FUNDERMENTALS OF NURSING

FEVER
JESSICA SHIMWENSE
LUSAKA APEX MEDICAL UNIVERSITY
 INTRODUCTION
• Fever is an unusually high body temperature,
a thermometer is used to measure the body
temperature, temperatures varies when taken
in different part of the body, if it is taken in the
rectum/anus the temperature is generally one
degree higher than if the temperature is taken
under the arm, on a degree lower.
• Pyrogen is a substance that induces fever or
rise in the body temperature.
 INTRODUCTION
• Fever is not a disease but symptoms of
another sickness. During a fever, the body
requires extra energy, which it generates by
muscular activity in the form of shivering and
by metabolizing (chemically breaking down)
proteins, carbohydrates, vitamins, and
minerals at a faster rate than normal.
 INTRODUCTION
• A fever is considered one of the body's
immune mechanisms to attempt a
neutralization of a perceived threat inside the
body, be it bacterial or viral. Carl Wunderlich
discovered that fever is not a disease, but the
body's response to a disease.
 DEFINITION
• Fever (also known as pyrexia, from the Greek
pyretos meaning fire, or a febrile response, from
the Latin word febris, meaning fever, and
archaically known as ague) is a frequent medical
sign that describes an increase in internal body
temperature to levels above normal.
• Fever is most accurately characterized as a
temporary elevation in the body's
thermoregulatory set-point, usually by about 1–2
°C (1.8-3.6 °F).
 ETIOLOGY
• Fever is caused by an elevation in the
thermoregulatory set-point, causing typical
body temperature (generally and
problematically considered to be 37 °C or 98.6
°F; see below for specifics) to rise, and effector
mechanisms are enacted as a result.
 CONT..
• A feverish individual has a general feeling of
cold despite an increased body temperature,
and increases in heart rate, muscle tone and
shivering, all of which are caused by the
body's attempts to counteract the newly-
perceived hypothermia and reach the new
thermoregulatory set-point
 CAUSES OF FEVER
• Infectious disease, e.g. influenza, HIV, malaria,
infectious mononucleosis, or gastroenteritis
• Various skin inflammations, e.g. boils, pimples,
acne, or abscess
• Immunological diseases, e.g. lupus
inflammatory bowel diseases
• Tissue destruction, which can occur in
hemolysis, surgery, infarction, crush syndrome,
cerebral hemorrhage, etc.
 CONT..

•Directly caused by the drug, e.g, progesterone,

or chemotherapeutics causing tumor necrosis
•As an adverse reaction to drugs, e.g. antibiotics
or sulfa drugs.
•After drug discontinuation, e.g. heroin or
fentanyl withdrawal
 CONT…
•Reaction to incompatible blood products
•Cancers, most commonly renal cancer and
leukemia and lymphomas
•Metabolic disorders, e.g. gout or porphyria
•Thrombo-embolic processes, e.g. pulmonary
embolism or deep venous thrombosis.
• Persistent fever which cannot be explained after
repeated routine clinical inquiries is called fever
of unknown origin.
MEASUREMENT AND NORMAL VARIATION
OF TEMPERATURE
• When a patient has or is suspected of having a
fever, that person's body temperature is
measured using a thermometer. At a first
glance, fever is present
 CONT..
• Temperature in the anus (rectum/rectal) is at
or over 37.8 °C (100.0 °F)
• Temperature in the mouth (oral) is at or over
37.5 °C (99.5 °F)
• Temperature under the arm (axillary) is at or
over 37.2 °C (99.0 °F)
 CONT…
• Temperature in the ear (otic) is at or over 37.2
ºC (99.0 ºF)
• The common oral measurement of normal
human body temperature is 36.8±0.7 °C
(98.2±1.3 °F). This means that any oral
temperature between 36.1 and 37.5 °C (96.9
and 99.5 °F) is likely to be normal.
 CONT…
• However, there are many variations in normal
body temperature, and this needs to be
considered when measuring for fever.
 CONT..
• The values given are for an otherwise healthy,
non-fasting adult, dressed comfortably, indoors,
in a room that is kept at a normal room
temperature (22.7 to 24.4 °C or 73 to 76 °F),
during the morning, but not shortly after arising
from sleep.
• Furthermore, for oral temperatures, the subject
must not have eaten, drunk, or smoked anything
in at least the previous fifteen to twenty minutes
 CONT…
• Body temperature normally fluctuates over
the day, with the lowest levels around 4 a.m.
and the highest around 6 p.m.[1] (assuming
the subject follows the prevalent pattern, i.e.,
sleeping at nighttime and staying awake
during daytime).
• ). Therefore, an oral temperature of 37.2 °C
(99.0 °F) would strictly be a fever in the
morning, but not in the afternoon
 CONT….
• An oral body temperature reading up to
37.5 °C (99.5 °F) in the early/late
afternoon or early/late evening also
wouldn't be a fever.
• Normal body temperature may differ as
much as 1 °F (0.6 °C) between individuals
or from day to day.
 CONT..
• In women, temperature differs at various
points in the menstrual cycle, and this
can be used as part of fertility awareness
(although temperature is only one of the
variables).
 CONT..
• Temperature is increased after eating, and
psychological factors also influence body
temperature.
• There are different locations where
temperature can be measured, and these
differ in temperature variability.
• Tympanic membrane thermometers measure
radiant heat energy from the tympanic
membrane (infrared).
 CONT…
• These may be very convenient, but may
also show more variability
• Children develop higher temperatures
with activities like playing, but this is not
fever because their set-point is normal.
 CONT…
• Elderly patients may have a decreased ability
to generate body heat during a fever, so even
a low-grade fever can have serious underlying
causes in geriatrics.
• Fever is usually accompanied by sickness
behavior which consists of lethargy,
depression, anorexia, sleepiness, hyperalgesia,
and the inability to concentrate
 MECHANISM OF FEVER
• Temperature is ultimately regulated in the
hypothalamus. A trigger of the fever, called a
pyrogen, causes a release of prostaglandin E2
(PGE2).
• PGE2 then in turn acts on the hypothalamus,
which generates a systemic response back to
the rest of the body, causing heat-creating
effects to match a new temperature level.
 CONT…
• Hyperthermia: Characterized on the left.
Normal body temperature (thermoregulatory
set-point) is shown in green, while the
hyperthermic temperature is shown in red. As
can be seen, hyperthermia can be
conceptualized as an increase above the
thermoregulatory set-point.
 CONT…
• Hypothermia: Characterized in the center:
Normal body temperature is shown in green,
while the hypothermic temperature is shown
in blue.
• As can be seen, hypothermia can be
conceptualized as a decrease below the
thermoregulatory set-point.
 CONT…
• Fever: Characterized on the right: Normal
body temperature is shown in green. It reads
"New Normal" because the thermoregulatory
set-point has risen.
• This has caused what was the normal body
temperature (in blue) to be considered
hypothermic.
 CONT…
• Pyrogens=A pyrogen is a substance that
induces fever. These can be either internal
(endogenous) or external (exogenous) to the
body. The bacterial substance
lipopolysaccharide (LPS), present in the cell
wall of some bacteria, is an example of an
exogenous pyrogen.
• Pyrogenicity can vary, as in extreme
examples some bacterial pyrogens
known as superantigens can cause rapid
and dangerous fevers. Depyrogenation
may be achieved through filtration,
distillation, chromatography, or
inactivation
 CONT…
Endogenous
• Cytokines (especially interleukin 1) are a part of the
innate immune system, are produced by phagocytic cells,
and cause the increase in the thermoregulatory set-point
in the hypothalamus.
Exogenous
• One model for the mechanism of fever caused by
exogenous pyrogens includes LPS, which is a cell wall
component of gram-negative bacteria. An immunological
protein called lipopolysaccharide-binding protein (LBP)
binds to LPS.
• The LBP–LPS complex then binds to the CD14
receptor of a nearby macrophage. This binding
results in the synthesis and release of various
endogenous cytokine factor, and the tumor
necrosis factor-alpha. In other words,
exogenous factors cause release of
endogenous factors, which, in turn, activate
the arachidonic acid pathway.
 CONT….
• PGE2 release
• PGE2 release comes from the arachidonic acid
pathway.
• PGE2 is the ultimate mediator of the febrile
response. The set-point temperature of the
body will remain elevated until PGE2 is no
longer present.
 CONT…
• EP3-expressing neurons in the POA innervate the
dorsomedial hypothalamus (DMH), the rostral
raphe pallidus nucleus in the medulla oblongata
(rRPa) and the periventricular nucleus (PVN) of the
hypothalamus .
• Fever signals sent to the DMH and rRPa lead to
stimulation of the sympathetic output system,
which evokes non-shivering thermogenesis to
produce body heat and skin vasoconstriction to
decrease heat loss from the body surface.
 CONT…
• Hypothalamus response
• The brain ultimately orchestrates heat effector
mechanisms via the autonomic nervous
system. These may be:
• Increased heat production by increased muscle
tone, shivering and hormones like epinephrine.
• Prevention of heat loss, such as
vasoconstriction.
 CONT…
• The autonomic nervous system may also
activate brown adipose tissue to produce heat
(non-exercise-associated thermogenesis, also
known as non-shivering thermogenesis), but
this seems mostly important for babies.
Increased heart rate and vasoconstriction
contribute to increased blood pressure in
fever.
 TYPES OF FEVER
• Most of the time, fever types cannot be used
to find the underlying cause. However, there
are specific fever patterns that may
occasionally hint the diagnosis:
• Pel-Ebstein fever: A specific kind of fever
associated with Hodgkin's lymphoma, being
high for one week and low for the next week
and so on. However, there is some debate as
to whether this pattern truly exists.[5]
 CONT….
•Continuous fever: Temperature remains above
normal throughout the day and does not
fluctuate more than 1 °C in 24 hours, e.g. lobar
pneumonia, typhoid, urinary tract infection,
brucellosis, or typhus. Typhoid fever may show a
specific fever pattern, with a slow stepwise
increase and a high plateau.
 CONT….
•Intermittent fever: Elevated temperature is
present only for some hours of the day and
becomes normal for remaining hours, e.g.
malaria, kala-azar, pyaemia, or septicemia. In
malaria, there may be a fever with a periodicity
of 24 hours (quotidian), 48 hours (tertian fever),
or 72 hours (quartan fever, indicating
Plasmodium malariae).
 CONT…
•Remittent fever: Temperature remains above
normal throughout the day and fluctuates more
than 1 °C in 24 hours, e.g. infective endocarditis.
 CONT….
• A neutropenic fever, also called febrile
neutropenia, is a fever in the absence of
normal immune system function. Because of
the lack of infection-fighting neutrophils, a
bacterial infection can spread rapidly and this
fever is therefore usually considered a medical
emergency.
 CONT….
• This kind of fever is more commonly seen in
people receiving immune-suppressing
chemotherapy than in apparently healthy people.
• Febricula is a mild fever of short duration, of
indefinite origin, and without any distinctive
pathology.
• Relapsing Fever - type that recurs sometimes a
number of times, several days after the
temperature has returned to normal
 STAGES OF FEVER
• In the first stage of fever also known as the
invasion period the patient will experience
chill, loss of appetite, and headache. Chill
occurs, occurs because of the tightening of
blood vessels near the skin.
 CONT…
• In the next stage, the body is hot and flushed,
the skin dry, and the pulse and respiration are
rapid. The patient will experience thirst and
he/she will feel restless. In high fever, delirium
and convulsions may occur.
• In the final stage before returning to normal,
the temperature falls, breathing and pulse
slow down, and the skin becomes moist. The
patient often sweats.
 TREATMENT/MANAGEMENT
• Fever should not necessarily be treated. Fever
is an important signal that there's something
wrong in the body, and it can be used to
govern medical treatment and gauge its
effectiveness. Moreover, not all fevers are of
infectious origin.
 CONT….
• Even when treatment is not indicated,
however, febrile patients are generally advised
to keep themselves adequately hydrated, as
the dehydration produced by a mild fever can
be more dangerous than the fever itself.
 CONT…
• Water is generally used for this purpose, but
there is always a small risk of hyponatremia if
the patient drinks too much water. For this
reason, some patients drink sports drinks or
electrolyte-replacing products designed
specifically for this purpose.
 CONT…
• Most people take medication against
fever because the symptoms cause
discomfort. Fever increases heart rate
and metabolism, thus potentially putting
an additional strain on elderly patients,
patients with heart disease, etc. This may
even cause delirium..
 CONT…
• Therefore, potential benefits must be
weighed against risks in these patients. In
any case, fever must be brought under
control in instances when fever escalates
to hyperpyrexia and tissue damage is
imminent
 CONT…
• Treatment of fever is normally done by
lowering the set-point, but facilitating heat
loss may also be effective. The former is
accomplished with antipyretics such as
ibuprofen or paracetamol (US
acetominophen).
 CONT….
• Aspirin can also be given to adults, but can
cause Reye's Syndrome in children. Heat
removal is generally by wet cloth or pads,
usually applied to the forehead,[15] but also
through bathing the body in tepid water. This
is particularly important for babies, where
drugs should be avoided.
 CONT…
• However, using water that is too cold can
induce vasoconstriction, and reduce effective
heat loss.
• Heat loss may also be accomplished by heat
conduction, convection, radiation, or
evaporation (sweating, perspiration), or a
combination of these.
 SUMMARY

• Fever is defined as a frequent medical sign that

describes an increase in internal body
temperature to levels above normal. Fever is
most accurately characterized as a temporary
elevation in the body's thermoregulatory set-
point, usually by about 1–2 °C (1.8-3.6 °F).it has
three stages and has different types that differ in
occurrence and duration hence treatment
depends on how the fever presents and what the
etiology of the fever was.
 REFERENCES
• Guyton A.C.; Hall J.E (2006).25.Textbook Of
Medical Physiology.11th Edition. Elsevier
Saunders.
• Campbell. N.A and Cummings .B,
(1996).Biology 4th Edition. Isbn. Wilkins,
Philadelphia
• Potter. P.A and Perry. A.G (2015).Fundamentals
Of Nursing.6th Editions. Mosby, Inc