Fever
Fever: Excerpt from Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
Fever is a common sign that can arise from any one of several disorders. Because these disorders can affect virtually any body system, fever in the absence of other signs usually has little diagnostic significance. A persistent high fever, though, represents an emergency.
Fever can be classified as low (oral reading of 99° to 100.4° F [37.2° to 38° C]), moderate (100.5° to 104° F [38° to 40° C]), or high (above 104° F). Fever over 106° F (41.1° C) causes unconsciousness and, if sustained, leads to permanent brain damage.
Act Now: If you detect a fever higher than 106° F (41.1° C), take the patient’s other vital signs and determine his level of consciousness. Administer an antipyretic and begin rapid cooling measures: Apply ice packs to the axillae and groin, give tepid sponge baths, or apply a cooling blanket. These methods may evoke a cooling response; to prevent this, constantly monitor the patient’s rectal temperature.
Fever may also be classified as remittent, intermittent, sustained, relapsing, or undulant. Remittent fever, the most common type, is characterized by daily temperature fluctuations above the normal range. Intermittent fever is marked by a daily temperature drop into the normal range and then a rise back to above normal. An intermittent fever that fluctuates widely, typically producing chills and sweating, is called hectic, or septic, fever. Sustained fever involves persistent temperature elevation with little fluctuation. Relapsing fever consists of alternating feverish and afebrile periods. Undulant fever refers to a gradual increase in temperature that stays high for a few days and then decreases gradually.
Further classification involves duration — either brief (less than 3 weeks) or prolonged. Prolonged fevers include fever of unknown origin, a classification used when careful examination fails to detect an underlying cause.
Assessment
History
If the patient’s fever is mild to moderate, ask him when it began and how high his temperature reached. Did the fever disappear, only to reappear later? Did he experience any other symptoms, such as chills, fatigue, or pain?
Obtain a complete medical history, noting immunosuppressive treatments or disorders, infection, trauma, surgery, diagnostic testing, and use of anesthesia or other medications. Ask about recent travel because certain diseases are endemic.
Physical examination
Let the history findings direct your physical examination. Because fever can accompany diverse disorders, the examination may range from a brief evaluation of one body system to a comprehensive review of all systems. (See How fever develops, pages 148.) Assess vital signs and evaluate the patient for complications related to the fever such as dehydration, body aches, fatigue, anorexia, and seizure activity.
Pediatric pointers
Infants and young children experience higher and more prolonged fevers, more rapid temperature increases, and greater temperature fluctuations than older children and adults.
Keep in mind that seizures commonly accompany extremely high fever, so take appropriate precautions. Also, instruct parents not to give aspirin to a child with varicella or flulike symptoms because of the risk of precipitating Reye’s syndrome.
Common pediatric causes of fever include varicella, croup syndrome, dehydration, meningitis, mumps, otitis media, pertussis, roseola infantum, rubella, rubeola, and tonsillitis. Fever can also occur as a reaction to immunizations and antibiotics.
Geriatric pointers
Elderly people may have an altered sweating mechanism that predisposes them to heatstroke when exposed to high temperatures; they may also have an impaired thermoregulatory mechanism, making temperature change a much less reliable measure of disease severity.
Medical causes
Anthrax, cutaneous
The patient may experience a fever along with lymphadenopathy, malaise, and headache. After the bacterium
Bacillus anthracis enters a cut or abrasion on the skin, the infection begins as a small, painless or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days, the lesion develops into a vesicle and then into a painless ulcer with a characteristic black, necrotic center.
Anthrax, GI
Following the ingestion of contaminated meat from an animal infected with the bacterium
Bacillus anthracis, the patient experiences fever, loss of appetite, nausea, and vomiting. The patient may also experience abdominal pain, severe bloody diarrhea, and hematemesis.
Anthrax, inhalation
The initial signs and symptoms of inhalation anthrax are flulike ones, including fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours.
Escherichia coli O157:H7. Fever, bloody diarrhea, nausea, vomiting, and abdominal cramps occur after eating undercooked beef or other foods contaminated with E. coli O157:H7. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop (in which the red blood cells are destroyed), and this may ultimately lead to acute renal failure.
Immune complex dysfunction
When present, fever usually remains low, although moderate elevations may accompany erythema multiforme. Fever may be remittent or intermittent, as in acquired immunodeficiency syndrome (AIDS) or systemic lupus erythematosus, or sustained, as in polyarteritis. As one of several vague, prodromal complaints (such as fatigue, anorexia, and weight loss), fever produces nocturnal diaphoresis and accompanies such associated signs and symptoms as diarrhea and a persistent cough (with AIDS) or morning stiffness (with rheumatoid arthritis). Other disease-specific findings include headache and vision loss (temporal arteritis); pain and stiffness in the neck, shoulders, back, or pelvis (ankylosing spondylitis and polymyalgia rheumatica); skin and mucous membrane lesions (erythema multiforme); and urethritis with urethral discharge and conjunctivitis (Reiter’s syndrome).
Infectious and inflammatory disorders
Fever ranges from low (in patients with Crohn’s disease or ulcerative colitis) to extremely high (in those with bacterial pneumonia, necrotizing fasciitis, or Ebola or Hantavirus). It may be remittent, as in those with infectious mononucleosis or otitis media; hectic (recurring daily with sweating, chills, and flushing), as in those with lung abscess, influenza, or endocarditis; sustained, as in those with meningitis; or relapsing, as in those with malaria. Fever may arise abruptly, as in those with toxic shock syndrome or Rocky Mountain spotted fever, or insidiously, as in those with mycoplasmal pneumonia. In patients with hepatitis, fever may represent a disease prodrome; in those with appendicitis, it follows the acute stage. Its sudden late appearance with tachycardia, tachypnea, and confusion heralds life-threatening septic shock in patients with peritonitis or gram-negative bacteremia.
Associated signs and symptoms involve every system. The cyclic variations of hectic fever typically produce alternating chills and diaphoresis. General systemic complaints include weakness, anorexia, and malaise.
Listeriosis
Signs and symptoms of listeriosis include fever, myalgias, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; symptoms include fever, headache, nuchal rigidity, and change in level of consciousness.
Neoplasms
Primary neoplasms and metastasis can produce prolonged fever of varying elevations. For instance, acute leukemia may present insidiously with low fever, pallor, and bleeding tendencies, or more abruptly with high fever, frank bleeding, and prostration. Occasionally, Hodgkin’s disease produces undulant fever or Pel-Ebstein fever, an irregularly relapsing fever.
Besides fever and nocturnal diaphoresis, neoplastic disease often causes anorexia, fatigue, malaise, and weight loss. Examination may reveal lesions, lymphadenopathy, palpable masses, and hepatosplenomegaly.
Plague (Yersinia pestis)
The bubonic form of plague (transmitted to patient when bitten by infected fleas) causes fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the bite. The septicemic form develops as a fulminant illness generally with the bubonic form. The pneumonic form manifests as a sudden onset of chills, fever, headache, and myalgias after person-to-person transmission via the respiratory tract. Other signs and symptoms of the pneumonic form include productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.
Q fever
Q fever is a rickettsial disease that’s caused by the infection of
Coxiella burnetii causes fever, chills, severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. Fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.
Rhabdomyolysis
Rhabdomyolysis results in muscle breakdown and release of the muscle cell contents (myoglobin) into the bloodstream, with signs and symptoms including fever, muscle weakness or pain, nausea, vomiting, malaise, or dark urine. Acute renal failure is the most frequently reported complication of the disorder. It results from renal structure obstruction and injury during the kidney’s attempt to filter the myoglobin from the bloodstream.
Rift Valley fever
Typical signs and symptoms of Rift Valley fever include fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss.
Severe acute respiratory syndrome (SARS)
SARS is an acute infectious disease caused by a coronavirus called SARS-associated coronavirus (SARS-CoV). Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have cropped up in Europe and North America. The incubation period is 2 to 7 days, and the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache, malaise, a dry nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.
Smallpox (variola major)
Initial signs and symptoms of smallpox include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After about 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.
Thermoregulatory dysfunction
Sudden onset of fever that rises rapidly and remains as high as 107° F (41.7° C) occurs in life-threatening disorders, such as heatstroke, thyroid storm, neuroleptic malignant syndrome, and malignant hyperthermia, and in lesions of the central nervous system (CNS). Low or moderate fever appears in dehydrated patients.
Prolonged high fever commonly produces vomiting, anhidrosis, decreased level of consciousness (LOC), and hot, flushed skin. Related cardiovascular effects may include tachycardia, tachypnea, and hypotension. Other disease-specific findings include skin changes: dry skin and mucous membranes, poor skin turgor, and oliguria with dehydration; mottled cyanosis with malignant hyperthermia; diarrhea with thyroid storm; and ominous signs of increased intracranial pressure (decreased LOC with bradycardia, widened pulse pressure, and increased systolic pressure) with CNS tumor, trauma, or hemorrhage.
Tularemia
Tularemia, also known as
rabbit fever, is an infectious disease that causes abrupt onset of fever, chills, headache, generalized myalgias, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.
Typhus
With typhus — a rickettsial disease — the patient initially experiences headache, myalgia, arthralgia, and malaise. These signs and symptoms are followed by an abrupt onset of fever, chills, nausea, and vomiting. A maculopapular rash may be present in some cases.
West Nile encephalitis
A brain infection caused by West Nile virus, the mosquito-borne flavivirus is commonly found in Africa, West Asia, the Middle East and, rarely, in North America. Mild infection is common; signs and symptoms include fever, headache, and body aches, often with skin rash and swollen lymph glands. More severe infection is marked by high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, occasional convulsions, paralysis and, rarely, death.
Other causes
Diagnostic tests
Immediate or delayed fever infrequently follows radiographic tests that use contrast medium.
Drugs
Fever and rash commonly result from hypersensitivity to antifungals, sulfonamides, penicillins, cephalosporins, tetracyclines, barbiturates, phenytoin, quinidine, iodides, phenolphthalein, methyldopa, procainamide, and some antitoxins. Fever can accompany chemotherapy, especially with bleomycin, vincristine, and asparaginase. It can result from drugs that impair sweating, such as anticholinergics, phenothiazines, and monoamine oxidase inhibitors. A drug-induced fever typically disappears after the involved drug is discontinued. Fever can also stem from toxic doses of salicylates, amphetamines, and tricyclic antidepressants.
Inhaled anesthetics and muscle relaxants can trigger malignant hyperthermia in patients with this inherited trait.
Medical treatments
Remittent or intermittent low fever may occur for several days after surgery. Transfusion reactions characteristically produce abrupt onset of fever and chills.
Nursing considerations
Regularly monitor the patient’s temperature, and record it on a chart for easy follow-up of the temperature curve. Provide increased fluid and nutritional intake. When administering a prescribed antipyretic, minimize resultant chills and diaphoresis by following a regular dosage schedule. Promote patient comfort by maintaining a stable room temperature and providing frequent changes of bedding and clothing. Prepare the patient for laboratory tests, such as complete blood count and cultures of blood, urine, sputum, and wound drainage.
Patient teaching
If the patient hasn’t been admitted to the facility, ask him to measure his oral temperature at home and record the time and value. Explain that fever is a response to an underlying condition that plays an important role in fighting infection. For this reason, advise him not to take an antipyretic until his body temperature reaches 101° F (38.3° C). Discuss signs and symptoms related to dehydration and when to notify the physician.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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