Fever
Fever: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
Fever, or pyrexia, 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. (See How fever develops, page 286.)
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 of fever involves duration — either brief (less than 3 weeks) or prolonged.
Emergency Actions
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 (LOC). Administer an antipyretic and begin rapid cooling measures: Apply ice packs to the axillae and groin, give tepid sponge baths, or apply a hypothermia blanket. These methods may evoke a cooling response; to prevent this, constantly monitor the patient’s rectal temperature.
History
If the patient’s fever is only 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 other symptoms, such as chills, fatigue, or pain?
Obtain a complete medical history, noting especially 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 assessment
Begin by taking your patient’s vital signs. 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 Taking an accurate temperature.)
Medical causes
Anthrax, cutaneous
The patient with cutaneous anthrax 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 meat contaminated 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, 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 0157:H7
Fever, bloody diarrhea, nausea, vomiting, and abdominal cramps occur after eating foods contaminated with the bacterial strain Escherichia coli 0157: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 immune complex dysfunction is 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 virus or Hantavirus). It may be remittent, as in those with infectious mononucleosis or otitis media; hectic 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. General systemic complaints include weakness, anorexia, and malaise.
Neoplasms
Primary neoplasms and metastases 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.
In addition to fever and nocturnal diaphoresis, neoplastic disease typically causes anorexia, fatigue, malaise, and weight loss. Examination may reveal lesions, lymphadenopathy, palpable masses, and hepatosplenomegaly.
Plague
Plague is an infection caused by the bacterium Yersinia pestis. The bubonic form of plague 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 myalgia 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.
Rhabdomyolysis
Rhabdomyolysis produces fever, muscle weakness or pain, nausea, vomiting, malaise, or dark reddish brown urine. Acute renal failure is the most frequently reported complication of the disorder.
Severe acute respiratory syndrome
Severe acute respiratory syndrome (SARS) is an acute infectious disease of unknown etiology that 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
Initial signs and symptoms of smallpox (also known as variola major) 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 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
Also known as rabbit fever, tularemia is an infectious disease that causes abrupt onset of fever, chills, headache, generalized myalgia, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.
West Nile encephalitis
Mild infection is common from West Nile encephalitis, a mosquito-borne Flavivirus. Signs and symptoms include fever, headache, and body aches, commonly with skin rash and swollen lymph glands. More severe infection is marked by high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, occasional seizures, paralysis and, rarely, death.
CULTURAL CUE:West Nile encephalitis is commonly found in Africa, West Asia, and the Middle East. It rarely occurs in North America.
Other causes
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.
Special 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.
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. 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.
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.
Geriatric pointers
Elderly people may have altered sweating mechanisms that predispose 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.
Patient counseling
If the patient hasn’t been admitted to the hospital, ask him to measure his oral temperature at home and record the time and value. Explain to him that fever is a response to an underlying condition and that it plays an important role in fighting infection. Therefore, advise him not to take an antipyretic until his body temperature reaches 101°F (38.3° C). Encourage the patient with a fever to drink plenty of fluids, unless contraindicated.
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Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, 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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