Fever Management: Nurses Knowledge, Attitudes, and Influencing Factors - Case Study Example

Clinical Reflection Fever Management: Nurses’ knowledge, attitudes and influencing factors of fever management and antipyretic usage for febrile patients. Clinical Practice Incident A registered nurse caring for a patient with febrile neutropaenia was preparing to collect blood samples when she directed the endorsed enrolled nurse working within her team to administer PRN febridol to the patient. The clinical nurse in charge of the ward overheard this instruction and asked the registered nurse to refrain from giving this antipyretic because it would mask the fever symptoms in the neutropenic patient. Although the RN did not agree with this decision she asked the EEN not to administer the medication. It was a busy oncology ward at a large private hospital. The student nurse knowing that in a neutropaenic patient a high temperature is sometimes the only sign of an infection could understand this directive however, because the RN was not happy about this the student began to question why nurses are always in a hurry to administer antipyretics to febrile patients. INTRODUCTION The practice incident made me aware of a very important clinical question that involves the administration of anti-pyretics to febrile patients. The incident spurred my inquiry into the physiological basis of fever and best practice evidence for fever management. I now realise that this very common symptom reflects an incompletely understood physiological response to infection and disease that requires careful assessment. Context issues relevant to practice incident Definition of fever Fever defines an elevated body temperature that is above the daily normal range (about 37C). It occurs as a systemic response to an immune immune stimulus (Broom, 2007). In researching this concept, although the definition of fever as an elevation of body temperature appears very simple, in actuality, fever is a complex bodily response that has been misunderstood by clinicians, patients and their families. Part of the reason for this ambiguity is that fever is a symptom rather than a disease process. As such, the occurrence of fever has many interpretations and may elicit different clinical responses depending on the circumstances in which it occurs. Physiology of fever My study of the physiology of fever indicated that it is a very complicated systemic event. Fever represents an immune response that occurs in response to pyrogens of exogenous origin such as bacterial infection or endogenous causes such as interferon (Broom, 2007). Phagocytic attack of bacterial pathogens by macrophages results in the production of cytokines that induce body temperature increases. The pyrogenic effects are mediated via regulation of intracellular adenyl cyclase activity and also via the thermoregulatory center in the hypothalamus. Behavioural, endocrine and autonomic nervous system responses produce changes in the body temperature set point by the hypothalamus. Adrenaline production increases heart and respiratory rate. Increased glycolysis occurs in the cell. Body temperaure rarely exceeds 40C as an internal feedback mechanism by the hypothalamic setpoint and the regulation of prostaglandin E2 (Broom, 2007). Benefit of fever Fever represents an adaptive response that increases metabolic rate and, in so doing, increases immune system responses to infectious agents. In addition, the elevated body temperature is destructive to bacteria and viruses (Thompson, 2007). Harmful effects of fever Childhood convulsions may result from high fevers. Very high temperatures (43C) may cause nerve damage, cell and protein destruction occurs at 45C. In addition, the high metabolic rate associated with elevated temperature is stressful to the body and may pose a risk for individuals with congenital heart disease, immuno-suppression or other systemic deficits (Thompson, 2007). Treatment of fever Due to the complex physiology of fever and the impreciseness with which it is frequently defined, its treatment is often controversial. For many centuries, fever was feared as it was associated with serious illness and death. Research studies over the past several decades suggest, however, that fever may serve an important immunological function that is adaptive to prevent the destructive events of infection (Broom, 2007). Anti-pyretics are generally effective in reducing fever, and act by blocking the actions of prostaglandins (Thompson, 2007). My inquiry into fever treatment options revealed that the ambiguity I sensed in my personal clinical incident reflects the controversy surrounding the treatment of febrile patients. Critical review of the relevant literature/ evidence Given the complex physiology of fever, it was not surprising to me that this is a very active area of clinical research. These research studies addressed many issues relevant to clinical practice in regard to the administration of anti-pyretics to febrile patients (O’Connor, 2002). These studies indicate that there are two basic viewpoints among primary care clinicians and nurses regarding the treatment of fever. Many clinicians currently feel that, in the absence of systemic disease or immunological dysfunction, fever requires no anti-pyretic treatment as it is a self-limited therapeutic response to infection. Moreover, the use of anti-pyretics may mask some of the symptoms of illness and make diagnosis more difficult (Thompson, 2002). On the other hand, an argument has been made for the use of anti-pyretic drugs in patients with fever to relieve the discomfort associated with elevated body temperature (Meremikwu & Oyo-Ita, 2008). In addition, convulsions, particularly in young children between the ages of 6 months and 6 years, are frightening events associated with elevated body temperature (Thompson, 2002). Several important research studies have provided evidence of the beneficial effects of fever (Edwards et al, 2007). Among the positive effects cited are the inhibition of bacterial growth, as microorganisms generally grow in a very restricted temperature range. In addition, elevated fever increases antibody production and other important immune responses to infection. These findings support the clinical practice of restricting the use of anti-pyretics in febrile patients in order to maximise the natural therapeutic benefits of fever (Edwards, 2007). A Japanese study of nurses' attitudes about fever involving several hundred nurse respondents indicated that the two major indicators of fever were elevated temperature and chills (Ikematsu, 2004). These two parameters were considered most significant to nurses' decisions regarding treatment options. The most common therapeutic approaches to fever by this group of nurses involved mechanical cooling of the febrile patient. Afterward the patient's body was warmed and the patient was given an anti-pyretic medication (Ikematsu, 2004). An Australian research study was conducted to examine the effects of peer training in nurses' attitudes about fever and therapeutic management of febrile patients (Watts, Robertson & Thomas, 2003). Approximately 75 nurses were queried before and after a peer training program on fever management. The nurses' responses were compared to those of a similar group who received no educational mentoring. The study concluded that educational programs are very useful in increasing nurses' breadth of knowledge about fever management. However, it did not address specific evidence based practice effects of this training program. This research study on nurses' attitudes toward fever management in paediatric patients indicated that many nurses hold the view that fever in children is generally harmful and should be treated aggressively with anti-pyretics to prevent convulsions and brain damage (Watts, Robertson & Thomas, 2003). Additional research studies have shown, however, that in many areas of the world, including US, Canada and Saudi Arabia, the body temperature at which anti-pyretic medication is administered by nurses in clinical settings has increased approximately one degree (38C to 39C) over the past 10-15 years. A lesser increase has been observed in Australia (Watts, Robertson & Thomas, 2003). Additional basic research suggests that anti-pyretics may actually do little to affect convulsions in young children and that the main effect is to make the patient more comfortable (Walsh et al, 2005). A concern raised by researchers assessing the trend towards more restricted use of anti-pyretics in fever management is the association of high body temperature with dehydration and electrolyte imbalances which may have very harmful physiological effects (Henker & Carlson, 2007). These research studies highlight the complexity of fever and the care and concern necessary to achieve the appropriate use of anti-pyretic medications. The research supports the general lack of consensus among nurses about when to administer anti-pyretics to a febrile patient. There are no simple answers to achieve best practice. An important retrospective study on the use of paracetamol in children with malaria produced ambiguous results (Meremikwu, Logan & Garner, 2008). The general standard of care for children suffering from malaria involves mechanical cooling and the use of anti-pyretics during the chills and fever phase of infection. A clinical assessment of children treated with anti-pyretic drugs versus a control group given a placebo suggested that anti-pyretics produced limited if any effect on the duration of the fever phase of infection and little effect on the parasitic infestation (Meremikwu, Logan & Garner, 2008). Once again, the clinical data support the use of anti-pyretics to relieve the uncomfortable effects of elevated temperature, but point to little true therapeutic impact. Conversely, approaches that do not involve the use of anti-pyretic drugs to treat children with malaria-induced fever did not appear to produce a noticeable deleterious effect (Meremikwu, Logan & Garner, 2008). Conclusion The clinical practice incident on fever management has brought to the forefront an extremely important issue in clinical nursing practice. Fever is one of the most common symptoms encountered in clinical medicine in both children and adults and is often a presenting symptom that may be associated with a broad spectrum of infections and physiological conditions. My study and reflection on this important issue highlights the fact that there are often many causes of a single symptom in human physiology. It also helped me to realise that what may at first appear to be an abnormal physiological state may also be seen as a normal physiological response to the disruption of bodily homeostasis. For this reason, it is important to explore the physiological basis of systemic responses to infection and disease, as this may affect decisions in regard to best practice approaches to therapeutic management. An assessment of relevant research studies conducted in the area of fever management indicates that there has been a change in approach to treatment of the febrile patient as a greater understanding of the physiological role of fever has been better elucidated. These studies suggest that the occurrence of fever may itself be therapeutic, resulting in augmented immune responses and direct destruction of infectious disease agents in the body (O’Connor, 2002). Moreover, a significant amount of research suggests that the use of anti-pyretics is largely palliative and may accomplish little by way of shortening the duration or lessening the physiological impact of infection and disease (Thompson, 2007). My reflection on this issue also brings to mind the importance of symptoms, that the occurrence of fever in a patient is an extremely important indicator of systemic physiological distress. Fever should not be viewed simply as a discomfort to be treated and subsequently ignored, but should be used as a diagnostic tool to assess the underlying causes of this systemic response. On the other hand, although fever is a symptom, it can also be destructive in its own right. High fever can damage proteins, cells and body functions directly. In addition, the increased metabolic rate and physiological cooling processes can produce rapid dehydration and electrolyte imbalance that can be life-threatening in the febrile patient. For these reasons, the occurrence of fever demands a careful assessment of degree of temperature elevation and other associated symptoms of potentially dangerous effects of high body temperature (Walsh et al, 2008). I found that the consensus of research suggests that mechanical cooling does little to bring down body temperature in the febrile patient, as the body will attempt to compensate to maintain the higher setpoint associated with elevated body temperature (Henker & Carlson, 2007). These studies suggest that the administration of anti-pyretics is the optimal therapeutic approach to fever management. Many anti-pyretics, including ibuprofen, aspirin (contra-indicated in children) and paracetamol appear to be equally efficacious in restoring body temperature due to their inhibitory effects on prostaglandin production. The real question involves the decision of whether to administer anti-pyretics to the febrile patient. Based on my investigation of this question, it appears that there is no one answer that is best for all patients in all circumstances. My original bewilderment over the apparent ambiguity in nursing practice illustrated in the practice incident has not entirely disappeared. I now realise that this feeling was legitimate, in that there is some uncertaintly in best practice medicine over when to administer anti-pyretics to the febrile patient. I better understand that the most important consideration is the body temperature itself; life itself cannot be sustained at temperatures significantly above 43C. Very high body temperature requires immediate therapeutic intervention and careful monitoring until the fever abates. Moreover, any sign of dehydration or electrolyte imbalance associated with fever requires aggressive intervention. For less serious temperature elevation, it may not be necessary to administer anti-pyretics as long as the patient can be kept reasonably comfortable and monitored frequently for temperature changes. Elevated temperature may be a useful diagnostic barometer and it may be useful to delay the administration of anti-pyretics under medical diagnosis of the cause of fever has been determined. This practice incident has given me a new respect for the complexity of the human body and its response to infection and disease. I also appreciate more thoroughly the thoughtful consideration that must be given to each individual patient who suffers a fever in evaluating the decision to intervene in this naturally occurring defense mechanism. References Broom, M. (2007). Physiology of fever. Paediatric Nursing, 19(6), 40-45. Edwards, H., Walsh, A., Courtney, M., Monaghan, S., Wilson, J. & Young, J. (2007). Improving paediatric nurses’ knowledge and attitudes in childhood fever management. Journal of Advanced Nursing, 57(3), 257-269. Henker, R. & Carlson, K. (2007) Fever: applying research to bedside practice, Advanced Critical Care, 18, 76-87. Ikematsu, Y. (2004). Characteristics of and interventions for fever in Japan. International Nursing Review,51, 229-239. Meremikwu, M., Logan, K. & Garner, P. (2008). Antipyretic measures for treating fever in malaria. The Cochrane library, 3, 1-12. Meremikwu, M. & Oyo-Ita. (2008). Paracetamol for treating fever in children. The Cochrane Library, 3, 1-25. O’Connor, S. (2002). Antipyretics in the paediatric A&E setting: a review. Paediatric Nursing, 14(3), 33-35. Thompson, H. (2007). Fever: a concept analysis. Journal of Advanced Nursing, 51(5), 484-492. Walsh, A., Edwards, M., Courtney, M., Wilson, J. & Monaghan S. (2005). Fever management: Paediatric nurses’ knowledge, attitudes and influencing factors. Journal of Advanced Nursing, 49(5), 453-464. Watts, R., Robertson, J. & Thomas, G. (2003). Nursing management of fever in children: a systematic review. International Journal of Nursing Practice, (9), s1-s8. Read More