise

in temperature

Endogenous

pyrogens

released, which

cause the set-

point to rise

Deep body

temperature

may or may not

be raised to the

same level

Incapacity of the environment to absorb

heat from the body surface

Failure to activate peripheral mechanisms

such as vasodilation or sweating to cool

Set-point may or may not be normal, but

body temperature is higher than set-point

Temperature 38C 41C 41C or higher

Cytokines Interleukin-1

Interleukin-6

Tumor necrosis

None

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factor

Symptoms Flushed face, chills

and shivering,

muscle achiness,

sweating

Inability to sweat, exaggerated increase in

temperature, death

Environment Injury

Infection

Systemic

infection

Drugs

Disease

Exposure to warm environment

It is important to understand the normal thermoregulatory mechanisms and the

pathophysiology of fever. These mechanisms bring out the various phases of the

febrile response and throughout each phase, warming and cooling mechanisms

respond to the thermoregulatory control system.

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2.3.4. The febrile response

The febrile response consists of three phases, as illustrated in Figure 2.4.

FIGURE 2.4: The three phases of the febrile response (Holtzclaw & Faan,

1992:484).

2.3.4.1 Phase 1: Chill phase

The hypothalamic set point responds to elevations in endogenous pyrogens by

resetting at a higher level. The chill phase is elicited by differences between the set

point and the actual temperature. The initial temperatures increase is fairly rapid. The

patient may experience chills and mild muscle rigidity. The skin becomes cool and

pale as the body restricts heat loss by diverting blood to deeper vessels. At the same

time, heat production through involuntary mechanisms, such as shivering, increases

(McKenzie,1998).

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2.3.4.2 Phase 2: Plateau phase

Compensatory warming responses cause body temperature to rise higher. During this

phase, blood flow to the skin and heat loss normalizes. The patients skin becomes

warm and flushed. The temperature remains elevated because increased metabolism

generates heat and speeds heart rate and breathing.

2.3.4.3 Phase 3: Defervescence phase

The set point readjusts to the normal temperature range, compensatory cooling

mechanisms promote heat loss. The patient begins to perspire, and cutaneous

vasodilation increases blood flow to the skin. Body temperature returns to normal.

Why do we need to maintain body temperature? Chemical reactions of the body are

most efficient as the body temperature rises, but above 43C there may be damage of

membranes or denaturing of proteins. Therefore it is necessary to keep the body

temperature at a safe level. An oral temperature of 37C represents a safe level for a

human being. By maintaining body temperature, we do not need to depend on the

external temperature of the environment (Ganong,2000).

Although fever may be troubling, it is not always the enemy. Research has shown

improved outcomes when fever is allowed to run its course (McKenzie,1998).

Research suggests that fever helps an organism fight off infection and thus is beneficial

to the host.

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The fever response is part of the resistance mechanism of the body, and does the

following:

Increases the production of antimicrobial agents such as interferon, which has

antiviral and anti-tumor effects, thus increases leucocyte bacteriocidal activity.

Supports increased phagocytic activity of some cells (Phipps,2002),

Enhances immune function, such as anti-body production (McKenzie,1998)

As cited in Phillips (2000) the following are also responses of fever:

Stimulation of T-lymphocyte and B-lymphocyte proliferation

Reduction in plasma iron concentration to suppress bacterial growth.

Enhancement of immune/inflammatory response.

Increased leucocyte migration to the site of infection.

Decreased circulating iron, which decreases bacterial growth.

Increased oxygen extraction from the blood.

According to McKenzie (1998) the metabolic costs of fever may outweigh potential

benefits in compromised patients. High fevers may damage cells, especially those of

the central nervous system (Corwin, 2000:76).

Fever causes the following:

An increased metabolic rate. For every 1C rise in temperature, the oxygen

consumption and cardiac output, increase with 13% (Beers & Berkow, 1997:1093).

Metabolic demands of fever may compromise oxygenation in these patients.

Calories are expended that compromised patients cant afford to loose.

Febrile shivering is a primary source for heat generation. This can increase energy

expenditure up to 400% above resting levels. Large amounts of oxygen are

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consumed, glycogen stores are depleted, lactic acid and other metabolites

accumulate.

Diffusion of oxygen across the alveolary-capillary membrane is impaired in the

critically ill and a low cardiac output leads to less oxygen delivered to the cells.

Fever may also affect the pharmokinetics of certain drugs (Holtzclaw & Faan,

1992:486).

Dehydration, which increases insensible fluid loss by 10% for every 0.5C (Phillips,

2000).

2.3.5 Causes of fever

The causes of fever may be infectious or non-infectious. The pattern may be

intermittent, characterized by daily spikes followed by a return to normal temperature

or remittent, in which the temperature does not return to normal.

In the following situations, (Slavkovsky,1995) fever may be caused by changes in the

thermoregulation center (these changes initiate the production of endogenic pyrogens)

:

Infections caused by organisms such as bacteria, viruses and parasites.

Immune/ Inflammatory processes for example during the destruction of tissues,

such as trauma, infarctions and heat gain in the surgical environment

Neoplastic processes.

Acute metabolic failures for example Addisons crisis (fever is usually due to

infection of the adrenal gland) and dehydration.

Certain drugs, for example penicillin, sulfonamides and barbiturates can lead to

drug fever during an anaphylactic reaction (Beers & Berkow, 1997:1065).

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Administration of foreign proteins for example blood transfusion reaction.

2.3.6 The role of pyrogens in the induction of fever

In the majority of diseases, fever is caused by pyrogens. Either exogenic pyrogens, or

endogenic pyrogens provoke fever. There are situations, when fever may be caused

directly by changes in the thermoregulation centre without the participation of

pyrogens, for example brain tumours and intracranial bleeding (Slavkovsky,1995).

Exogenic pyrogens include bacteria and their endotoxins, viruses, yeasts, protozoa,

immune reactions, several hormones, medications, and synthetic polyneuclotides.

Exogenic pyrogens stimulate cells to produce cytokines called endogenic pyrogens

(Slavkovsky,1995).

Endogenic pyrogens affect the thermosensitive neurons in the hypothalamus

(Rowsey, 1997:203). These endogenic pyrogens reach the anterior hypothalamus

through a permeable vascular network referred to as the organum vasculosum laminae

terminalis, causing the release of prostaglandin E2 which then diffuses into the anterior

hypothalamus and affects the change in the hypothalamic set point by decreasing the

firing rate of warm sensitive neurons (Pile,1998). These substances (Phipps,2002)

cause a resetting of the body temperature set point. The set point will remain elevated

for as long as these substances are in circulation.

As cited in Corwin (2000:75) fever occurs in response to production of certain

cytokines. Cytokine is a term given to intercellular messengers, which include

interleukins, interferons and tumor necrosis factors.

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The most important endogenic pyrogens (heat producers) are IL-1 (Interleukin), IL-6,

interferon and TNF (tumour necrosis factor). These are glycoproteins that also have

other important effects (Slavkovsky,1995).

2.3.6.1 The role of Interleukin-1 during the inflammatory process

Interleukin-1 induces inflammatory responses. It promotes the production of

interleukin-2, prostaglandins, the growth of leucocytes and augments the release of

corticosteroids (Knies,2001).

Interleukin-1 is produced mainly by the brain, and consists of two types: alpha and

beta. Both types bind to the same receptor, but differ in the site of action. Interleukin-1

alpha is involved in functions that require cell to cell contact. Interleukin-1 beta is

released into the tissue microenvironment and can be detected in the systemic

circulation. These two types induce fever, and many phagocytic cells including

monocytes, macrophages and astrocytes produce both (Slavkovsky,1995).

2.3.6.2 The induction of fever by Interleukin-6

The pathway by which interleukin-6 induces fever, is likely to involve the production of

prostaglandines. It stimulates several types of leucocytes, and the production of acute

phase proteins in the liver. It is particularly important in inducing B-cells to differentiate

into antibody forming cells (Rowsey, 1997:204).

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2.3.6.3 The role of Interferon

Interferon has pyrogenic and antiviral properties. These cytokines are categorized as

alpha, beta and gamma. Interferon induces the release of macrophages, augments

natural killer function, and synergizes with a variety of microbial agents to augment

macrophage tumoricidal function and enhance IL-1 secretion. Interferon acts to induce

other cytokine production and regulate the febrile response (Rowsey, 1997:204).

2.3.6.4 The fever causing effect of tumor necrosis factor (TNF)

There are two forms of tumor necrosis factor, alpha and beta. TNF-alfa is the pyrogenic

form of this cytokine, and is known to cause fever. The two forms of TNF have similar

biological functions, but their cellular sources differ. TNF-alpha is secreted by

macrophages and targets tumor and inflammatory cells. It has cytotoxic effects and

induces cytokine secretion. TNF-beta is secreted by certain T-cells. It also targets

tumor cells where it induces cytotoxic effects.

The pyrogenic cytokines are released by several different cells, including monocytes,

macrophages, T-helper cells, and fibroblasts, in response to tissue infection or injury.

These pyrogens appear to cause fever by producing prostaglandine that raises the set

point of the hypothalamus. When the source of the pyrogen is removed, its level

decreases, which returns the set point to normal. For a short time, body temperature

will lag behind the return of the set point and the hypothalamus will perceive the body

temperature as too high. In response, the hypothalamus will stimulate responses such

as sweating to cool the body. This fever cascade is visualised in Figure 2.5.

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FIGURE 2.5: Role of cytokines in the fever cascade (Rowsey, 1997:203 )

Nurses can monitor and intervene to prevent systemic fever reactions by

understanding the role of pyrogens. The critical care nurse utilises the scientific

nursing process as a framework within which she/he can identify the patient with fever,

make plans to solve the problem, implement the plan and evaluate to what degree

her/his actions were effective.

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2.4 THE APPLICATION OF THE SCIENTIFIC NURSING PROCESS IN THE

NURSING MANAGEMENT OF FEVER IN THE CRITICALLY ILL PATIENT

The role and competences of the critical care nurse, include the application of critical

thinking and evidence based nursing when utilising the scientific nursing process.

According to Neuman as stated by Holguin-Trupp (2000) the goal of nursing is to

facilitate optimal wellness through retention, attainment, or maintenance of the patient

system stability by means of primary, secondary and tertiary prevention. Neuman

believes the root of intervention is prevention, and must be recognized as soon as the

stressor, in this case fever, arises.

Primary prevention identifies risks, attempts to eliminate the stressors, and focuses on

protecting the patient system. A reaction has not yet occurred, but the degree of risk is

known. The goal is to acknowledge the stressor as soon as it arises and provide

interventions before the client reacts to the stressor. As cited by Sundeen, Stuart,

Rankin and Cohen (1998:3) primary prevention involves lowering the incidence of

illness by counteracting the causative factors before they have a chance to do harm.

During primary prevention, the critical care nurse must try to identify possible causes of

fever this is part of the assessment phase of the scientific nursing process.

Secondary prevention relates to interventions or active treatment initiated after

symptoms have occurred (Neuman, 1982:88). The focus is to strengthen resistance,

reduce the reaction, and increase resistance factors. Early diagnosis and effective

treatment can shorten the duration of a problem. During secondary prevention, the

focus would be to deal with the symptoms of fever, and identifying and listing

interventions. A nursing diagnosis will be made, outcomes identified, for example a

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normal body temperature, and the interventions taken to reduce the fever will be

planned for.

As cited by George (1985:266) it was stated by Neuman that the results of

interventions done in secondary prevention, must be evaluated during the tertiary

phase. Tertiary prevention refers to intervention following that in the secondary stage.

It focuses on readaptation and stability and protects reconstitution or return to wellness

following treatment (Kozier, et al., 1995:52 to 53). This is part of the evaluation phase

of the nursing process. The nursing activity must result in a desired level of wellness

and patient system stability.

The nursing process is described by Kataoka-Yahiro and Saylor in Leddy and Pepper

(1998:203) as a method for problem solving and decision-making, and is a discipline-

specific version of critical thinking. The nursing process is a systematic, rational

method of planning and providing individualised nursing care (Kozier, et al., 1995:83).

Hudak, Gallo and Morton (1998:4) described the nursing process as a systemic

framework for critical thinking in which the nurse seeks information, responds to clinical

cues and identifies and responds to issues affecting the patients health.

The goals of the nursing process are to identify a patients actual or potential health

care needs, to establish plans to meet the identified needs, and to deliver and evaluate

specific nursing interventions to meet those needs. The process is organized into six

interrelated, interdependent phases: assessing, diagnosis, outcomes identification,

planning, implementing and evaluating (Figure 2.6).

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FIGURE 2.6: The six overlapping phases of the nursing process (adapted from

Kozier et al.,1993:16a).

Assessing

+Documentation Diagnosis

+Documentation

Outcomes

Identification+

Documentation

Planning+

Documentation

Implementing+

Documentation

Evaluating

+Documentation

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As cited in Kozier et al. (1993:85), the nursing process is patient centered, and it

enables the critical care nurse to respond to the changing health needs of the patient.

It is also interpersonal and collaborative.

Dossey, Guzzetta and Kenner (1992:54) stated that when the nursing process is used,

it fulfills the purposes of nursing, which are as follows:

Maintain the patients health.

Provide nursing care that will return patients to a state of health or help them

achieve a peaceful death.

Prevent, detect, and treat illness and the complications of illness.

Provide care and treatment necessary to promote comfort.

Maximize the quality of life by improving patients resources

2.4.1 Assessment

This phase is the beginning of the nurse-patient relationship (Sundeen, et al.,1998:7).

The assessment phase is an ongoing process of data collection to determine the

patients health status or problems. Relevant patient data are collected by observation,

examination, interview and history taking, and reviewing of the records.

During this phase, the critical care nurse must know the anatomic, physiologic,

pathophysiologic and etiologic elements of fever, as well as its psychological and

clinical sequelae. In the patient with fever, this will be the stage where data concerning

the fever will be collected. The physiologic alterations of the febrile condition are

identified. The patient is assessed to determine the thermoregulation.

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According to Holtzclaw and Faan(1992:490) and Slavkovsky (1995), it is important

during this stage to observe the patient for the following physiologic responses:

Shivering and vasoconstriction a sign that the hypothalamic set point has been

raised.

Diaphoresis and vasodilation an indication that cooling compensatory

mechanisms are functional. This can lead to oligemia and the worsening of the

cardiovascular functions.

Increases in heart and respiratory rates reflects the increased metabolic rate and

need for oxygen.

The blood pressure increases in the period of increasing fever, but decreases in the

period of decreasing fever because of the decrease in peripheral vascular

resistance.

Irritability comfort are influenced by fever.

Fever itself can cause damage to the kidneys with the presence of proteins and

hyaline casts in the urine.

It is important that all information gathered during this phase be clarified and validated.

The assessment data must be accurate because it forms the basis for the remaining

steps of the nursing process. The critically ill patient will be assessed for the possible

causes of fever. Through assessment and data collection the formulation of a nursing

diagnosis can be facilitated.

2.4.2 Nursing Diagnosis

Diagnosing is a process, which results in a nursing diagnosis. The nurse asks

her/himself the following questions:

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what are the actual and potential health problems for which the client needs

nursing assistance? and

What factors contributed to this problem? (Kozier, et al., 1995:83).

In this study, the critical care nurse will make a nursing diagnosis of high temperature,

and she/he will determine the etiologic factor(s), as well as the signs and symptoms

that are of relevance.

A nursing diagnosis is the independent judgement of a nurse that identifies the nursing

problems of the client (Sundeen,et al., 1998:11). A nursing diagnosis for this study,

can be made as; ineffective thermoregulation.

Perry and Potter (1998:243) stated that to define characteristics from the assessment

data may reveal the following nursing diagnosis:

Risk for altered body temperature

Hyperthermia

Hypothermia

Ineffective thermoregulation .

2.4.3 Outcomes identification

As cited in Hudak, Gallo and Morton (1998:53), the identification of patient outcomes

forms part of the nursing process. After the nursing diagnosis has been established,

specific nursing outcomes are written. This provides a standard that the patient can

achieve realistically as a result of nursing care. Outcome identification builds on the

assessment and nursing diagnosis phase of the nursing process and increases the

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probability of successful planning, implementation and evaluation (Sundeen, et al.,

1998:14).

The following expected outcomes can be formulated in a patient with fever (Perry &

Potter, 1998:243):

The patients body temperature will be within the normal range of 36C to 38C

(Perry and Potter,1998:239).

The patient will maintain thermoregulation.

The patients body temperature will return to normal following interventions for

abnormal temperature.

The next phase will consist of designing a plan of care for the management of the

patient.

2.4.4 Planning

During the planning phase a written plan of care is being designed. Patient outcomes

are the guide for selecting nursing interventions. The nurse develops specific

interventions for her/his nursing diagnosis. This plan is used to coordinate the care

provided by all the health team members. According to Uys and Mulder (1995:23)

during this phase, plans are made to solve the problems. The nursing care plan is

both a blueprint for action and a framework for evaluation (Uys & Mulder, 1995:24).

Thus, in the patient with fever, the following are being planned:

Identify priority of patients concerns,

Determine desired outcomes,

Select appropriate nursing interventions by generalizing principles,

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Design interventions to address the patient with fever scientific rationale.

According to Holtzclaw and Faan(1992:490) the following steps determine nursing

action:

Identify the physiologic alteration in the patient to determine whether responses

that affect thermal regulation are functioning normally

Clarification of the therapeutic goal before an appropriate nursing action can be

selected

Determination of intervention strategies to modify patient responses.

Holtzclaw and Faan(1992:487) gave the following guideline to guide management of

fever:

Mild temperature elevations up to 39C appear to have few detrimental effects.

Some immunoregulatory functions are enhanced by mild temperature elevations up

to 39C.

There appear to be no beneficial effects to high fever and vigorous febrile shivering,

and adverse effects accompany both phenomena in critically ill patients.

An ongoing debate exists over whether to treat a fever, or not. Evidence suggests that

host defense mechanisms may be enhanced by a fever. Fever can thus be beneficial,

and must not be suppressed routinely. Levy concluded after a study done by him:

the routine treatment of fever less than 39C or 39.5C in the critical care unit is

another example of a common practice that does not stand up to scrutiny

(Begany,2000).

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The critical care nurse plays an important role in assessing the critically ill patient and

applying appropriate cooling down methods.

2.4.4.1 Cooling down methods and environmental management

It is best practice to implement cooling down procedures approximately one hour after

an antipyretic is given (Wong & Whaley, 1983:898). This ensures that the

hypothalamic set point is lowered. When cooling down is done without an antipyretic

given, the patient will shiver. The hypothalamus will attempt to produce heat to

maintain the core temperature at the set point, this will result in the fever further raising

(Wong & Whaley, 1983:898). An untreated fever will not rise indefinitely the

hypothalamus serves as a thermostat that prevents the temperature from rising too

high.

When febrile patients are cooled down drastically, the patients thermoregulatory ability

needs to be monitored closely. A danger of surface cooling, is the tendency for central

temperatures to slide uncontrollably in the direction of skin temperature. This loss of

thermoregulation is called poikilothermia (Holtzclaw & Faan, 1992:485).

The following interesting observations were made by the researcher during the

management of two patients in the critical care unit (in both cases the attending nurses

asked the researcher if any interventions can be done in order to lower the fever.

Seeing that both patients, at the time, were not hemodynamically compromised, the

researcher suggested that the fever must be left to take its course):

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The first patient was diagnosed with falciparum malaria. He developed a fever, but

no interventions concerning the fever were undertaken by the critical care nurse.

The temperature rhythm for a 12 hour period, was as follows (all readings were

taken axillary):

07hoo: 38C

08h00: 39C

09h00: 38,2C

11h00: 37,8C

12h00: 37,5C

13h00: 38,3C

14h00: 37,5C

from 14h00 until 18h00 the patient remained apyrexial, without any

interventions done.

The second patient had a small bowel resection with septicaemia and respiratory

failure. No interventions were undertaken concerning the fever, and she had the

following temperature rhythm (all readings were taken axillary):

07h00: 38C

09h00: 38,4C

11h00: 38,5C

12h00: 38C

13h00: 38C

15h00: 38,4C

18h00: 38C

20h00: 37,5C

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This patient also stayed apyrexial without any interventions implemented.

It is important for the critical care nurse to be aware of the advantages and

disadvantages of cooling down methods in order for her to use the correct method on

her patient.

a Sponge baths

Sponge baths reduce temperature by covering the skin with a thin layer of water, which

evaporates and cools the body. Sponge baths causes evaporation and elicit such

vigorous warming responses that they are counterproductive. If an antipyretic is not

given before the sponge bath, the temperature setting in the hypothalamus is not

lowered, instead, it remains at the higher setting that was brought about by the

pyrogens. When the body is cooled during the bath, its temperature drops below that

which is pre-set and, as a result it will begin to work towards reaching the high pre-set

temperature by shivering and vasoconstriction. The patient will feel cold and

uncomfortable, which will defeat the purpose of the sponge bath. Thus it should be

avoided.

Wong (1999)described a study done by Sharber. Sharber found that sponge bathed

children cooled faster during the first hour but there was no significant temperature

difference after 2 hours. External cooling may produce heat loss but may also activate

heat conserving and heat producing mechanisms, such as vasoconstriction, shivering

and goosebumps .

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The researcher observed the following during the treatment of a 18 month old child

who was brought to the casualty department with febrile seizures: her temperature was

39C on admission into the department. She was given an empaped (paracetamol)

suppository rectally and the fever came down to 38C. (She also received the

necessary treatment for the seizures). In spite of the fact that her temperature started

coming down, the doctor kept her covered with wet linen. She developed goosebumps

and started to shiver, after which her temperature raised again to 38.5C. The baby

was admitted to the critical care unit where she was kept uncovered, and her

temperature normalised without any further interventions.

b Light blanket

Holtzclaw and Faan (1992:493) suggests the following: Allow heat to escape from

trunk by applying a sheet and loosely woven blanket over the patient. Avoid fanning

bed covers or rapid removal of clothing that might cause chilling. Thermosensory

nerve endings for heat loss are not uniformly distributed over the body. Because the

trunk is poorly defended by these neurons heat may be lost from this region without

eliciting a strong warming response.

c Electrical fan

As cited in Marks (2001:40), Hotzclaw commented that electrical fanning should be

avoided because it can cause vasoconstriction with shivering and a further increase in

temperature . During the management of a critically ill patient with septic shock, the

researcher observed that the patient had a temperature of 38C. The attending nurse

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kept the electrical fan on the patient for 4 hours. The patients temperature remained at

38C for this period, and the intervention did not make a difference on the temperature.

d Ice packs

Ice packs overwhelm the patients warming defenses. Heat is lost but at great

expense of metabolic energy to the patient (Rowsey,1997:253).

e Cool room temperature

Patient must be kept comfortable. Care must be taken in avoiding chilling.

(Rowsey,1997:253).

f Cooling blankets

The use of th

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