http libserv5.tut.ac.za 7780 pls eres wpg docload.download file p filename=f1731598754 bester
TRANSCRIPT
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
1/169
NURSING MANAGEMENT OF FEVER
IN CRITICALLY ILL PATIENTS
HESTER SOPHIA ELIZABETH BESTER
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
2/169
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
3/169
NURSING MANAGEMENT OF FEVER
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
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
4/169
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
ii
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
5/169
I dedicate this study with
love to
my husband Louis and
children, Wimpie and Marina
for their support and personal
sacrifices.
iii
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
6/169
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?
iv
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
7/169
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.
v
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
8/169
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.
vi
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
9/169
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:
vii
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
10/169
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.
viii
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
11/169
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.
ix
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
12/169
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.
x
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
13/169
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
xi
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
14/169
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
xii
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
15/169
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
xiii
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
16/169
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
xiv
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
17/169
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
xv
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
18/169
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
xvi
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
19/169
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
xvii
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
20/169
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
xviii
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
21/169
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
registered nurses per hospital 100
FIGURE 4.15: The frequency of planning for the management of fever recorded by
registered nurses per hospital 101
xix
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
22/169
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
xx
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
23/169
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
xxi
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
24/169
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
xxii
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
25/169
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.
1
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
26/169
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.
2
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
27/169
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?
3
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
28/169
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.
4
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
29/169
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
5
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
30/169
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).
6
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
31/169
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).
7
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
32/169
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.
8
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
33/169
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.
9
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
34/169
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.
10
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
35/169
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.
11
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
36/169
2.2 THE ROLE AND COMPETENCES OF THE CRITICAL CARE NURSE IN THE
NURSING MANAGEMENT OF FEVER
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.
12
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
37/169
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.
13
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
38/169
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.
14
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
39/169
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.
15
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
40/169
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
16
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
41/169
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).
17
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
42/169
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.
18
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
43/169
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.
19
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
44/169
FIGURE 2.3: Negative feedback mechanisms that conserve heat and increase
heat production (Tortora & Grabowski, 1996: 811).
20
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
45/169
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
21
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
46/169
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.
22
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
47/169
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
23
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
48/169
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.
24
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
49/169
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
25
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
50/169
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
26
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
51/169
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.
27
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
52/169
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).
28
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
53/169
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.
29
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
54/169
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
30
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
55/169
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).
31
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
56/169
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.
32
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
57/169
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).
33
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
58/169
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.
34
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
59/169
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.
35
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
60/169
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
36
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
61/169
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).
37
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
62/169
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
38
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
63/169
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.
39
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
64/169
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:
40
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
65/169
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
41
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
66/169
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,
42
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
67/169
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).
43
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
68/169
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):
44
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
69/169
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
45
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
70/169
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 .
46
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
71/169
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
47
-
7/31/2019 Http Libserv5.Tut.ac.Za 7780 Pls Eres Wpg Docload.download File p Filename=F1731598754 Bester
72/169
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