NURSING MANAGEMENT OF FEVER IN CRITICALLY ILL PATIENTS

HESTER SOPHIA ELIZABETH BESTER

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

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: Date:

_______________ 200 107 217 31 October 2003

Copyright @ Technikon Pretoria 2003

ii

I dedicate this study love to my husband Louis and

with

children, Wimpie and Marina for their support and personal sacrifices.

iii

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

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.

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

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 kritiekesorgverpleegkundiges 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

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

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

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 and me with of the the initial research

statistics tools.

development

Sarah for endless patience with me and for the language revision. Elsabe for the final technical revision.

 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 for

to

my

supervisor,

Dr.

Jakkie

Bornman,

her

encouragement,

support and assistance throughout the period of study.

INDEX PAGE Abstract.. iv Ekserp vii Acknowledgements. x

Addenda xvi List of Figures.. List of Tables xvii xxi

CHAPTER 1

xi

ORIENTATION TO THE STUDY

1.1. 1.2. 1.3. 1.4. 1.5. 1.6.

INTRODUCTION .. 1 THE RESEARCH PROBLEM. .2 AIM OF THE STUDY AND SPECIFIC OBJECTIVES4 ETHICAL CONSIDERATIONS. 5 DEFINITIONS . 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

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

CHAPTER 3

RESEARCH METHODOLOGY

3.1. 3.2. 3.3.

INTRODUCTION. 56 RESEARCH DESIGN . 56 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 3.4. 65

ANALYSIS OF DATA 67

3.4.1. Nursing documentation. 67 3.4.2. Questionnaires.. 68 3.5. 3.6. VALIDITY AND RELIABILITY OF THE STUDY.. 68 SUMMARY. 70

CHAPTER 4

DATA ANALYSES AND RESULTS OF THE STUDY

4.1. 4.2.

INTRODUCTION.. 71 DATA GATHERED BY MEANS OF THE QUESTIONNAIRES. 71

4.2.1. Professional category of respondents.. 72

xiv

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. 4.4. DATA GATHERED BY MEANS OF THE CHECKLIST. 96 SUMMARY.. 111

CHAPTER 5

JUSTIFICATION, RECOMMENDATIONS AND CONCLUSIONS

5.1. 5.2.

INTRODUCTION. .. 114 JUSTIFICATION 114 114

5.2.1. The aim and objectives of the study.

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.. 5.4. RECOMMENDATIONS 118 119 120 120 121

5.4.1. Education in South Africa 5.4.2. Nursing practice. 5.4.3. Further research 5.5.

CONCLUSIONS. 121

BIBLIOGRAPHY 123

xv

ADDENDA ADDENDUM A ADDENDUM B ADDENDUM C ADDENDUM D ADDENDUM E ADDENDUM F Covering letter of questionnaire 128 Questionnaire130 Approval from ethics committee.135 Checklist 137 Example of a letter of consent from hospitals. 139 Results of questionnaires142

xvi

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

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

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

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

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

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

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.

1.2. 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. management strategies also do not coincide with what the literature suggests. These

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 : 39,4C : 37,9C : 37,8C : 37,8C : 38C : Codis cocktail Codis cocktail Codis cocktail and electrical fan Largactil 12,5mg intravenously Electrical fan Codis cocktail

Only one (1) of the critical care nurses in above scenario, evaluated the effect of the treatment given in her nursing plan.

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. questionable. The use of the electrical fan for lowering fever is thus

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?

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.

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. respondents. The researcher intended to do good and not to do harm to the 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

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).

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).

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.

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.

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

CRITICAL THINKING AND EVIDENCE BASED NURSING

THE THE CRITICALLY ILL PATIENT WITH FEVER

SCIENTIFIC

NURSING PROCESS

THE CRITICAL CARE NURSE

FIGURE 2.1: 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

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

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

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

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

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 humid atmosphere (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

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

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

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

FIGURE 2.3: Negative feedback mechanisms that conserve heat and increase heat production (Tortora & Grabowski, 1996: 811).

20

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

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

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

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

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

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 Physiology Fever Prostaglandin mediated rise in temperature Endogenous pyrogens released, which cause the setpoint to rise Deep body temperature may or may not be raised to the same level Temperature Cytokines 38C 41C Interleukin-1 Interleukin-6 Tumor necrosis 41C or higher None Hyperthermia 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

26

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

2.3.4. The febrile response

The febrile response consists of three phases, as illustrated in Figure 2.4.

FIGURE 2.4: 1992:484).

The three phases of the febrile response (Holtzclaw & Faan,

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

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

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

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

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

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

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

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

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

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 disciplinespecific 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

Assessing + Documentation Diagnosis + Documentation Outcomes Identification + Documentation

Planning + Documentation

Implementing + Documentation Evaluating + Documentation

FIGURE 2.6: The six overlapping phases of the nursing process (adapted from Kozier et al.,1993:16a).

38

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

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. her/himself the following questions:

The nurse asks

40

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

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

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

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

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

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 Thus it should be

uncomfortable, which will defeat the purpose of the sponge bath. 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

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

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. (Rowsey,1997:253).

Care must be taken in avoiding chilling.

f Cooling blankets

The use of these should be reserved for patients whose core temperature is uncontrollable (Rowsey,1997:253). Cooling blankets also overwhelms the patients

warming defenses. Heat is lost but at great expense of metabolic energy to the patient

g Alcohol sponging

Alcohol sponging must be avoided. Alcohol causes rapid evaporation. This causes vasoconstriction and shivering. The fumes are also toxic when inhaled (Phillips,2000).

48

h Hydration

Fluid replacement improves hydration and ion balance and affects the hypothalamic set point (Holtzclaw & Faan, 1992:496). hypothalamus and induce fever. Dehydration can raise the set point of the

Anti-pyretic therapy should be considered for febrile patients with preexisting cardiac or pulmonary insufficiency because fever can increase oxygen demands.

2.4.4.2 Pharmacological management

The critical care nurse is responsible for the administration of medications as prescribed by a doctor. Searle (2000:243) pointed out that it is the doctors

responsibility to see that a clear prescription is given, and he can assume that the medications has been administered by examining the entries made on the patients documentation. It is important for the critical care nurse to bear knowledge of the pharmacological content, dosages, effects, side-effects and contra-indications of medication administered by him/her to the patient.

Antipyretics are used for immunocompromised patients only if discomfort cannot be tolerated. In these patients, fever is the only reliable sign of infection or response to antibiotics. The Maryland Researchers (2000) found that anti-fever drugs such as

aspirin and acetaminophen may prolong certain infections. They stated that The good news is that anti-fever drugs make people feel better when they have infections. The bad news is that they may cause the illness to linger longer.

49

Aspirin and acetaminophen (paracetamol) are the preferred drugs for Aspirin and other non-steroidal anti-inflammatory drugs

management of fever.

inhibit fever by blocking prostaglandin synthesis (Corwin,2000:76). These drugs also inhibit brain cyclooxygenase. Aspirin and acetaminophen are given alternatively for high fevers. In most cases, temperature decreases at night; therefore, three to four doses in 24 hours are usually sufficient to control most fevers. Aspirin and

acetaminophen reduce fever by inhibiting the synthesis of prostaglandins (Tortora & Grabowski, 1996:812).

b Acetaminophen works by altering the temperature set point. This is considered to be the safest fever reducer (McKenzie,1998). opiate compound. Acetaminophen is a synthetic, non-

It inhibits the action of endogenous pyrogens on the anterior The

hypothalamus by blocking the formation and release of prostaglandins.

thermoregulatory center is reset with a reduction in core temperature (Murphy, 1992: 429). Acetaminophen has been associated with allergic reactions and liver disease (Holtzclaw & Faan, 1992: 498).

c.

Ibuprofen is a nonsteroidal anti-inflammatory drug and has analgetic, anti-

inflammatory and antipyretic actions. Researchers believe that ibuprofen inhibits the synthesis of prostaglandins (Tortora & Grabowski, 1996:812) and Murphy (1992:430).

d.

Antibiotics do not lower fever, but only destroy bacteria. Therefore, nothing can

be done for a viral infection (Mother child laboratory,2001).

e. Codeine is an opiate agonist with antipyretic and anti-inflammatory actions (MIMS, 2000).

50

f. Chlorpromazine is an aliphatic phenotiazine.

It elicits their antipsychotic and

antiemetic effects via interference with central dopaminergic pathways in the brain. As adverse effects it may impair sensitivity and adaptation to changes in environmental temperature so that fatal hyperthermia and heat stroke are possible complications. It

also has direct negative inotropic effects on the heart and causes severe hypotension (Long,2000). Shivering increases the metabolic rate of the muscles and more metabolic waste products are produced. Since the patients circulation is already

weakened, metabolic acidosis can occur as a result of the accumulation of hydrogen ions. Largactil suppresses shivering and causes vasodilation (Uys & Mulder,

1995:120).

Interventions are based on alleviating uncomfortable responses to fever. After expected outcomes for nursing care have been determined, the plan is implemented.

2.4.5

Implementation

The implementation phase is the carrying out of the plan of care by the patient and nurse. Knowledge is applied to perform interventions. Baseline data are compared with the patients changing status. The care plan are being revised and updated. This phase ends when the nurse records the care given and the patients response to care in the patients record.

Nurses must be able to give a reason for nursing actions. If a reason cannot be given, the nurse is practicing irresponsibly. It is thus necessary for nurses to keep up with current, acceptable standards of nursing (Sundeen, et al., 1998:190).

51

Nursing care is not completed before it has been evaluated.

2.4.6. Evaluation

Evaluating is assessing the patients response to nursing interventions and then comparing the response to the outcomes criteria written in the planning phase. The plan of care is revised. When nursing care is evaluated, all steps of the nursing

process should be reviewed (Sundeen , et al., 1998:22).

2.4.7. Documentation

Documentation is an important part of this scientific process. Data is collected and recorded about the effects of the nursing interventions on patient outcomes. Temperature patterns, cooling measures and antipyretic drugs are recorded. When relevant information is recorded, all members of the health team have a clear understanding of the patients progress.

Nurses use interpersonal, technical and intellectual skills when applying the nursing process (Kozier, et al., 1995:85). They must at all times enhance the patients dignity through effective communication methods. They must be competent when using

equipment and performing procedures, and be able to solve problems through critical thinking.

52

2.5

THE UTILISATION OF CRITICAL THINKING AND EVIDENCE BASED NURSING DURING THE NURSING MANAGEMENT OF FEVER

Critical care nursing requires an ability to deal with crucial situations rapidly and with precision. Since the time of Florence Nightengale, the scientific method of inquiry has played an important role in nursing.

Critical thinking is a process that is deliberate, analytical and logical. This process includes the nursing process, diagnostic reasoning and problem solving. Critical

thinking is a skill that is used in performing the nursing process (Southalabama,1999).

Evidence based nursing is based on evidence-based medicine.

Evidence based

medicine is defined by Sackett (2002) as: The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external evidence from systematic research (Closs & Cheater, 1998:10).

Decision making needs to incorporate clinical expertise and the unique clinical circumstances of the individual patient. Evidence based nursing combines the clinical decision making element with current best evidence. Wherever possible, care should be based on research findings. Evidence based nursing is necessary if nurses are to provide clinically effective and cost-effective care.

53

The critical care nurse needs the following scientific knowledge (critical thinking skill) about normal and altered thermoregulation in order to guide her/his nursing actions, based on evidence: Knowledge about the thermoregulatory alteration in order to predict the patients thermal responses. The critical care nurse has to understand the dynamics of the febrile response. Knowledge about the patients physiologic status. If she/he understands the physiological compensation mechanisms the nurse can plan actions that enhance, replace, suppress, or avoid thermal responses. Knowledge to critically assess nursing care outcomes in order to evaluate her/his actions for efficacy (Holtzclaw & Faan , 1992:490).

Patients with fever need to be assessed to determine if cooling down methods are necessary. It is important for guidelines to be set in order to treat fever effectively in critically ill patients.

54

2.6

SUMMARY

A theoretical perspective on fever and the nursing management thereof in the critically ill patient was discussed in chapter 2 (two). The aim of the chapter was to describe the role and competences of the critical care nurse and the application of the scientific nursing process in the nursing management of the critically ill patient with fever. The

need to base nursing actions on critical thinking and evidence based nursing was emphasised.

Thermoregulatory mechanisms and the dynamics of fever in the critically ill patient were discussed on the hand of the literature study. The discussion included the

physiology of thermoregulation, the pathophysiology of fever and the management of fever in the critically ill patient. The importance of the hypothalamus as central

regulatory organ of body temperature was described. Cooling down methods and the advantages or disadvantages of these methods, were described.

The research methodology is described in the chapter 3 (three).

55

CHAPTER 3

RESEARCH METHODOLOGY

3.1.

INTRODUCTION

Chapter 2 was devoted to a theoretical overview of fever and the management thereof. The role and competencies of the critical care nurse in the nursing management of fever and the application of the nursing process in the management of fever was elaborated on.

The aim of chapter 3(three) was to give an exposition of the research design, the population and sampling methods, methods of data collection and data analysis. Polit and Hungler (1997:461) defined research methods as: the steps, procedures and strategies for gathering and analysing the data in the research investigation.

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, and how they utilised the nursing process.

3.2.

RESEARCH DESIGN

The type of research design used in this study was quantitative. The strategy was descriptive and contextual. Ruben and Babbie stated in De Vos (2000:77) that the research design deals with the act of designing the study in its broadest sense. This refers to all the decisions made in planning the study. These decisions include the

56

overall type of design, sampling, sources and procedures for data collection, measurement issues and data analysis.

Quantitative

A quantitative design was used. Quantitative research is defined by Polit and Hungler (1997:466) as: the investigation of phenomena that lend themselves to precise measurement and quantification, and often involving a rigorous and controlled design. A set of logical steps was taken by the researcher to answer the research question. The aim of quantitative research was to determine how one thing affects another in a population. determined. In this study, the critical care nurses management of fever was It is stated by Brink (1994:15), that data is gathered in the form of

numbers, when quantitative research is done.

Descriptive.

The purpose of descriptive research was to obtain complete and accurate information about a phenomenon through observation, description and classification (Brink,1999:11). Burns and Grove (1997:250) stated that the purpose of descriptive studies, was to provide a picture of situations as they naturally happen.

57

Contextual.

The context of this study was contextual. Mouton and Marais (1990:45) defined context as the description of a study in which the phenomenon of interest is studied in terms of its immediate context. People were studied in a natural setting. The context was critical care nurses working in hospitals belonging to a private healthcare group in Gauteng.

3.3. RESEARCH METHODS

Research methods are the steps, procedures and strategies used by the researcher in order to gather and analyse data for the study.

3.3.1. Population and unit of analysis

The target population for this study consisted of critical care nurses, critical care trained or experienced, and critical care students, permanently employed, involved with the nursing care of critically ill patients. The target population was defined by Polit and Hungler (1997:470) as: the entire population in which the researcher is interested and to which he or she would like to generalise the results of a study. The accessible population refers to those cases that conform to the eligibility criteria and that are accessible to the researcher as a pool of subjects for the study (Polit and Hungler, 1997:224). The accessible population in this study was registered nurses working in critical care units in hospitals belonging to a private healthcare group in the Gauteng area. Brink (1999:213) described the population as a set of persons that has common characteristics that is of interest to the researcher. The researcher did not use a

58

sample of the population, due to the fact that the sample would then be too small. The size of the accessible population (N) was 35, thus N=35.

The criteria for inclusion of respondents into the study were: They had to be registered nurses, critical care trained, experienced or students, and permanently employed. They had to work in critical care units. They had to give consent to participate.

The unit of analysis was all the critical care flow sheets of the patients admitted to the critical care units over a period of one (1) month. The context was critical care units of hospitals belonging to a private healthcare group in Gauteng. The researcher was assisted by the statistician of Technikon Pretoria in determining the number of flow sheets needed for the study. The researcher randomly decided to use the files of patients admitted to the critical care units during the month of July 2002. The sampling frame for each hospital was established by numbering all the patient files for that specific month. The total number of flow sheets for each specific unit for that month was determined by the number of days the patient stayed in the unit (a new flow sheet is written every 24 hours). determined in this manner. The total number of flow sheets for each unit was

The statistician advised the researcher on the sample drawing method. All files were supplied with a number, starting at one (1) and ending at Nf (where Nf represents the number of files in that unit for the period in question). Thereafter a random number between one (1) and Nf was generated. The researcher made use of chance number tables as cited in Steyn, Smit, Du Toit and Strasheim (1994:678-681). The file with the

59

corresponding number was selected for inclusion in the sample.

Once a file was

selected, all the flow sheets contained therein were included in the study. The process of random number generation and file selection continued until enough flow sheets were selected to reach the predetermined sample size. The sample size for each unit was determined by using the formula SQRT (20 * Ns) (where Ns represented the number of flow sheets in that unit for the period in question).

SQRT represents the term square root. The square root of a number is obtained by identifying a number that when multiplied by itself gives the number under the square root sign. The researcher made use of a calculator in order to determine the sample size for each unit. (n=523).

It was decided to make use of a cluster sampling approach to streamline data collection, i.e. logistically it was easier to collect files (with all its flow sheets) at random rather than to collect flow sheets (from many files) at random. According to Reid and Boore (1991:36), a cluster sample is when clusters containing smaller units are selected, rather than direct selection of the smaller units. Note that this sampling

protocol was designed in such a way that the probability of selecting files was equal and since all flow sheets within a file were selected, all the flow sheets had equal probability of inclusion in the sample. A total of 523 flow sheets were analysed, and these included day and night reports. (n = 523).

The researcher made use of research tools to gather data.

60

3.3.2. Data gathering

Data gathering is an important part of the research and plays an important role in the success of the study (Brink, 1999:148). The tools for data gathering, the pilot study and the data gathering methods were described.

3.3.2.1.

Tools for data gathering

Research tools were necessary to gather data. A questionnaire and checklists were used for data gathering.

a. Questionnaire

A questionnaire is a set of questions on a form which is completed by the respondent in respect of a research project (De Vos, 2000:152). The aim of the

questionnaire was to determine the critical care nurses knowledge of fever and fever management.

The questionnaires were hand delivered by the researcher. The questionnaires were all accompanied by a covering letter, in which the researcher was identified. A brief description of the purpose of the study was given in order to motivate respondents to give their cooperation. The covering letter (refer Addendum A) also gave an indication of the importance of the study. The anonymity of the respondents was guaranteed clearly in the covering letter and a clear indication given that all information will be treated with confidentiality. The name, address and telephone number of the

researcher appeared on the covering letter.

61

The questionnaire was developed by the researcher, in collaboration with the Division for Statistical Support and Strategic Research of Technikon Pretoria. Questions were formulated from information gathered through the literature study (Refer Addendum B).

The questionnaire consisted of open- and close-ended questions. The close-ended questions were those in which the response alternatives were designated by the researcher. The alternatives ranged from true or false or do not know. Some closeended questions gave the respondents a choice of possibilities where one choice would be the correct answer. The open-ended questions allowed respondents to

respond to questions in their own words.

Twelve (12) main questions were asked, of which some were subdivided into more questions. This gave a total of 20 responses.

The following information was gathered through the questionnaires: The category of the nursing staff, i.e. either a critical care trained registered nurse, a critical care experienced registered nurse, or a critical care student. The respondents knowledge of the physiology of thermoregulation. The respondents knowledge of the pathophysiology of fever. The respondents knowledge of the management of fever. The respondents own opinion of the nursing management of fever.

62

It was suggested by the ethics committee that the word motivate to be replaced throughout the questionnaire with the word justify. The words motivate and justify are explained as follows: Justify: show to be right or just or reasonable (Pollard,1995:435). Motivate: give a motive or incentive, be the motive of (Pollard,1995:526).

It was decided by the researcher not to change the words, but to keep the word motivation.

b. Checklist

According to De Vos (2000:89) a checklist consists of a series of statements where relevant items are ticked as a yes or a no. The checklist was developed by the researcher, also in collaboration with the Division for Statistical Support and Strategic Research of Technikon Pretoria (Refer Addendum D). The purpose of the checklist was to determine the utilisation of the nursing process in the management of fever in the critically ill patient.

It is stated by Polit and Hungler (1997:426) that the findings from research can assist nurses in making more informed decisions and in taking actions that have a solid, scientifically based rationale, by utilising the phases of the nursing process.

The following information appeared on the checklists: The date of data gathering by researcher The name of the hospital from which data was collected The date of the flowsheet The hospital number of the patient (in case it was necessary for a cross-reference back to the patients file) The age of the patient

63

 The diagnosis of the patient The patients temperature range for 12 hours

The following items were ticked as a yes or a no: Assessment: was the patient assessed as having a fever, or being apyrexial, or for having the potential of developing a fever? Nursing diagnosis: was a nursing diagnosis written down concerning the thermoregulation/temperature of the patient? Outcomes identification: was an outcome identified concerning the patients temperature? Planning: Did the registered nurse plan for treatment/ management of fever or the possibility thereof? Implementing: Did the registered nurse document the implementation of the management of fever? Evaluating: Did the registered nurse evaluate the effect of the method used to cool the patient down/ or did he/she evaluate the patients temperature again?

The documentation of the day and night staff were analysed on the flow sheets. Data was gathered from 5 (five) hospitals.

3.3.2.2.

Pilot study

A pilot study was undertaken at a critical care unit. The aim of this pilot study was to exclude unforeseen problems that could arise, and to test the feasibility of the data gathering process. A pilot study is a small-scale version of the major study (Brink, 1999:44).

64

Questionnaires were handed out to all ten (10) permanently employed registered nurses working in the unit. All ten (10) responded and gave their completed

questionnaires back to the researcher. Only one (1) question needed to be changed because it was ambiguous. Question 2.6. :Alcohol sponging is good practice

because it causes rapid evaporation was changed to :Alcohol sponging is good practice. 20% of the respondents gave different answers after the question was

changed. The results of the responses of the pilot study were included as part of the main study.

A total of 73 flow sheets were studied and the checklists completed no change was made by the researcher to the checklist. The number of flow sheets was determined by using the square root formula as described in the sampling frame in paragraph 3.3.1:60).

Reid and Boore(1991:28) stated that by examining the results of the pilot study problems will be identified with the wording of questions or recording of data and will help to improve the study instruments.

3.3.2.3.

Method of data gathering

Consent for the study

Letters of consent were e-mailed to the hospital managers of the hospitals in Gauteng which had critical care units. Only three (3) managers responded via the e-mail. The researcher then contacted the remaining hospital managers either through their

65

assistants or the nursing service managers.

A total of six (6) managers gave

permission for the study to be conducted at the hospitals under their management (Refer Addendum E). Permission was also given by the National Nursing Services Manager of the private hospital group to conduct the study.

Utilisation of the checklist

Data was gathered by evaluating the flow sheets of patients within the sample. A study was done of the patient records in respect of fever management. The nursing care notes were explored to see if the critical care nurses described fever as a potential problem, plan any interventions if necessary, and evaluate the effect of these interventions. A checklist based on the nursing process was used for record keeping (Refer Addendum D).

Distribution of the questionnaire

Data was gathered through a questionnaire containing closed and open questions. Questionnaires were completed by all available, permanently employed critical care nurses. The researcher had to travel to the hospitals in order to be able to gather information regarding the utilisation of the nursing process. At the same time the

questionnaires were handed out to the registered nurses. A two week period was given for the completion of the questionnaires. 35 nurses were willing to participate. Questionnaires were numbered in order for the researcher to be able to keep track of the questionnaires. A total of 35 were returned and used for analysis.

66

Some of the questionnaires were excluded from the study because of the following reasons: Completed by other categories of staff who were not included in the study.

3.4.

ANALYSIS OF DATA

3.4.1. Nursing documentation The data of the nursing documentation was analysed through descriptive statistics, using frequency tables and diagrams. Computer technology was used in order to

analyse the data by means of WORD and EXCEL. The data was typed into EXCEL by the researcher, and then analysed by the computer.

According to Brink (1990:23) descriptive statistics cover methods for the following: Data was presented by means of frequency tables, line and bar diagrams and statistical pies. Data was described by values such as a percentage, a range or a standard deviation.

By using frequency tables, measurements were grouped into classes or in order of magnitude and the frequency of the numbers in each class was reported on. The term frequency refers to the occurrence of an event, that is to the number of times that a result or value occurs (Brink, 1990:32).

The bar diagram consists of a number of rectangular bars whose height or length represents the frequency of a given category. The bars in these diagrams are

separate, usually of the same width and may be either vertical or horizontal (Brink,

67

1990:42). The categories for the independent variable are placed on the x-axis and the values for the dependent variable are placed on the y-axis. A line diagram shows trends in data at equal intervals.

The pie diagram is often used to show proportions. It is an effective way of comparing components and their share of a whole (Brink, 1990:41). De Vos (2000:212) stated that the name, pie diagram, came from the analogy of a pie that is cut into slices. The area of each slice is proportional to the size of the figure represented.

3.4.2. Questionnaires

The results of the questionnaires were analysed through descriptive statistics and presented by means of a pie diagram, frequency tables and bar and line diagrams. In order to distinguish between the results of the participating hospitals, the hospitals were labeled from A to E.

3.5.

VALIDITY AND RELIABILITY OF THE STUDY

As cited in Brink (1990:157) there are two considerations that are of critical importance, namely reliability and validity. Polit and Hungler (1997:471) defines validity as : the degree to which an tool measures what it is intended to measure and reliability as: the degree of consistency or dependability with which an instrument measures the attribute it is designed to measure (Polit and Hungler,1997:467).

Reliability is defined as the extent to which measures are consistent or repeatable over time (Brink, 1990:158). During their training, all registered nurses are exposed to

68

the utilisation of the nursing process. The checklist was developed in order to see if the steps of the nursing process were utilised during the management of a critically ill patient, concerning fever. The researcher used the criteria as explained in para 1:40 by simply ticking yes or no for each step in the nursing process. The checklists actually measures the concept in question i.e. did the registered nurses utilise the steps of the nursing process? The researcher analysed the flow sheets herself.

According to De Vos (2000:86) Reliability is primarily concerned not with what is being measured but with how well it is being measured.

A very important aspect of a tool development is validity. Data is not meaningful when a tool does not measure what it intended to measure(Wilson, 1993:156).

Content validity reflects whether the questions are measuring the concepts in which the researcher is interested, and whether it is necessary for inclusion in the questionnaire. As cited by Hudson in De Vos (2000:84) Content validation is by and large a judgemental process. The researcher relies on the judgement of her

colleagues to establish the questionnaires validity. A pilot study was done and the questions were tested before the questionnaires were distributed to other hospitals.

Face validity refers to what a tool appears to measure. Respondents may be resistant to participate if questions are not reasonable and acceptable (Molzahn-Yanitski, 1983:10). Again, face validity was established through means of the pilot study.

The measuring tools were also developed with the assistance of the Division for Statistical Support and Strategic Research of Technikon Pretoria, and by using

69

information gathered from the literature study. The measuring tools were apparently consistent.

3.6.

SUMMARY

The purpose of chapter 3(three) was to give an exposition of the research design, the population and sampling methods, methods of data collection and the units of analysis. A quantitative research study was discussed. The relationship between the critical care nurse and the management of fever was described. The context of the study consisted of critical care units of hospitals belonging to a private healthcare group in Gauteng.

The target population (N=35) was critical care nurses working in the critical care units. The unit of analysis was critical care flow sheets (n=523) of patients admitted to these units over a one (1) month period.

The design of the research tools was described.

The researcher made use of a

questionnaire and checklist for collection of data. A pilot study was undertaken at a critical care unit to test the feasibility of the data collection process.

Data was analysed through descriptive statistics and visualised by means of pie, line and bar diagrams. A discussion of the validity and reliability of the of the tools for data collection followed.

The results of the study is described in the next chapter.

70

CHAPTER 4

DATA ANALYSIS AND RESULTS OF THE STUDY

4.1 INTRODUCTION

Chapter 3(three) of the study elicited the research design and methods used to determine the critical care nurses management of and knowledge regarding fever. The results of the data analysis were explained in chapter 4(four) (Refer addendum F). All results were included and these were presented by means of visual presentations and literary descriptions. Data were presented by means of figures (bar charts, pie diagrams and line diagrams), and tables (frequency tables), as described in chapter 3(three).

4.2.

DATA GATHERED BY MEANS OF THE QUESTIONNAIRES

Twelve (12) main questions were asked, of which some were subdivided into more questions. This gave a total of 20 responses to be given. The following were

measured by the questionnaire: The respondents professional category (Question 1) The respondents knowledge on the physiology of thermoregulation (Questions 2.1; 2.3; 3.1; 3.4; 3.5; 3.6; 3.7). The respondents knowledge on the pathophysiology of fever (Questions 2.2; 2.4; 2.5; 3.8). The respondents knowledge on the management of fever (Questions 2.6; 3.3; 3.9; 3.12; 3.13).

71

The respondents own opinions concerning fever and the management thereof (Questions 3.2; 3.10; 3.11).

4.2.1. Professional category of respondents

The target population for this study consisted of registered nurses, working in critical care units in five hospitals belonging to a private healthcare group. These registered nurses were either trained in critical care nursing, nurses experienced in working in critical care units or currently being trained as critical care nurses. Nurses working in a critical care unit need the necessary theoretical knowledge and skills required for their practice. According to the American Association of Critical Care Nurses (AACCN,

2000) the critical care nurse is responsible for ensuring that all critically ill patients receive optimal care. In Figure 4.1 the percentages of the respondents professional categories were presented by means of a pie diagram . (N=30).

72

9% Critical Care students 41% Critical Care Trained Registered Nurses

50% Critical Care Experienced Registered Nurses

FIGURE 4.1. The respondents professional categories

In Figure 4.1 the professional category of the respondents were visualised by means of a pie diagram. The study described the competencies and critical thinking skills of registered nurses concerning the nursing management of fever. The respondents were all registered nurses, but were either trained, experienced or currently being trained in critical care nursing. 50%(15) of the registered nurses were experienced in critical care nursing, 41%(12) critical care trained and 9%(3) currently being trained in critical care nursing.

4.2.2. Knowledge of the physiology of thermoregulation

The respondents knowledge concerning the physiology of thermoregulaton was measured by questions 2.1; 2.3; 3.1; 3.4; 3.5; 3.6; 3.7. The number of respondents answering the 7 (seven) questions differed, thus percentages were determined in terms of each question. The findings were presented graphically in Figure 4.2.

73

120%

100%

80%

60%

40%

20%

0%

Question
Correct Wrong

2.1 97% 3%

2.3 66% 34%

3.1 63% 37%

3.4 31% 69%

3.5 44% 56%

3.6 26% 74%

3.7 22% 78%

FIGURE 4.2. The respondents knowledge concerning the physiology of thermoregulation.

In Table 4.1 all the questions visualised graphically in Figure 4.2 were discussed and compared with what was being stated in the literature .

74

Table 4.1 :Discussion of questions measuring the respondents knowledge of the physiology of thermoregulation. QUESTION 2.1 (N=31) DISCUSSION Question 1 expected the respondents to identify the organ in the human body that controls body temperature. The main center for the regulation of body temperature is located in the hypothalamus (Uys & Mulder, 1995:112). 31 respondents answered this question. 30

(97%) respondents gave the correct answer.

In order for the critical care nurse to understand the physiology of thermoregulation, they have to know and understand the role that the hypothalamus is playing in the control of body temperature. 2.3 (N=32) 32 respondents answered this question. They had to state if shivering generates heat or not. answer. 21 (66%) respondents knew the correct

Gendelman (2000) stated that heat production can be

increased by as much as 400-500% by shivering.

Shivering is part of the normal febrile response of the body and the critical care needs to understand the effect of shivering so that the patient with fever will be managed correctly. 3.1 The determination of body temperature had to be identified in question 3.1. 32 respondents reacted to this question of which 20 (63%) gave (N=32) the correct answer.

75

Bunch (1999) explained the control and determination of body temperature, as sensed by cold and warm sensitive receptors found throughout the body. Signals from these receptors are conveyed to the central regulatory system, primarily the hypothalamus. 3.4 (N=32) In terms of this question the respondents had to answer if electrical fanning causes shivering with an increase in body temperature or not. There were 32 responses to this question.

As explained in paragraph 2.4.4.1c:48 an electrical fan causes vasoconstriction with shivering and a further increase in body temperature.

10 (31%) respondents knew the correct answer to question 3.4.

In

question 3.2, 66% respondents knew that shivering generates heat, but this is contradicted in question 3.4. 3.5 (N=32) In question 3.5 the respondents had to identify the normal set point of the hypothalamus. correctly. Of the 32 responses, 14 (44%) answered

The normal setpoint for the hypothalamus is 37C. It is important for the critical care

(Holtzclaw & Faan, 1992:483).

nurse to know what the normal set point of the hypothalamus is, in order to identify abnormlities.

The set point temperature range is defended by physiologic responses because it is optimum for the individuals cellular metabolism (Holtzclaw & Faan, 1992:483).

76

3.6 (N=31)

Respondents had to answer by what organ shivering is initiated. As described by Tortora and Grabowski (1996:251) shivering is initiated by the hypothalamus. correct answer. 8 (26%) of the 31 respondents knew the

In question 2.1, 97% of the respondents knew that body temperature is controlled by the hypothalamus, but only 26% answered correctly to the fact that shivering is initiated by the hypothalamus. Although

nurses know the function of the hypothalamus, they do not understand the physiology of thermoregulation. The body has a positive response to fever (Rowsey, 1997:251), and the critical care nurse needs to decide which patients to cool down and which ones not to cool. 3.7 (N=32) 32 responded to question 3.7. They had to state the percentage of increase in cellular metabolism and oxygen consumption with a rise in temperature. Seven (22%) answered correctly.

Fever increases the cellular metabolism rate in cells. For every 1C rise in temperature, 13% more chemical reactions take place (Kozier et al, 1993:160). In the unstable, compromised critically ill patient

increased cellular metabolism can be detrimental.

In Figure 4.3 the comparison between the total percentages of questions answered correct or wrong in terms of the respondents knowledge concerning the physiology of thermoregulation was visualised graphically. 50% of the respondents answered

correct and 50% gave the wrong answer.

77

60%

50%

40%

30%

Correct Wrong

20%

10%

0%

FIGURE 4.3. A comparison between the total percentages answered correct or wrong in terms of the respondents knowledge concerning the physiology of thermoregulation.

Holtzclaw and Faan(1992:490) stated that the critical care nurse must have knowledge on the physiology of thermoregulation. This will enable the nurse to plan actions that enhance, replace, suppress or avoid thermal responses. According to Rowsey (1997:205) the physiology of fever helps the nurse to prevent or assess the fever cascade in critical care patients.

50% of the respondents knew the correct answers to the physiology of thermoregulation. This means that 50% did not know the correct answers. The

78

researcher also found that although the respondents answered correctly to some of the answers, they could not relate their knowledge to the physiology of thermoregulation. The critical care nurse needs to understand the physiology of thermoregulation. Lack of knowledge of the physiology of thermoregulation could affect the effectiveness of managing the patient with fever.

4.2.3. Knowledge of the pathophysiology of fever

The respondents knowledge concerning the pathophysiology of fever was measured in questions 2.2; 2.4; 2.5; 3.8. The findings were presented graphically in Figure 4.4.

100%

90%

80%

70%

60% %

50%

40%

30%

20%

10%

Question

0% 2.2 50% 50% 2.4 66% 34% 2.5 86% 14% 3.8 50% 50%

Correct Wrong

FIGURE 4.4. The respondents knowledge concerning the pathophysiology of fever.

79

In Table 4.2 all the questions visualised graphically in Figure 4.4 were discussed and compared with what was being said in the literature concerning the pathophysiology of fever.

Table 4.2 : Discussion of the questions measuring the respondents knowledge of the pathophysiology of fever QUESTION 2.2 (N=32) DISCUSSION Fever is the elevation of the temperature setpoint in the hypothalamus. With an increase in setpoint, the hypothalamus sends out signals to increase body temperature. The body

responds by shivering and an increase in the basal metabolic rate (Corwin, 2000:75).

Hyperthermia involves dysfunction of thermoregulatory ability. Core temperature can be as high as 40C and above. These high temperatures cause denaturation of 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).

Fever and hyperthermia does not describe the same concept. There is a big difference between the management of fever and that of hyperthermia. 16 (50%) respondents answered that fever and hyperthermia describe the same concept.

80

2.4 (N=30)

In question 2.4 the respondents had to confirm that fever supports phagocytic activity of some cells. 30 respondents

answered to this question. 20 (66%) answered correctly. The fever response is part of the resistance mechanism of the body, and it supports phagocytic activity of some cells (Phipps,2002). 2.5 (N=30) Respondents had to agree or disagree to the fact that fever does not enhance the immune/inflammatory response. 30 answered this question. 26 (86%) answered correctly. As cited in Phillips (2000) fever enhances the immune/inflammatory response. 3.8 (N=30) According to Corwin (2000:75) fever occurs in response to production of certain cytokines. Cytokines are pyrogens. Of the 30 responses to question 3.8, 15 (50%) were correctly answered.

The release of cytokines is part of the febrile response. Cytokines act on the hypothalamus. Certain antipyretic drugs act on these cytokines. By understanding the role of cytokines in the fever cascade, the nurse can monitor and intervene to prevent a systemic fever reaction (Rowsey, 1997:206).

In Figure 4.5 the comparison between the total percentages of questions answered correct or wrong in terms of the respondents knowledge concerning the pathophysiology of fever was visualised graphically. 63% respondents answered correct and 37% gave the wrong answer.

81

70%

60%

50%

40% Correct Wrong 30%

20%

10%

0%

FIGURE 4.5. A comparison between the total percentages answered correct or wrong in terms of the respondents knowledge concerning the pathophysiology of fever.

Nurses can monitor and intervene to prevent systemic fever reactions by understanding the pathophysiology of fever. As stated by Rowsey (1997:206) the

nurse can monitor and intervene to prevent a systemic fever reaction if she/he has the necessary knowledge concerning the pathophysiology of fever.

The critical care nurse will also be able to distinguish between fever and hyperthermia and this will help to treat the patient effectively. 63% of therespondents answered correctly to all the questions concerning the pathophysiology of fever. 50% of the respondents did not know that fever and hyperthermia are different concepts. There seemed to be a vague understanding of the pathophysiology of fever. By

understanding the pathophysiology, the critical care nurse can monitor the critically ill patient and manage the fever with the most effective method based on evidence, while

82

the immune response is supported. Holtzclaw and Faan (1992:489) wrote that the effect to antibiotics can be evaluated by observing the febrile response. If anti-pyretic management is used, these patterns could be confused.

4.2.4. Knowledge of the management of fever

The respondents knowledge concerning the management of fever was measured in questions 2.6; 3.3; 3.9; 3.12; 3.13. The findings were presented graphically in Figure 4.6.
90%

80%

70%

60%

50% % 40%

30%

20%

10%

0% Question Correct Wrong 2.6 31% 69% 3.3 52% 48% 3.9 22% 78% 3.12 50% 50% 3.13 50% 50%

FIGURE 4.6. The respondents knowledge concerning the management of fever

In Table 4.3 all the questions visualised graphically in Figure 4.6 were discussed and compared with what was being said in the literature concerning the management of the patient with fever.

83

Table 4.3 : Discussion of questions measuring the respondents knowledge on the management of fever QUESTION 2.6 (N=32) DISCUSSION In question 2.6 the respondents had to state if alcohol sponging is good practice or not. This question was answered by 32 of which 10 (31%) answered correctly. Alcohol causes rapid

evaporation. This causes vasoconstriction and shivering. The fumes are also toxic when inhaled (Holtzclaw & Faan, 1992:493). 3.3 (N=31) Respondents had to identify the safest and most effective medication to treat a fever with. answer. setpoint. 16 (52%) gave the correct

Acetaminophen works by altering the temperature This is considered to be the safest fever reducer

(McKenzie, 1998). 3.9 (N=27) Aspirin reduces fever by inhibiting the synthesis of prostglandins (Tortora & Grabowski, 1996:812) and the respondents had to agree to this fact. This question was answered by 27

respondents. 6 (22%) answered correctly. 3.12 (N=14) In question 3.12 the respondents had to identify the best and worst method for treating fever. 7 (50%) answered correctly.

It is best practice to implement cooling down procedures approximately one hour after an antipyretic is given (Wong & Whaley, 1983:898). point is lowered. This ensures that the hypothalamic set When cooling down is done without an

84

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. 3.13 (N=30) The respondents had to give the correct answer for why they will treat a fever. 15 (50%) gave the correct reason. Beers and Berkow (1997:1093) stated that metabolic demands of fever may compromise oxygenation in these critically ill patients. Calories are expended that compromised patients cant afford to loose.

In Figure 4.7 the comparison between the percentages of questions answered correct or wrong in terms of the respondents knowledge concerning the management of fever was visualised graphically. 47% respondents answered correct and 53% gave the wrong answer.

85

54%

53%

52%

51%

50% Correct Wrong

49%

48%

47%

46%

45%

44%

FIGURE 4.7. A comparison between the total percentages answered correct or wrong in terms of management of fever in the critically ill patient.

Pharmacological treatment

The presence of fever frequently results in the performance of diagnostic tests and procedures that significantly increase medical costs and expose the patient to unnecessary invasive procedures and the inappropriate use of antibiotics. Fever is caused by either infection or non-infectious causes (Marik,2000). Some of the

respondents tend to focus on infection as a single cause of fever and 42% (13) answered in question 3.3 that antibiotics are the most effective to treat a fever (N=31). Antibiotics do not treat a fever, but an infection. Antibiotics act on organisms by inhibiting cell wall synthesis and activating enzymes that destroy the cell wall (Beers &

86

Berkow,1997:1101). This study investigated the management of fever and not the management of infection.

The frequency of cooling methods In question 3.12 the respondents had to identify the best and worst methods for management a fever. One (1) would be the best method and 6 (six) the worst method. The comparison between what methods were rated as best and worst methods, was calculated into percentages. This comparison is visualised graphically in Figure 4.8.

60%

50%

40%

30%

20%

10%

0% Sponge baths Light blanket Electrical fan Ice packs Cooling blankets Pharmacology

1 BEST METHOD 37% 22% 9%

2 32% 33% 19% 9%

3 26% 11% 9%

4 5% 17% 29% 9%

6 WORST METHOD

6% 29% 27% 21%

11% 5% 55% 16% 22%

5% 52%

16% 7%

16% 15%

26% 4%

FIGURE 4.8. The frequency of cooling methods rated by registered nurses as the best or worst methods for managing a fever.

As can be seen in Figure 4.8 critical care nurses had a difference in opinion of what method was the best or worst for managing a fever with. For example, 22%

respondents saw a light blanket as the best method, and 11% saw it as the worst method. 52% respondents answered that pharmacolgy would be the best method but

87

22% thought it to be the worst method. The implication of this difference in opinion could be that there were no consistency in the way that critical care nurses managed patients with fever.

According to literature, the best method for cooling down a patient with fever, is to give an antipyretic such as acetamenophin and to implement a cooling down method approximately one hour thereafter (refer paragraph 2.4.4.1:44).

4.2.5. The respondents own opinions of the nursing management of fever

Figures 4.9, 4.10 and 4.11 visualised respondents own opinions on the nursing management of fever. They could also motivate their answers. Not all the

respondents gave motivations to their answers. The motivations that were given were quantified in tables 4.4, 4.5 and 4.6.

In question 3.2 the respondents had to give their opinions on how often patients with fever were cooled down in the units where they were working. These frequencies were visualised as percentages in figure 4.9 and the motivations quantified in table 4.4.

88

50%

45%

40%

35%

30%

25%

20%

15%

10%

5%

0% %

Always 27%

Mostly 27%

Sometimes 46%

FIGURE 4.9. The respondents opinions on how often patients with fever were cooled down in the units where they worked

Figure 4.9 demonstrated how critical care nurses opinions differ on the frequency of cooling down of patients. Not only did critical care nurses differed on the best or worst cooling down methods (Figure 4.8) but also on the frequency of cooling down.

89

Table 4.4: Respondents motivations on how often patients with fever were cooled down in the units where they were working MOTIVATION Treat the infection or the origin of the fever first Pyrexia will always be treated Electrical fan or other cooling down methods are used It depends on the treating doctor It will be treated if the temperature is above 39C or if the patient looks uncomfortable Not all fevers are cooled down because it is a systemic response Fever is treated to prevent further complications such as dehydration It depends which measures are taken to treat a fever Total 16 100 1 6 1 6 1 6 2 1 13 6 N=16 f= 3 3 4 % 19 19 25

Table 4.4 demonstrated the difference of opinions to question 3.2.

In question 3.10 the respondents had to motivate when they would start managing a patient with fever. These answers were visualised as percentages in Figure 4.10 and the motivations quantified in Table 4.5.

90

60%

50%

40%

30%

20%

10%

0% 37.5 38 Degrees Celcius 38.5 >39

FIGURE 4.10. The respondents opinions on when they would start treating a fever.

Figure 4.10 demonstrated how critical care nurses opinions differ on when they would start treating a fever. Not only did critical care nurses differed on the best or worst cooling down methods (Figure 4.8:87) but also on the frequency of cooling down in the units where they were working (Figure 4.9:89), as well as when they would start managing a fever. Two (9%) would start managing the fever at 37.5C, 12 (54%) would start managing at 38C, Five (23%) would manage the fever at 38.5C and three (14%) at above 39C. (N=22)

91

Table 4.5: Respondents motivations on when they would start managing a patient with fever. MOTIVATION Do not want it high because extra energy is needed 37.5C is a low grade fever The fever has to be above 38C Above 38.5C is abnormal/ start treating above 38.5C Personally I start treating a fever at 39C More than 40C because discomfort and haemodynamically unstable The body must be given a chance to fight the infection without taking away the immune response Total 16 100 2 13 1 1 6 6 1 4 2 6 25 13 N=16 f= 5 % 31

Table 4.5 demonstrated the difference of opinions to question 3.10.

In question 3.11 the respondents had to give their opinions whether they felt comfortable with the way fever was managed in the unit where they were working. These frequencies were visualised as percentages in Figure 4.11 and the motivations quantified in Table 4.6.

92

60%

50%

40%

30%

20%

10%

0% Always Mostly Usually Sometimes Never

FIGURE 4.11. The respondents opinions whether they felt comfortable with the way fever was managed in the units where they were working.

(N = 22). One (5%) respondent always felt comfortable, 12 (54%) felt mostly comfortable with the way fever was manged, two (9%) usually felt comfortable, four (18%) felt comfortable sometimes and three (14%) never felt comfortable. Figure 4.11 demonstrated how critical care nurses opinions differed on if they felt comfortable with the way fever was treated in the units where they were working. They also differed on the best or worst cooling down methods (Figure 4.8:87), the frequency of cooling down in the units where they were working (Figure 4.9:89), as well as when they would start managing a fever (Figure 4.10:91).

93

Table 4.6: Motivations why respondents felt comfortable or not comfortable with the way fever was managed in the units where they were working

MOTIVATION Only do what the doctor says or prescribe Do not like the electrical fan or the electrical fan is not very effective Only treated mostly with largactil or electrical fan Fever is managed correctly I feel patients should have a chance to correct their body temperature without anti-pyrexial medication. Bloodcultures are done Sometimes nothing helps Total

N=15

f= 5 4

% 33 26

1 1

7 7

2 1 15

13 7 100

Eight (8) respondents have written comments on the management of fever. These answers were quantified in Table 4.7.

94

Table 4.7: Respondents final comments. MOTIVATION Do not always approve of pharmacological management Fever in ICU is not treated how it should be because our knowledge is not up to date. I wonder if we are treating fever in the correct manner. I think a protocol should be 4 50 N=8 f= 1 % 12.5

compiled for the treatment of fever. I would like to get the correct answers if possible. The body mechanism against bacteria is to cause fever and the rise in body temperature is the bodys way of killing the bacteria. Only treat if the patient becomes 1 12.5 1 12.5

haemodynamically unstable No comments- we are good in treating fever Total 1 8 12.5 100

The researcher found these comments to be very illuminating for this study. It seemed that critical care nurses were lacking in knowledge on how or when to manage a patient with fever. If cooling down methods are used without knowledge of the physiology of thermoregulation, responses contrary to the therapeutic goal can be triggered.

95

4.3.

DATA GATHERED BY MEANS OF THE CHECKLIST

It was noted by Aaronson and Burman (1994:72) that health records of patients were important sources of data, that it was accessible and practical to use; but health records were not infallible. The validity and reliability of both the health record and the extracted data must be considered and assessed by all investigators who intend to use health records in their studies.

The purpose of the checklist was to determine the utilisation of the nursing process in the management of fever in the critically ill patient. As cited by Hickley in Booyens (2001:206) the nursing process was a problem solving technique that helped 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.

During the assessment phase, the registered nurse will collect data concerning the patients fever. This will be done by means of physical observation. The assessment data then needs to be recorded on the flow sheet. Figure 4.12 represented the assessment of fever or the potential to develop fever at hospitals A to E.

96

% a s s e s s m e n t p e r h o s p it a l 90 80 70 60 50 % 40 30 20 10 0
YES %

NO %

Ho sp A

Ho sp B

Ho sp C

Ho sp D

Ho sp E

FIGURE 4.12. The frequency of assessment of fever recorded by registered nurses per hospital.

The assessment of the patient with fever or the potential to develop fever was not always recorded in the documentation. Information gathered from the 523 flowsheets analysed showed the following: in hospital A 60 (60%) (n=100) of patients were not assessed concerning fever, in hospital B 49 (39%) (n=127), in hospital C 44 (72%) (n=61) were not assessed, in hospital D 18 (20%) (n=92) and in hospital E 88 (62%) (n=143) were not assessed.

Nurses must assess patients carefully to determine the need for cooling down methods. Perry and Potter (1998:250) suggested a patients first assessment of

temperature, establishes a baseline if it is in normal range. This baseline is then used to compare future temperature measurements. Comparison reveals abnormalities. Omission of the assessment phase can impair the quality of the nursing care rendered.

97

A nursing diagnosis is made after data had been gathered. The nursing diagnosis is a definition of the patients problem from a nursing perspective. The nursing diagnosis defines the problem, which must then be addressed. It then becomes the nurses responsibility to put the nursing process into operation in order to address the problem (Booyens, 2001:209). The nurse addressed the patients reaction to illness while the doctor addressed the illness itself. In Figure 4.13 the percentages of nursing diagnosis made at the different hospitals, after fever had been assessed, were visualised by means of a bar diagram.

% Nursing diagnosis per hospital

120

100

80

60

YES %

NO%

40

20

0 HOSP A HOSP B HOSP C HOSP D HOSP E

FIGURE 4.13. The frequency of nursing diagnosis concerning fever recorded by registered nurses per hospital.

Assessment had no meaning if a nursing diagnosis was not made. The correct manner how to make a nursing diagnosis, will be through the connective term due to,

98

for example: Increased body temperature due to infection evidenced by positive bloodcultures. The nurse can not make a medical diagnosis (Sundeen et al,1998:11). N=523. No nursing diagnosis was made per hospital as follows: Hospital A 61 (61%) n=100; Hospital B 120 (94%)n=127; Hospital C 46 (75%)n=61; Hospital D 84

(91%)n=92 and Hospital E 140 (98%)n=143.

Out of the analysis of the flow sheets, the researcher observed that different registered nurses used the same concepts for different temperatures. The concept pyrexia Some critical care

would be given to temperatures of between 37.3C and 40C.

nurses described 37C and 37.5C as a low grade pyrexia or a slight pyrexia, or even a moderate pyrexia, and 38.5C was described as a high body temperature. In some cases 38.4C and 39C were described as hyperpyrexia. Patients with

temperatures of 38C and 39.4C respectively were described as febrile patients and 36C and 37C respectively were normothermic (normothermia means a normal temperature). The respondents seemed to be confused on when to link a specific concept to a certain temperature. How can a temperature of 37C be described as a low grade pyrexia and as normothermic?

The nursing diagnosis identifies a patients response to a health problem (Sundeen, et al., 1998: 11). Through the nursing diagnosis, stressors that contribute to the problem are identified, and signs and symptoms that relate to the health problem, in this case fever, are described.

An outcomes identification is a desired outcome in the direction of health.

The

nursing diagnosis guides the type of outcome. An outcome may reflect the restoration of normal body temperature. An outcome is a statement about the expected change in

99

the status of the temperature after the patient received nursing interventions (Kozier et al, 1993:32). The identified outcomes of the patients with fever or the potential to develop a fever, were visualised as percentages per hospital in Figure 4.14.

% Outcomes identification per hospital

120

YES %
100

80

NO%

% 60

40

20

0 Hosp A Hosp B Hosp C Hosp D Hosp E

FIGURE 4.14. The frequency of outcomes identification of fever recorded by registered nurses per hospital.

As can be seen in Figure 4.14, 1% outcomes were identified at hospital B (1 out of 127 flow sheets) and 2% (2 out of 92 flowsheets) at hospital D. If a nursing diagnosis was not done, an outcome cannot be identified because the diagnosis guides the outcome (Kozier et al, 1993:32). The more specifically an outcome is identified, the more useful it will be in planning nursing care.

100

During the planning phase, the nurse takes steps to intervene by formulating specific objectives and nursing actions to bring down the temperature. Objectives are

formulated which comply with the following: who will do what, how, when and to what degree (Booyens, 2001:21). This plan should be recorded in the nursing

documentation. Figure 4.15 visualised the percentages of planning done per hospital.

% Planning per hospital

120
YES %

100

80

NO%

% 60

40

20

0 Hosp A Hosp B Hosp C Hosp D Hosp E

FIGURE 4.15. The frequency of planning for the management of fever recorded by registered nurses per hospital.

As visualised in Fig 4.15, the percentages of planning done for the management of fever was as follows: Hospital A: 0% (0 out of 100 flow sheets) Hospital B: 9% (12 out of 127 flow sheets) Hospital C:2% (1 out of 61 flow sheets) Hospital D:2% (2 out of 92 flow sheets)

101

Hospital E: 1% (2 out of 143 flow sheets)

Failure to approach nursing care in the scientific manner is likely to result in illogical descion making and a plan based on trial and error (Sundeen, et al., 1998:16).

In the implementation phase, the nurse puts the nursing strategies listed in the nursing care plan into action to attain the desired outcome (Kozier et al., 1993:40). In Figure 4.16 the documentation of implementation of the plan was visualised as percentages per hospital.

% Im plem e nting p er hos pital

12 0 10 0 80
%

Y ES %

60 40 20 0 Ho sp A Ho sp B Ho sp C Ho sp D Ho sp E

NO %

FIGURE

4.16.

The frequency of implementation of management of fever

recorded by registered nurses per hospital.

Less than 20% documentation of implementation was written at hospitals A to E. At hospital A no planning was done (see Figure 4.15) but a small percentage of staff documented that fever management was implemented. If not planned, how can implementation be done? Sundeen, et al. (1998:19) stated that every nursing action

102

should be supported by a rationale if a reason for her/his actions cannot be given, she/he is practicing irresponsible.

Interventions

The researcher observed out of the analysis of the flow sheets, that different registered nurses used different cooling down methods at different temperatures. These were visualised in Figures 4.17 to 4.22. These methods included removal of blankets,

pharmacology, electrical fan, no treatment, sponge baths, extra fluids, exposure, light sheet and bloodcultures. In Figure 4.17 the removal of blankets at different

temperatures was visualised by means of a line diagram.

40.5

40

39.5

39

38.5

C
38

37.5

37

36.5

36 1 2 3 4 Blanket removed 5 6 7

N=7

FIGURE 4.17. The removal of blankets at certain temperatures.

From Figure 4.17 it can be concluded that not all respondents remove extra blankets at the same temperatures. Blankets were removed at temperatures ranging from lower

103

than 37.5C up to 40C. Figure 4.18 illustrated the administration of pharmacological measures at different temperatures. It was visualised by means of a line diagram.

40.5

40

39.5

39

38.5

38

37.5

37

36.5

36

35.5

N=8

4 Pharmacology

FIGURE 4.18. The administration of medication at certain temperatures.

From Figure 4.18 it can be concluded that not all respondents administered pharmacological measures at the same temperatures. Medication was given at

temperatures ranging from lower than 37.5C up to 40C. In Figure 4.19 the utilisation of an electrical fan at different temperatures was visualised by means of a line diagram.

104

40

39.5

39

38.5

38

C
37.5

37 1 2 Electrical fan 3 4

N=4

FIGURE 4.19. The utilisation of an electrical fan at certain temperatures.

From Figure 4.19 it can be concluded that not all respondents utilised an electrical fan at the same temperatures. Electrical fanning was utilised at temperatures ranging from 38C up to less than 39.5C. In Figure 4.20 the utilisation of no treatment at different temperatures was visualised by means of a line diagram.

40

39.5

39

38.5

38

37.5

C
37

36.5

36

N=8

5 No treatment

FIGURE 4.20. The utilisation of no treatment at certain temperatures.

105

From Figure 4.20 it can be concluded that some respondents did not manage the fever at certain temperatures. Nothing was done at temperatures ranging from 37.5C up to more than 39.5C. In Figure 4.21 the utilisation of sponge baths at different

temperatures was visualised by means of a line diagram.

40.5

40

39.5

39

38.5

38

C
37.5

37

36.5

36 1 2 3 4 Sponge bath 5 6 7

N=7

FIGURE 4.21. The utilisation of sponge baths at different temperatures.

From Figure 4.21 it can be concluded that respondents utilised sponge baths at different temperatures. Sponge baths were utilised at temperatures ranging from 37.5C up to 40C. In Figure 4.21 the utilisation of other cooling down methods at different temperatures was visualised by means of a bar diagram.

106

39.4

39.2

39

38.8

38.6

38.4

38.2

C
38

37.8

37.6

37.4

Method

Bloodcultures done

Exra fluids

Exposed

Light sheet

FIGURE 4.22. The utilisation of other cooling down methods.

From Figure 4.22 it can be concluded that respondents utilised other cooling down methods at different temperatures. These methods included the taking of

bloodcultures, administration of extra fluids, exposure of the patient and covering of patient with a light blanket. These methods were utilised at temperatures ranging from 38C to 39.2C.

The researcher also observed that the time intervals in which temperatures were recorded, differed and there were no consistency from shift to shift, or patient to patient. The following intervals were observed over the 12 hour periods:

Sometimes not done/recorded at all Once in 12 hours Hourly

107

2 hourly 4 hourly 6 hourly

In one of the hospitals, the flowsheet had a framework for the planning phase of temperature management. This forced the registered nurses to plan for example to do temperatures one to two hourly, but although it was planned, this plan was mostly not implemented. Knies (1999) stated we need to incorporate regularly temperature assessment in the plan of care. Some suggest every two hours.

According to Kozier et al (1993:40), evaluation is an exceedingly important aspect of the nursing process. The conclusions drawn from the evaluation determine whether the nursing interventions can be terminated, or must be reviewed or changed. Evaluation should be continuous and ongoing. Booyens (2001:213) stated that however, if it is

registered nurses may regard evaluation as threatening.

implemented positively and objectively, the quality of nursing care is improved. She continued that quality promotes health and the profession. evaluation recorded per hospital was visualised in Figure 4.23. The percentages of

108

% Evaluating per hospital

120 100 80
%

YES %

60 40 20 0 Hosp A Hosp B Hosp C Hosp D Hosp E

NO %

FIGURE

4.23. The frequency of evaluation of fever or the effect of the

management of fever recorded by registered nurses per hospital.

If the plan of management was not documented or the implementation of the plan was not written down, how could it then be evaluated? The effect of the implementation of nursing interventions was not always recorded in the evaluation. The fact that the evaluation of pyrexia was recorded in the nursing process, did not necessarily mean that the plan of action was revised. The researcher observed that it was recorded on the medication list that certain anti-pyrexials were given, but this was nowhere recorded on the nursing documentation. It is essential that the critical care nurse

constantly evaluates fever and the effect interventions had on it.

Matthews and Whelan stated in Booyens (2001:206) the following: although the nursing process can be interpreted differently in different hospitals or units, it always comprises a permanent written record of planned care and its outcome. The total

109

percentages of the documentation of the steps of the nursing process done by all the hospitals, was visualised in Figure 4.24.

Total as % - all hospitals

120 100 80
%

YES %

60 40 20 0
Assessment
Nursing Diagnosis Outcom es Identification Planning Implementing Evaluating

NO %

FIGURE 4.24. A comparison between the utilisation of the steps in the nursing process by the registered nurses in the different hospitals.

In a case study done by the Foundation of Nursing studies (Mulhall & Le May,1999: 192) it was observed that nurses were using the nursing process because they felt they had to, with little understanding of why they were using it. Assessment and care

planning were being narrowly construed as recording admission data and describing rather than prescribing care. They tended to plan care around medical diagnoses. It appeared that the care given, was often completely at odds with what was written on the care plan. Evaluation was poorly understood and therefore not well done.

110

In Figure 4.24, 50.47% assessment was done by all hospitals, 13.76% nursing diagnosis was formulated, 0.57% outcomes were identified, 18.16% planning was

done, 7.64% implementation was documented and 13.95% evaluation was done.

The researcher observed the following regarding the nursing process: Critical care nurses did not utilise all the steps of the nursing process. The nurses tended to focus on the medical diagnosis and medical management of the patient with fever. The nursing care given did not correlate with what was written on the flow sheets. Evaluation was not well done.

4.4.

SUMMARY

In chapter 4(four) the results of the data obtained from the questionnaires and the checklists were analysed. These results were visualised by means of pie, bar and line diagrams, as well as frequency tables.

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.

111

The critical care nurses also demonstrated a difference of opinion concerning the patient with fever. There was inconsistency in the way the patients with fever were managed. It seemed that critical care nurses lacked knowledge on how to or when to manage a patient with fever.

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 use her knowledge and skills to nurse the critically ill patient with fever. The steps in the nursing process are overlapping.

During the assessment phase data concerning the patients temperature was collected. In total only 50.47% assessments were done of the evaluated flowsheets. Not assessing the patient can lead to mistakes during the management of the patient with fever.

The next step involved formulation of the nursing diagnosis. Assessment had no meaning if a nursing diagnosis was not made. formulated. 13.76% nursing diagnosis were

Critical thinking skills are needed for the outcomes identification. The outcomes identification is guided by the nursing diagnosis. 0.57% identified outcomes of the patients with fever or the potential to develop fever.

112

The planing phase was then entered. During the planning phase specific objectives were formulated to bring down the temperature. This plan should be recorded in the flow sheet. A total of 18.16% plans were recorded on the flow sheets.

Implementaton is the phase where the nurse puts the nursing strategies listed in the care plan into action. 7.64% recorded the implementation of the plan. During the

evaluation phase it was determined whether nursing interventions should be terminated or reviewed and changed. Evaluation was recorded by 13.95%.

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.

The next chapter will consider the justification, recommendations and conclusions of the study.

113

CHAPTER 5

JUSTIFICATION, RECOMMENDATIONS AND CONCLUSIONS

5.1.

INTRODUCTION

In chapter 5 (five) a justification of the study was presented. A reference to the aim of the study and the literature review was included in the discussion. An appraisal of the overall strengths and limitations of the study was undertaken. Recommendations for professional practice and further research were made.

5.2.

JUSTIFICATION

The outcomes of the study will be justified in terms of the aim and objectives of the study. A short discussion will also be presented in terms of the research design,

strategy and the literature review versus the results of the study.

5.2.1. The aim and objectives of the study

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 fever is implemented in practice.

114

To determine how critical nurses management of fever compares to suggestions contained in literature.

5.2.2. Literature review versus results of the study

There was controversy in the opinions of the respondents on the management of fever. The management was not done scientifically or based on evidence out of research. The opinions of medical practitioners also seemed to have an effect on the opinions of the respondents, as well as on the manner in which a fever was managed.

The importance of the utilisation of the nursing process, was overlooked.

The

registered nurses seemed to concentrate on the medical diagnoses as well as the medical management of the patient with fever. As found by Mulhall and Le May (1999:192), the researcher also observed that the care given, was often completely at odds with what was written on the care plan. Evaluation was poorly understood and therefore not well done.

The following results illustrated the range of answers obtained from the study. The results focused on: The knowledge of registered nurses working in critical care units, on the physiology of thermoregulation, the pathophysiology of fever and the management of a critically ill patient with fever. The opinions of registered nurses working in intensive care units on the management of fever. The utilisation of the nursing process during the treatment of critically ill adults.

115

From the questions that focused on the knowledge on the physiology of thermoregulation, the pathophysiology of fever and the nursing management of a critically ill patient with fever, 53% respondents answered correctly. 47% were either wrong, or did not know the correct answer.

As illustrated in Figure 4.8 critical care nurses had a difference in opinion of what method was the best or worst for managing fever. For example, 22% respondents saw a light blanket as the best method, and 11% saw it as the worst method; 52% respondents answered that pharmacolgy would be the best method but 22% thought it to be the worst method. The implication of this difference in opinion could be that there were no consistency in the way that critical care nurses managed patients with fever.

Figure 4.10 demonstrated how critical care nurses opinions differ on when they would start treating a fever. Not only did critical care nurses differed on the best or worst cooling down methods but also on the frequency of cooling down in the units where they were working, as well as when they would start managing a fever.

The researcher came to the following conclusions: Nurses did not utilise the nursing process in the management of the critically ill patient with fever. Critical care nurses tended to focus on medical diagnosis and medical management of the patient with fever. The care given was at odds with what was written on the care plan. Evaluation was not always well done.

116

The outcomes of the study corresponded with the aims and objectives of the study, and the statement can therefore be made that the aim of the study has been achieved. The critical care nurses knowledge concerning the physiology of thermoregulation, the pathophysiology of fever and the management thereof, were obtained. The study also revealed the utilisation of the nursing process during the management of the critically ill patient with fever. The researcher found that critical care nurses lacked in the

knowledge of the physiology of thermoregulation, the pathophysiology of fever and the nursing management of fever. The nursing process was not utilised effectively during the nursing management of the critically ill patient with fever.

The type of research design used in this study was quantitative. The strategy was descriptive and contextual.

5.3.

EVALUATION

An evaluation in terms of limitations of the study and the overall strengths of the study was discussed.

5.3.1. Limitations of the study

Miller stated in Leddy and Pepper (1998:156) :it has been found that although the majority of nurses are aware of research-based interventions, few use them even sometimes.

The researcher identified the following barriers to the research: A negative attitude among nursing staff towards research.

117

Minimal value placed on research by unit managers. A lack of time to actively participate in research by critical care nurses. Obtaining approval to do research in hospitals was time-consuming. Hospital

managers were slow in responding to the request by the researcher to do research, or they did not respond at all. Dependence on traditional ways of managing patients. Reliance on policies and procedures rather than openness to change. As cited in Drury (1998), Aldnsanya stated although most nursing research reports contain at least one finding that could be implemented in hospital wards, there are many examples of nursing care that continue to be driven according to the procedure book rather than through research. Staff do not understand the importance of research. Little time is spent on the nursing research process during the basic training of nurses (Drury,1998). In a study done by Voda as described by Drury (1998) the research-practice gap was also due to the fact that clinical nurses are not directly involved in research projects; researchers are not directly involved with patient care and nurses fail to read research.

5.3.2. Strengths of the study

The following strengths of the study was identified: The possibility exists that the patients with fever and the critical care nurse nursing the patient, will benefit from the knowledge produced from the study. The findings can potentially help to improve nursing practice through critical thinking, based on evidence.

118

More knowledge on the fever management of the critically ill patient can make a difference that matters. It can improve the quality of care given to patients with fever.

Elimination of medico-legal risks by improving knowledge.

5.4.

RECOMMENDATIONS

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 nurses to have

knowledge of their scope of practice and their role in the management of the critically ill patient with fever. The essential question that one needs to ask is, if fever should be managed or not? It is revealed in the literature that an uncomplicated fever is relatively harmless. Fever is essential in the immune/inflammatory process in the body. The use of interventions must be carefully considered. One aim of intervening might be to decrease cellular metabolism in the metabolically compromised patient.

The administration of antipyretics should be used selectively and with caution (Watts, Robertson & Thomas,2001:8). There were documented cases of hepatotoxicity after administration of anti-pyrexial medication. Management of fever needs to be based on knowledge.

The following recommendations regarding the nursing management of fever, were suggested by the researcher:

119

5.4.1. Education in South Africa

The researcher supports education in order to increase knowledge and skills in managing the critically ill patient with fever.

Inclusion of the physiology of thermoregulation, the pathophysiology of fever and the management thereof in the curriculum of all learning programmes for health care professionals.

Nurses need to develop their own decision-making and care management skills, based on evidence.

Workshops need to be conducted in order to improve practice. A learning environment must be facilitated that is conducive to education. Research methodology to be included in the curriculum of the undergraduate nursing students.

5.4.2. Nursing practice

There should be a shift from habits. The development of standards and criteria for the management of fever will play an important role.

It is necessary to incorporate regular temperature assessments in the plan of care for critically ill patients.

Nursing documentation should be user-friendly. All critical care nurses should carry out the audit process in order to improve the quality of nursing. They should keep in mind that the nursing process must be a written record.

120

5.4.3. Further research

Research regarding the nursing management of fever and the physiological responses associated with fever, should be an ongoing process and all critical care nurses should be involved in this process.

Scientific knowledge must be put into practice in order for the critical care nurse to deliver quality care.

A research study can be done to investigate what influence the medical practitioner has on the opinion of the critical care nurse on how fever should be managed.

5.5.

CONCLUSIONS

It was stated by Sheehan in Cormack(1996:389) that: 'applying research findings in nursing practice is perhaps the biggest challenge facing nursing research'. Based on evidence found in the literature, it is best not to actively manage a fever.

Findings need to be implemented.

Patients need to be assessed thoroughly to

determine the need for the active management of fever. No evidence could be found that demonstrated the effectiveness of certain cooling down methods. suppression of fever in critically ill adults may not be useful. The

The presence of fever frequently results in the performance of diagnostic tests and procedures that significantly increase medical costs and expose the patient to

121

unnecessary invasive diagnostic procedures and the inappropriate use of antibiotics. Fever is caused by either infection or non-infective causes (Marik,2000).

Fever is not an illness it is a symptom and should be managed the correct way. An untreated fever will not rise indefinitely the hypothalamus will prevent the temperature from rising too high (Wong & Whaley, 1983:898).

Cormack(1996:401) referred to the following chinese proverb:

'he who teaches and does not do research is like a man who drinks from a stagnant pool. He who teaches and does research is like a man who drinks from a flowing stream '.

122

BIBLIOGRAPHY

AARONSON, L.S. & BURMAN, M.E. 1994. Focus on psychometrics. Research in nursing and health, 1(1)7:67-72. AMERICAN ASSOCIATION OF CRITICAL CARE NURSES. 2000,February 23. Role of the critical care nurse. [On line]. Available at: <http://aacn.org/AACN/pubpolcy.nsf>. Accessed: 04/03/01. AMERICAN ORGANISATION OF NURSE EXECUTIVES. 1996. The evolving role of the registered nurse. [On line]. <http://www.anone.org/practiceresearch/evolving_role_registerde_nurse.htm>. Accessed at: 04/01/01. BEGANY, T. 2000. Intensivists oppose routine treatment of fever in the ICU. Pulmonary reviews.com. 5(6). [On line]. Available at: <http://www.pulmonary reviews.com/jun00/pr-jun00feverinicu.html >. Accessed at: 25/02/01. BEERS, M.H. & BERKOW, R.(eds.). 1997. The Merck manual of diagnosis and therapy. 7th ed. New York: Merck Research Laboratories. BOOYENS,S.W. (ed.). 2001. Introduction to health services management. 2nd ed. Cape Town: JUTA. BRINK, H. I. L. 1994. Basic issues in clinical nursing research. Nursing RSA Verpleging, 9(8): 15. BRINK, H. I. L. 1999. Fundamentals of research methodology for health care professinals. 2nd impression. Cape Town: JUTA. BRINK, H.I.L. 1990. Statistics for nurses. 3rd impression. Pretoria: Academica. BUNCH, B. 1999. Fever. The family encyclopedia of disease: a complete and concises guide to illness and symptoms. [On line]. New York: WH Freeman and company. Available at: <http://www.medic-planet.com/MP_article/internal_reference/fever>. Accessed at: 01/04/01. BURNS,N. & GROVE, S.K. 1997. The practice of nursing research conduct, critique and utilisation. 3rd ed. Philadelphia: W.B Saunders. CANADIAN ASSOCIATION OF CRITICAL CARE NURSES. 1997. Philosophy statement. [On line]. Available at: <http://www.execulink.com.htm.>. Accessed at: 04/03/01. CLOSS, S.J. & CHEATER, F.M. 1998. Evidence for nursing practice: a clarification of the issues. Journal of advanced nursing. 30(1): 10 17.

123

CORMACK, D.F.S.(ed.). 1996. The research process in nursing. 3rd ed. Oxford: Blackwell science. CORWIN, E. J. 2000. Handbook of pathophysiology. 2nd ed. Philadelphia: Lippincott. DE VOS,A.S.(ed.). 2000. Research at grass roots. 2nd impression. Pretoria: Van Schaik. DOSSEY, B.M. , GUZZETTA, C. E. & KENNER, C. V. 1992. Critical care nursing body, mind and spirit. 3rd ed. Philadelphia:Lippincott DRURY, P. 1998. Barriers to evidence-based nursing care: listen to the clinicians. [On line]. Available at: < http://www.clininfo.health.nsw.gov.au/hospolic/stvincents/stvin98/a0.html>. Accessed at:11/04/03. EICHELBERGER, W. I. 1999. Competency based practice. [ On line]. Available at: <http://healthsci.clayton.edu/eichelberger/competency218.ppt.>. Accessed at: 01/04/01. FALL. 1999. Philosophy of scientific method. [On line]. Available at: <http://www.angelfire.com/country/palestine/compareandcontrast.htm.>. Accessed at: 01/04/01. FINOCCHIO.L. 1998. Physicians and non-physician clinicians. [ On line]. Available at: <http://www.jama.ama-assn.org >. Accessed at: 10/04/03. FOWLER, B. 1996. Critical thinking across the curriculum project. [On line]. Available at: < http://www.kcmetro.cc.mo.us/longview/ctac/definitions.htm>. Accessed at: 01/04/01. GANONG. 2000. Why fever? [On line]. Available at: <http://plpk04.plp.edu.au/webstuts.>. Accessed at: 26/03/01. GENDELMAN, M. 2000. Temperature disorders. [On line]. Available at:: <http://www.pitt.edu/~mandel/hh.htm.>. Accessed at: 27/03.01. GEORGE, J. B.(ed.). 1985. Nursing theories: the base for professional nursing practice. 2nd ed. , New Jersey: Prentice Hall. HALLOWAY,N. 1993. Nursing the critically ill adult. 4th ed. Addison-Wesley Publishing.

HOLGUIN-TRUPP, K. 2000, October 28. Coursework Document: Theorist presentation. [On line]. Available at:: < http://dana.ucc.nau.edu/~krh23/WebWizard/courseworkdoco.html>. Accessed at: 23/03/01.

124

HOLTZCLAW, B.J. 1998. Keep the covers on. [On line]. Available at: < http://www.uthscsa.edu/mission/spring98/fever.html>. Accessed at: 02/03/02. HOLTZCLAW, B.J. & FAAN.R.N. 1992. The febrile response in critical care: state of the science. Heart and lung, 21(5): 482 501. HUDAK, C. M. , GALLO, B. M. & MORTON, P.G. 1998. Critical care nursing a holistic approach. 7th ed. New York: Lippincott. KNIES,R.C. S.a. Temperature Management in Acute Stroke. [On line]. Available at: <http://www.enw.org/Research-StrokeTemp.htm>. Accessed at: 25/02/01. KOZIER, B. ,ERB, G. ,BLAIS ,K & WILKINSON, J.M. 1995. Fundamentals of nursing. 5th ed. California: Addison-Wesley. KOZIER, B. ,ERB, G. ,BLAIS, K. ,JOHNSON, J. Y. & TEMPLE, J. S. 1993. Techniques in clinical nursing. 4th ed. Redwood City: Addison-Wesley. LEDDY, S. & PEPPER, J.M. 1998. Conceptual bases of professional nursing. 4th ed. New York: Lippincott. LONG, P.W. 2000. Clorpromazine [On line]. Available at: <http://www.mentalhealth.com/drug/p30-c01.html>. Accessed at: 22/03/01. MARIK,P.E. 2000. Fever in the ICU. Chest, 2000(117) :855-869. MARKS,C. 2001. Reflective practice in thermoregulatory nursing care. Nursing standard, 15(43): 38-41. MARYLAND RESEARCHERS. 2000. [On line]. Available at: <http://www.oes.umaryland.edu/news/2000/2000085_antipyretic_drugs.htm>. Accessed at: 11/04/03. McKENZIE, N.E. 1998, October. Fever: upping the bodys thermostat. [On line]. Available at: < http://www.springnet.com/ce/p810a.htm>. Accessed at: 05/08/00. MIMS DESK REFERENCE. 2000. [CD-ROM]. MOLZAHN-YANITSKI, B.S.N. 1983. Reliability and validity of a quality assurance instrument for a renal dialysis unit. Nephrology Nurse, November/December:8-12. MOTHER CHILD LABORATORY. 2001. How to care for fever in children. [On line]. Available at: <http://www.irfmn.mnegri.it/mrpm/dipmochild/moch2.htm>. Accessed at: 01/04/01. MOUTON, J. & MARAIS, H.C. 1990. Basiese begrippe: metodologie van die geesteswetenskappe. Pretoria: RGN Uitgewers. MULHALL, A & LE MAY, A(eds). 1999. Nursing research dissemination and implementation. Edinburgh: Churchill Livingstone.

125

MULLER, M. 1998. Nursing dynamics. 2nd ed. Sandton: Heinemann. MURPHY, K.A. 1992. Acetaminophen and ibuprofen: fever control and overdose. Pediatric Nursing, 18(4):428-431. NEL, W. E. 1993. Die funksies van die intensiewe verpleegkundige in die Republiek van Suid Afrika. M.Cur dissertation, Rand Afrikaans University. NEUMAN, B. 1982. The Neuman systems model. Application to nursing education and practice. Connecticut: Appleton. OH, T. E.(ed.). 1998. Intensive care manual. 4th ed. Oxford: Butterworth. PERRY, A. G. & POTTER, P. A. 1998. Clinical nursing skills and techniques. St Louis: Mosby. PHIPPS,R.P. 2002. B-cells and prostaglandines; fibroblasts as effector cells in immunity. [On Line]. Available at: <http://www.urmc.rochester.edu>. Accessed at: 10/04/03. PHILLIPS, J.P. 2000. Feverits not just sepsis. [On line]. Available at: <http://www/advancefornurses.com/1s1.html>. Accessed at: 19/01/02. PILE, J.C. 1998. Fever. General Medical Officer Manual: Clinical Section: Infectious diseases. [On line]. Available at: < http://www.vnh.org/GMO/ClinicalSection/30Fever.html>. Accessed at: 01/04/01. POLLARD, E.(ed.) 1995. The Oxford large print dictionary. 2nd ed. Avon: Bath Press. POLIT, D.F. & HUNGLER, B.P. 1997. Essentials of nursing research. 4th ed. New York: Lippincott. REID, N.G. & BOORE, R.P. 1991. Research methods and statistics in Health Care. London: Edward Arnold. ROWSEY, P.J. 1997. Pathophysiology of fever. Dimensions of critical care nursing. 16(4): 202-207 and 251-256. SACKETT,D. 2002. Evidence based nursing. [On line]. Available at: <http://www.nursenetwork.co.uk>. Accessed at: 10/04/03. SEARLE, C. 2000. Professional practice a South African nursing perspective. 4th ed. Durban: Heinemann. SLAVKOVSKY, P. 1995, June 27. Pathogenesis of fever. [On line]. Available at:<http://savba.savba.sk/logos/books/scientific/node48.html>. Accessed at: 09/08/00. SOUTHALABAMA. 1999. Critical thinking and the nursing process. [On line]. Available at: <http://www.southalabama.edu/nursing>. Accessed at: 04/01/01.

126

STEYN,A,G.W. , SMIT,C.F. , DU TOIT, S.H.C. & STRASHEIM, C. 1994. Moderne statistiek vir die praktyk. 5de uitgawe. Pretoria: Van Schaik. SUNDEEN, S. J. , STUART, G. W. , RANKIN, E. A. D. & COHEN, S. A. 1998. Nurse-client interaction: implementing the nursing process. 6th ed. St. Louis: Mosby. THELAN, L.A. , DAVIE, J.K. & URDEN, L.D. 2002. Critical care nursing diagnosis and management. St. Louis: Mosby. THE MANITOBA ASSOCIATION OF REGISTERED NURSES. 1999. Continuing competence for registered nurses in Manitoba. [On line]. Available at: <http://www.marn.mb.ca/continue.htm>. Accessed at: 02/03/02. THE SOUTH AFRICAN NURSING COUNCIL. SA. 1998. Information booklet. Pretoria:SANC. TORTORA, G.J. & GRABOWSKI, S. R. 1996. Principles of anatomy and physiology. 8th ed. New York: Harper Collins. TURNER, J. 1995. Overview: legal aspects of nursing documentation. [On line]. Available at: < http://www.vcsun.org/~mhighfi/vhsdoc.html>. Accessed at: 03/02/02. UYS, L. R. & MULDER, M. 1995. Nursing: humane, scientific health care. 6th impression. Bloemfontein: Kagiso. WATTS,R., ROBERTSON,J & THOMAs,G. 2001. The nursing management of fever in children. Australia:The Joanna Briggs Institute. WILSON, H.S. 1993. Introducing research in nursing. 2nd ed. Redwood City: Cummings Publishing. WONG. D. L. 1999. Tepid sponge bathing and fever management. [On line]. Available at: <http://www.harcourthealth.com/Mosby/Wong/hcom-wong-w33.html>. Accessed at: 25/02/01. WONG, D. L. & WHALEY, L. F. 1983. Nursing care of infants and children. 2nd ed. St.Louis: Mosby.

127

ADDENDUM A COVERING LETTER OF QUESTIONNAIRE

128

129

ADDENDUM B QUESTIONNAIRE

130

131

132

133

134

ADDENDUM C APPROVAL FROM ETHICS COMMITTEE

135

136

ADDENDUM D CHECKLIST

137

138

ADDENDUM E EXAMPLE OF A LETTER OF CONSENT FROM HOSPITALS

139

140

141

ADDENDUM F RESULTS OF QUESTIONNAIRES

142

143

144

145