Fever is a common distressing symptom in patients. Elevations in normal body temperature are instigated by prostaglandins exerting their effect on the hypothalamus in the event of cellular injury (Scrase & Tranter, 2011). When fever is uncorrected, the body may reach dangerously high temperatures and thus its management is a priority. To achieve safe and effective care, the chosen nursing interventions must be based on evidence. Thus, established practice must continually be evaluated against current evidence to ensure accountability. An interview with a registered nurse, with answers to the questions summarized below, reveals the common fever management practices in a pediatric unit. The interventions identified are then analyzed in light of recent research.
Interview Summary
The respondent is a registered nurse working as a staff nurse in the pediatric unit of a local hospital. She has been in the profession for 16 years with the past five years spent in pediatric nursing. She is currently seeking certification as the facility has decided to seek magnet status. The interview was conducted during a scheduled break as it is the most convenient for the staff nurse.
1. Is there a unit or hospital protocol for the management of fever in children?
The respondent stated that unlike other hospitals she previously worked at, both the facility and the unit do not have an established protocol in place. Interventions to manage fever are within the discretion of individual nurses in coordination with physician orders.
2. What interventions do you usually provide to patients with fever?
The staff nurse replied that fever is first reported to the physician who then gives the order to administer an antipyretic in specified dosages and routes. During the chill phase of fever, the nurse ensures that the child has enough blankets to generate warmth. During the plateau stage, the nurse gives her patient sponge baths. When tepid water does not result in temperature reduction, the nurse applies ice packs to facilitate cooling. She also ensures that room temperature is cool and that excess clothing is removed so that body heat can dissipate. To prevent dehydration, the nurse frequently encourages the patient to drink fluids. Body temperature is monitored via a tympanic thermometer and if all interventions fail, this fact is communicated to the physician.
3. How do you decide on what interventions to perform for a particular patient?
The respondent replied that interventions for fever depend on the grade and phase of fever and the patient’s physiologic responses. Many physicians prefer to have antipyretics administered when body temperature reaches a certain point, usually when it starts to become distressing to the patient as when fever is moderate or high grade. For this reason, it is given that above normal body temperatures are reported to the physician so that prescribed antipyretics can be promptly administered. Further, the phase of the fever, chill phase or febrile phase, also influences what management practices will be performed. Patient response to antipyretics also determines whether pharmacologic or non-pharmacologic interventions such as sponge baths will be given. The staff nurse reiterated that the key to making the right decisions is an accurate and prompt assessment of the child. Allowing the fever to remain unmanaged may lead to seizures.
4. Do you find sponge baths to be effective in bringing down fever?
Evidence Base
For decades, physical cooling methods such as sponge baths with alcohol, vinegar, cold water or tepid water have been utilized as an intervention both at home and in the hospital for the reduction of fever in children (Axelrod, 2000). However, historical use is not a sufficient basis in continuing the adoption of this practice. A search of literature reveals current evidence regarding the overall management of fever, particularly shedding light on whether sponge bathing febrile patients remains a relevant intervention.
A systematic review of trial studies seeking to compare the outcomes of physical cooling versus other interventions where no cooling is used was conducted by Chan, Chen & Assam (2010). The study samples consisted of adult patients in the acute care setting. In four of the six trials reviewed, there were no significant differences in the average reduction of temperature between patients treated with and without physical cooling regardless of whether other interventions were also used. Moreover, shivering occurred more in the groups who received physical cooling.
A review specifically involving studies of pediatric patients was done by Chiappini et al. (2009) for the purpose of updating the Italian Pediatric Society’s guidelines in fever management. Current recommendations include the use of paracetamol or ibuprofen as antipyretics and only when the patient is exhibiting discomfort. In the 2009 guidelines, physical cooling methods, including sponge bathing and ice pack application, were thought to be linked with adverse outcomes such as rebound fever and shivering which further uses up the body’s energy at a rate faster than the fever itself. Discomfort is also a common finding.
In another review, Holtzclaw (2013) validates the positive outcomes of interventions during the chill phase of fever and further supports the prevention of antipyretic overuse by giving the drug only when clinically warranted. The review also finds evidence for the prevention of dehydration, assessment of the fever’s phase and monitoring body temperature. Regarding cooling, the review also substantiates the negative outcomes associated with physical cooling measures. However, it provides evidence that inducing paralysis to prevent shivering helps achieve the intended results.
Analysis
Based on the research articles, it is clear that the respondent’s practice is not fully supported by current evidence. While determining the patient’s phase of fever and providing interventions to prevent chills conform to EBP as does ensuring adequate fluid intake, the use of physical cooling methods is no longer supported by evidence. The only exception is when a paralytic medication is given to prevent the shivering that frequently follows sponge bathing and the use of ice packs. However, no studies support the routine use of paralytics for the main purpose of making physical cooling methods effective. Maintaining the practice of physically cooling patients will result in suboptimal health outcomes.
Moreover, the absence of a hospital or unit protocol prevents nurses from having a uniform practice of fever management. In this scenario, nurses at the bedside make decisions as to what interventions to implement. Without instituting steps to ensure that nurses’ knowledge is current, RNs will continue to practice fever management based on variable knowledge and experience. This is a barrier to providing high quality patient care for children with fever. Protocols also represent guides in the adoption of evidence-based practices to make sure that nursing interventions are safe and effective (Chiappini et al., 2012). Therefore, protocols need to be instituted in the hospital or unit.
Conclusion
Physically cooling febrile patients remains a common non-pharmacologic intervention being utilized by nurses. Its practice is mainly supported by historical evidence and personal experiences. Recent research points to the need to reconsider this practice because of the negative effects identified. To facilitate nurse’s adoption of evidence-based practice in fever management, protocols or guidelines need to be established. Educating and training nursing staff regarding EBP are also important components of practice change initiatives.
References
Axelrod, P. (2000). External cooling in the management of fever. Clinical Infectious Diseases, 31(Supplement), S224-S229.
Chan, E.Y., Chen, W.T., & Assam, P.N. (2012). External cooling methods for treatment of fever in adults: A systematic review. JBI Library of Systematic Reviews, 8(20), 793-825.
Chiappini, E., Principi, N., Longhi, R., Tovo, P., Becherucci, P., Bonsignori, F., & Esposito, S. (2009). Management of fever in children: Summary of the Italian Pediatric Society guidelines. Clinical Therapeutics, 31(8), 1826-1843.
Holtzclaw, B.J. (2013). Managing fever and febrile symptoms in HIV: Evidence-based approaches. Journal of the Association of Nurses in AIDS Care, 24(Supplement), S86-S102.
Scrase, W., & Tranter, S. (2011). Improving evidence-based care for patients with pyrexia. Nursing Standard, 25(29), 37-41.
