Evidence-Based Fever Management Teaching Intervention for Emergency Room Nurses
Alonya Elgrably
Dominican University of California
E-MAIL: ERSPRSTAR@gmail.com

March 04, 2010

Signature Page This capstone project is assembled under the direction of the candidate’s program advisor and approved by the Director of the Master’s program and the Chair of the Nursing Department. It has been presented to and accepted by the Faculty of the School of Nursing, Dominican University of California, in partial fulfillment of the requirements for the degree of Masters of Science, Nursing.

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Candidate Date

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Advisor or Director Date

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Department Chair Date

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Dean of the School of Health Sciences Date

Evidence-Based Fever Management Teaching Intervention for Emergency Room Nurses Fever has long been a common childhood illness faced by parents, physicians, and nurses. In fact, 30 percent of visits to the emergency room included fever as the main complaint (Watts, Robertson, & Thomas, 2003). Over the decades the research has shown fever to be an adaptive physiological mechanism and shown to improve survival rates and shorten the duration of the disease (Broom, 2007). However, most nurses still view fever as harmful and administer antipyretics to children even when they are asymptomatic (Considine & Brennan, 2007). This nursing behavior can further confuse parents’ perceptions of fever and increase fear and anxiety which often lead to return visits to the emergency room for fever control; many of these visits can be prevented if parents are given accurate discharge teaching and reference materials to take home for aftercare. The phrase “fever phobia” was coined in 1980 and is meant to describe the caregiver’s unrealistic fears about fever in both parents and healthcare workers (Walsh & Edwards, 2006). Many of these fears can be eased through a thorough teaching intervention. Although this may sound like an easy task, a thorough review of the literature has shown that most nurses’ understanding of fever management is inconsistent across the spectrum of healthcare (Considine & Brennan, 2007).

Pathophysiology of Fever

Before any further discussion, it is important for nurses to clearly understand the pathophysiology of fever and what benefits or potential harm it cause to children. Throughout the literature the definition of fever ranges, according to NICE, fever can be defined as “an elevation of body temperature above the normal daily variation” (N.I.C.E., 2007, p. 29). In fact, fever is a normal adaptive systematic response to and immune stimulus. It is the body’s natural response to illness and has been shown to improve survival rates and shorten the duration of the disease (Brown, 2007). Despite the overwhelming evidence of the beneficial effects of a mild fever, there remains a general fear of the fever process among healthcare professionals. This is mainly due to the fact that fever is seen as an indicator of disease and treated aggressively by clinicians. However, most fevers are self limiting and children appear to tolerate mild to moderate fevers with relative ease (Brown, 2007). Oftentimes nurses will want to try to cool the child by undressing them, this is not always the best way to approach a febrile child. The literature suggests that any attempt to cool the periphery will result in an increase of metabolic rate and cause the body to work harder to try and conserve heat from the febrile child resulting in increase shivering, rigors, and other heat conservation measures (Brown, 2007). Thermometers and Detection of Fever Body temperature in children can be measured at a number of different anatomical locations using a wide range of thermometers Sites used to measure temperature include the mouth, rectum, axilla, aural canal and forehead . While rectal temperature readings have long been the “gold standard” for clinicians this procedure can cause discomfort to the patient and increase the anxiety levels of parents (Holzhauser, Reith, Sawin, & Yen, 2009). There are a variety of ways to measure body temperature, these include: Chemical Dots, Forehead Chrystal, Infrared Tympanic, and Temporal Artery thermometers. Mercury thermometers have been excluded due their risk of possible mercury exposure. According to the National Institute of Clinical Excellence 2007 Clinical Guidelines suggest that healthcare professionals should use the axillary route for children aged 3 months to 2 years. Other types of thermometers were all shown to underestimate body temperature.

Emergency Nurses’ Knowledge, Attitude, and Influence Factors of Fever Management

Even though fever has been a common childhood illness, nurses and other healthcare provider still perceive fever to be harmful and determine the severity simply by the height of the fever. The nurses’ “fever phobia” continues to be reported in the literature, and negative attitudes toward fever remain unchanged (Walsh, Edwards, Courtney, Wilson, & Monaghan, 2005).
Safety and Efficacy of Treating Fever with Antipyretics and Alternative Treatments

Historically, fevers were treated by a variety of methods, for example, the use of cold or ice sponge baths, sometimes with isopropyl alcohol added to the bath water, and swaddling with extra blankets. However, recent evidenced-based practice has shown that the adverse effects of physical cooling methods result in increased shivering, crying, and discomfort of the child, thus sponging is not recommended for febrile children (N.I.C.E., 2007). Acetaminophen, also known as Paracetamol, is one of the world’s most widely used over-the-counter medications and has long been the medication of choice in the treatment of fever. This is mainly due to the stated benefits of the drug which includes its analgesic effects that it is well tolerated, and that iatrogenic complications are infrequent and minor (Warwick, 2008). Even though the occurrence of complications related to Tylenol is low, children are still at risk for adverse side effects. The most serious side effect of Tylenol overuse has been reported to be hepatotoxicity. It has been suggested that the child at risk of liver toxicity is most likely to be under two years of age, sick, (i.e., repeated vomiting and diarrhea together with poor oral food/fluid intake), and received more than 90 mg/kg/day for more than one day ( Best Practices, 2007). The literature regarding the efficacy of Acetaminophen suggests no significant difference between treated and placebo group in duration of fever or other symptoms and has not been shown to prevent the onset nor recurrence of febrile seizures (Russell, Shann, Curtis, & Mulholland, 2003). Today the most controversial practice is the use of alternating does of acetaminophen and ibuprofen to help control fever. Previously, antipyretic medications, Acetaminophen and Aspirin, produced satisfactory reduction in temperature when given individually, and the alternation of these two medications would produce a more effective and sustained reduction of fever; however, that was before Aspirin was found to cause Reye’s syndrome in children. It was then that practitioners began to recommend alternating Acetaminophen with Ibuprofen instead of Aspirin for fever management (Carson, 2003). Another rationale for combining the two antipyretics was that the drugs have different mechanisms of action which might be more effective when used together instead of individually. Acetaminophen and Ibuprofen along with other non-steroidal anti-inflammatory medications exert their antipyretic effects by blocking the cyclo-oxygenase enzymes, thereby preventing the synthesis of prostaglandins from arachadonic acid. Because these medications do not suppress interleukin-2, these drugs do not diminish proliferation of T helper cells, thus, they do not adversely affect the body’s ability to fight infection (Browne et al., 2001). Unfortunately, alternation of the two medications was put into general practice without the sufficient research to support the safety of efficacy of this combined treatment regime. In fact, the research has shown that glutathione is needed to prevent the accumulation of Acetaminophen in the renal medulla; Ibuprofen inhibits glutathione production and also blocks the production of renal prostaglandins by reducing renal blood flow. As a result, significant tubular necrosis, and renal toxicity can occur, which can be even more pronounced when children are dehydrated (Carson, 2003). This is not to say that either Ibuprofen or Acetaminophen is not effective in treating fever. Many studies suggest that both are effective medications, but Ibuprofen has been shown to last longer and ultimately result in fewer doses of medication needed by children (Purssell, 2002). According to the NICE clinical guidelines, antipyretic agents should not be routinely used for the sole aim of reducing body temperature. On the other hand, antipyretic use should be considered in children with fever who appear distressed or unwell. The guideline also states that Acetaminophen or Ibuprofen can be used to reduce temperature in children with fever. However, the guideline clearly states that Acetaminophen and Ibuprofen should not be given at the same time or given alternately (N.I.C.E., 2007). (Does NICE say why?) The lack of information available about the safety of alternating Tylenol with Ibuprofen further highlights the need for more research before the alternation of both antipyretics is practiced in the clinical setting. (This literature review is very well done.)
Discharge Teaching for the Febrile Child

In a recent study, an evidence-based educational program resulted in more consistent patient education in addition to an increase of 67 percent of written nursing instructions and the percentage of parents leaving the emergency room with both written and verbal fever advice increased from 0 percent to 55 percent (Considine & Brennan, 2007).
Conclusion
Implementation of this educational intervention will help to dispel the current myths about fever control and highlight both existing and new attitudes nurses have surrounding fever. The data will help to augment the current research body and the data collected can be used to drive future of nursing research.

References
Brown, M. (2007, May 2007). Physiology of fever. Pediatric Nursing, 19, 40-44.
Browne, G. J., Currow, C., & Rainbow, J. (2001). Pediatric emergency medicine. Emergency Medicine, 13, 143-157.
Carson, S. (2003). Alternating acetaminophen and ibuprofen in the febrile child: examination of the evidence regarding efficacy and safety. Pediatric Nursing, 29, 379-382.
Considine, J., & Brennan, D. (2007). Effect of an evidence-based education programme on ED discharge advice for febrile children. Journal of Clinical Nursing, 16, 1687-1694.
Edwards, H., Walsh, A., Courtney, M., Monaghan, S., Wilson, J., & Young, J. (2007). Improving paediatric nurses’ knowledge and attitudes in childhood fever management. Journal of Advanced Nursing, 57, 257-269.
Hay, A. D., Costelloe, C., Redmond, N. M., Montgomery, A. A., Fletcher, M., Hollinghurst, S., & Peters, T. J. (2008, September). Paracetamol plus ibuprofen for the treatment of fever in children (pitch): a randomized controlled trial. British Medical Journal, 337, 729-733. Doi: 10.1136/bmj.a1302
Holzhauser, J. K., Reith, V., Sawin, K. J., & Yen, K. (2009, July 9, 2009). Evaluation of temporal artery thermometer in children 3-36 months old. Journal for Special in Pediatric Nursing, 14, 239-244. Doi: 10.1111/j.1744-1655.2009.00204.x
Johanna Briggs Institute. (2001) Management of the child with fever. Best Practice, 5(5), 1-6.
National Institute of Health and Clinical Excellence. (2007). Feverish illness in children: assessment and initial management in children younger than 5 years
Poirier, M., Davis, P., Gonzalez-del Rey, J., & Monroe, K. (2000). Pediatric emergency department nurses’ perspectives of fever in children. Pediatric Emergency Care, 16, 9-12.
Purssell, E. (2002). Treating fever in children: paracetamol or ibuprofen? British Journal of Community Nursing, 7, 316-320.
Russell, F. M., Shann, F., Curtis, N., & Mulholland, K. (2003). Evidence on the use of paracetamol in febrile children. Bulletin of the World Health Organization, 81, 367-372.
Thompson, M. (2005). Fever: a concept analysis. Journal of Advanced Nursing, 51, 484-492.
Walsh, A. M., Edwards, H. E., Courtney, M. D., Wilson, J. E., & Monaghan, S. J. (2005). Fever management: paediatric nurses’ knowledge, attitudes, and influencing factors. Journal of Advanced Nursing, 49, 453-464.
Walsh, A., & Edwards, H. (2006). Management of childhood fever by parents. Journal of Advanced Nursing, 54, 217-227.
Warwick, C. (2008). Paracetamol and fever management. The Journal of the Royal Society for the Promotion and Health, 128, 320-323.
Watts, R., Robertson, J., & Thomas, G. (2003). Nursing management of fever in children: a systematic review. International Journal of Nursing Practice, 9(9), 1-9
Xue, Y. (2009). Febrile response: management. Joanna Briggs Institute, 1-3.

Goals and Objectives Given the fact that the literature supports the supposition that nurses lack an understand of fever, the goals and objectives of this project will include information regarding the benefits of fever, the correct treatment of fevers, alternative cooling measures and appropriate times and doses of antipyretic medication. At the end of this project nurses will:
Goal: Demonstrate an understanding of the current treatment of fevers and the rationale for each.
Objectives: At the end of this educational presentation the RN will be able to: Articulate the definition of a fever. Demonstrate the correct technique and route for fever measurement based on the client’s age. State the correct timing and dosages of the antipyretics Ibuprofen and Tylenol. Identify signs and symptoms that require the administration of antipyretic medication. Name the alternative cooling measures and correctly state when each would be appropriate.
Goal: Demonstrate and understanding of the physiology of fevers and the implications for health.
Objectives: At the end of this session the RN will be able to: Name common causes of fever. State the correct diagnostic tests needed to find the source of a fever. The student will be able to discuss the benefits of fever. The student will be able to discuss the long term effects of febrile seizures. Demonstrate an understanding of the benefits of fever. Describe the long term affects of febrile seizures.

After the completion of the educational intervention, all participants will be given handouts of the material learned during the class. These handouts will highlight the best practices of pediatric fever management and include the current policy and procedures of fever management in the emergency room. New graduate nurses and staff nurses that come to work in the emergency room will be given a learning module that covers all the material covered in the initial teaching intervention as part of their orientation learning kit. In addition, this module, along with the current policies will be posted in the break room so that the information is readily accessible for review. Because best practices are constantly changing, ED nurses will be required to review this material annually and sign off on their yearly competency checklist.

Clientele This educational intervention will be focused on emergency room nurses that are employed by Northbay Healthcare Systems. Approval for this project has been granted by Emergency Department Manager Ricardo Segovia RN, MSN. After multiple peer discussion, the nurses have shown a shown significant interest in participating in this educational intervention.
Ethical Considerations There are no ethical issues regarding this project. All participants will be given an equal opportunity to participate. All surveys will be confidential and all data will be stored in a password secured computer.

Methods
The primary methods for achieving the project’s goals and objectives will be: 1. Create and educational intervention for emergency room nurses at Northbay Healthcare. The teaching plan will cover the following topics: physiology of fever, clinical management of febrile patients, antipyretic use, fever phobias, febrile convulsions, and discharge fever education. 2. All ER nursing staff will attend a one-hour educational PowerPoint lesson on Pediatric Fever Management presented by Alonya Elgrably RN, BSN. There will be two sessions held, one on the Northbay campus, and one at the Vacavalley campus. 3. This project will be managed by an implementation team that consists of the Project leader and MSN student Alonya Elgrably RN, Dr. Barbara Ganley, faculty advisor, Dr. Jerry Kim M.D. emergency room physician and physician champion, Ricardo Segovia RN emergency department manager, and Heather Venezio RN Clinical Nurse IV, clinical preceptor and nursing leadership. 4. Timeline
|Year 1: Ongoing creation and implementation of programs: |
|Plan, develop, and organize educational program for pediatric fever management. |
|Organize implementation team. |
|Get support from hospital administration for the project. |
|Design project proposal. |
|Receive approval from Faculty Proposal Committee. |
|Continue ongoing data collection, curriculum, and assessment evaluation. |
| |
|Year 2: Ongoing program implementation: |
|Schedule times and locations for classes at both campuses. |
|Continue refinement of instructional materials and assessments. |
|Disseminate class information to nursing staff at both locations. |
|Carry out full project implementation. |
|Possible redevelopment/corrections/adjustments in program implementation based on student outcomes and program evaluations. |
|Final program evaluation. |
|Project Dissemination and Future Plans for further research. |
|Data collection will begin in triage, when a patient is being seen for fever one of their patient identification stickers will be |
|attached to a form. |
|Provide a discharge questionnaire for patient’s parents to complete before being discharged from the ED. |
|A chart review will be conducted on each patient in order to reconcile nursing data with the patient data. |
|Organize patient information forms in a 12 month accordion folder and store information in a locked cabinet. |

Project Team The project implementation team consists of project leader, Alonya Elgrably RN; who has been an emergency room nurse for two years and is a member of the Emergency Nurses Association. Heather Venezio RN, MS who has been a trauma/emergency nurse for the last 8 years, she is also a certified emergency room nurse and an Advanced Trauma Nursing Instructor and Dr Jerry Kim M.D. who is the Director of Cardiovascular Services and ER physician for Northbay Healthcare Systems. Dr. Kim will be serving as the physician champion for this project. All team members have agreed to part of this project on a voluntary basis, no one will receive monetary reimbursement for their participation.
Resources
Facilities: Northbay Healthcare Systems consists of 3 campuses, there are ample conference rooms available free of charge. These rooms are all equipped with tables, chairs, and audio/visual equipment.
Equipment: A photocopy machine will be needed in order to print and collate learning materials and handouts, a computer and printer with internet access will be needed for general project support, and e-mail communication will be needed to communicate with other project team members, and to disseminate information regarding the project to participants.
Office Supplies: Copy paper, a large box of pencils, paper clips, post-it notes, printer ink cartridges, a stapler and staples, a binder/organizer will all be needed to carry out office tasks related to the project.

Budget A. Direct Costs 1. Salaries: The teaching interventions will be held during the second hour of the mandatory staff meetings. This requires nursing staff to be paid their hourly rate minus differentials for the meeting time. The average hourly rate of staff nurses at Northbay is $55.00 hourly. The average staff turnout to meetings is approximately 20 per campus. Thus the salary costs will equal $2200.00. All members of the implementation team have volunteered their services and will not receive reimbursement for any time or travel that is required. 2. Employee Travel: Due to the fact that the presentation will occur during ER staff meetings, the staff has the option of attending at the Northbay campus in Fairfield or at the Vacavalley campus in Vacaville at 2 different campuses on 2 different days and times. Because these meetings are mandatory, Northbay Healthcare Systems offers mileage reimbursement at the rate of $0.40 per mile traveled. Travel is a possibility but is not anticipated at this time because historically, no employees have traveled to separate campuses for meetings. 3. Equipment: All audio/visual equipment, tables, chairs and podiums will be provided free of charge by Northbay Healthcare. The project leader will use her personal laptop computer and printer for general project support. All Northbay employees have free access to free e-mail service.

4. Materials and Resources: Complete Instruction Manual 1@ 43.00= 43.00 Printer Cartridge Ink 1@76.00= 76.00 Box of Pencils 2@8.00 = 16.00 Box of Copy Paper 1@24.00=24.00 Stapler 1@6.00=6.00 Staples 1@2.00=2.00 Post-its 2@5.00=10.00 PowerPoint Template 1@24.00=24.00 Binder/organizer 1@20.00=20.00 ______________________________________________ Materials: 221.00 + Salaries: 2200.00 = $2421.00

Evaluation Plan
Formative Evaluation Tools: Participants will be asked to complete a pre-test and bring it with them on the day of the class. After the educational intervention the participants will be given the post- test and course instructor evaluation form. The data that will be evaluated include: increased knowledge, change in beliefs or attitudes about fever, if learning objectives were met, the overall course material and various aspects of the instructors presentation. Project leader Alonya Elgrably RN will be responsible for making evaluation decisions regarding collection, interpretation, dissemination, designs and subsequent revisions to the evaluation plan. The pre and post tests were designed by Queensland University of Technology, permission has been granted by Dr. Anne Walsh to use these tools for the project evaluation. (See attachment A)
Summative Evaluation Tools: At the completion of this program, confidential data will be collected on the quality of nursing discharge patient education. This data collection will be achieved by the use of a simple questionnaire given to patient’s parents or caregivers. This tool will gather data related to the time spent on patient education, the type of education provided, written, verbal, or both, and whether the caregivers felt that all questions were addressed during their ER visit. In addition, a patient visit sticker will be collected and attached to the questionnaire so that future data could be collected regarding subsequent return visits to the emergency department for fever management. All data collected will be analyzed using the SPSS program. (See attachment B)
Summary
In closing, I would like to you for your time and interest in this proposal. As stated earlier, this project has the ability to reshape nurses’ attitudes towards fever management and result in parents receiving both accurate and consistent information about the treatment of fever.

References
Broom, M. (2007). Physiology of fever. Pediatric Nursing, 40-44.
Browne, G. J., Currow, C., & Rainbow, J. (2001). Pediatric emergency medicine. Emergency Medicine, 13,
Carson, S. (2003). Alternating acetaminophen and ibuprofen in the febrile child: examination of the evidence regarding efficacy and safety. Pediatric Nursing, 29, 379-382.
Considine, J., & Brennan, D. (2007). Effect of an evidence-based education programme on ED discharge advice for febrile children. Journal of Clinical Nursing, 16, 1687-1694.
Holzhauser, J. K., Reith, V., Sawin, K. J., & Yen, K. (2009, July 9, 2009). Evaluation of temporal artery thermometer in children 3-36 months old. Journal for Special in Pediatric Nursing, 14, 239-244. Doi: 10.1111/j.1744-1655.2009.00204.x
Management of the child with fever. (2001). Best Practice, 5(5), 1-6.
National Institute of Health and Clinical Excellence. (2007). Feverish illness in children: assessment and initial management in children younger than 5 years
Purssell, E. (2002). Treating fever in children: paracetamol or ibuprofen? British Journal of Community Nursing, 7, 316-320.
Russell, F. M., Shann, F., Curtis, N., & Mulholland, K. (2003). Evidence on the use of paracetamol in febrile children. Bulletin of the World Health Organization, 81, 367-372.
Thompson, M. (2005). Fever: a concept analysis. Journal of Advanced Nursing, 51, 484-492.
Walsh, A. M., Edwards, H. E., Courtney, M. D., Wilson, J. E., & Monaghan, S. J. (2005). Fever management: paediatric nurses’ knowledge, attitudes, and influencing factors. Journal of Advanced Nursing, 49, 453-464.
Walsh, A., & Edwards, H. (2006). Management of childhood fever by parents. Journal of Advanced Nursing, 54, 217-227.
Warwick, C. (2008). Paracetamol and fever management. The Journal of the Royal Society for the Promotion and Health, 128, 320-323.
Watts, R., Robertson, J., & Thomas, G. (2003). Nursing management of fever in children: a systematic review. International Journal of Nursing Practice, 9(9), 1-9.

Appendix A
FEVER MANAGEMENT MAIN QUESTIONNAIRE ORIGIN OF ITEMS
1
SECTION 2 – THE NURSING MANAGEMENT OF A FEBRILE CHILD
The item in bold font is the correct answer and the reference the answer came from is at the base of the box.
1. The body’s thermoregulating centre is located in the:
1. Cerebrum
2. Hypothalamus
3. Medulla
4. Pons
5. Unsure
(Thomas, 1995)
2. Young children are at risk of serious infections because they:
1. Lack exposure to a variety of pathogens
2. Are immunologically immature
3. Lack needed passive immunity from the mother
4. Have ineffective thermoregulating mechanisms
5. Unsure
(Thomas, 1995)
3. Most elevated temperatures in young children are the result of:
1. Viral infections
2. Overdressing
3. Bacterial infections
4. Vascular disease
5. Unsure
(Thomas, 1995)
4. Beneficial consequences of fever include:
1. Increased heart rate
2. Decreased body metabolic needs
3. Increased antibody production
4. Fat catabolism
5. Unsure
(Bruce & Grove, 1992)
5. For every 1° C rise in temperature there is an associated increase in respiratory rate of:
1. 1 – 4 breaths per minute
2. 4 – 8 breaths per minute
3. Insignificant increase in breaths per minute
4. Insignificant decrease in breaths per minute
5. Unsure
(Gildea, 1992)
6. Which is NOT a beneficial effect of fever?
1. An increase in serum iron production
2. Stimulation of T-lymphocyte production
3. Acceleration of white blood cell production
4. Promotion of antibiotic activity
5. Unsure
(Thomas, 1995)
7. Which is NOT a result of fever in infants and children?
1. Increased oxygen demand
2. Increased fluid requirements
3. Increased appetite
4. Increased metabolic rate
5. Unsure
(Thomas, 1995)
8. The most common side effects of fever are:
1. Chills
2. Mild dehydration
3. Discomfort or irritability
4. All of the above
5. Unsure
(Reeves-Swift, 1990)
9. The principal danger of fever (excluding the underlying cause) is:
1. None
2. Brain damage
3. Febrile convulsions
4. Dehydration
5. Learning disabilities
6. Unsure
(Holtzcalw, 1992)
10. Sponging febrile children with tepid water may be implemented:
1. When an antibiotic is given
2. 30 minutes after the administration of an antipyretic 3. When the temperature is below 40 °C
4. When irritability and crying are present
5. Unsure
(Betz, Hunsberger, & Wright, 1994) in (Thomas, 1995)
FEVER MANAGEMENT MAIN QUESTIONNAIRE ORIGIN OF ITEMS
2
11. Which is NOT a sign of dehydration in infants?
1. Depressed fontanelle
2. Scanty urination
3. Tearful crying
4. Dry mucous membranes
5. Unsure
(Thomas, 1995)
12. All children with high fever require:
1. Antibiotics
2. Antipyretics
3. Hospitalisation
4. Thorough physical assessment
5. Unsure
(Thomas, 1995)
13. Which problem is associated with measuring the temperature rectally?
1. Bradycardia
2. Inaccurate measurement
3. Diarrhoea
4. Seizure disorders
5. Unsure
(Thomas, 1995)
14. Antipyretics reduce fever by:
1. Inhibiting prostaglandin activity
2. Reducing shivering
3. Eliminating viral activity
4. Decreasing bacterial response
5. Unsure
(Thomas, 1995)
15. The usual dose of Panadol given to children is:
1. 5 mg/kg/dose
2. 10 mg/kg/dose
3. 15 mg/kg/dose
4. 20 mg/kg/dose
5. Unsure
(Thomas, 1995)
16. The peak absorption time for Panadol is:
1. 10 – 60 minutes
2. 30 – 60 minutes
3. 60 – 90 minutes
4. 60 – 180 minutes
5. Unsure
(MIMS 1996-1999)
17. Febrile convulsions are most commonly associated with:
1. Gastroenteritis
2. Roseola infantum
3. Otitis media
4. Upper respiratory infections
5. Unsure
(Thomas, 1995)
18. Which of the following is TRUE regarding fever management in children over 3 months of age:
1. All children with increased temperatures require antipyretic therapy
2. Fever of 38 °C necessitates antibiotic therapy
3. Panadol is the preferred antipyretic for children
4. Fever in young children should be allowed to run its course
5. Unsure
(Thomas, 1995) Royal Children's Hospital practice from chart audit
19. Which of the following is TRUE regarding convulsion/seizure activity associated with fever?
1. Convulsions commonly occur in children with a low grade fever
2. Convulsions occur in more than 25% of children
3. Convulsions that occur during fevers are strongly associated with epilepsy
4. Convulsions are rare in children under 5 years
5. Unsure
(Thomas, 1995)
FEVER MANAGEMENT MAIN QUESTIONNAIRE ORIGIN OF ITEMS
3
For the following questions in this section please circle all the appropriate responses
20. Children at a high risk of serious illness associated with fever are:
(Please circle all appropriate responses)
1. Those who appear toxic, ie., those who are lethargic, poorly perfused, marked hypoventilation, hyperventilation or cyanosis
2. Those younger than 28 days with a temperature greater than 38 °C
3. Children under 4 years with a temperature greater than 41 °C
4. Unsure
(Thomas, 1995)
21. Effective non-pharmacological measures to reduce fever include:
(Please circle all appropriate responses)
1. Hydration
2. Dressing the child in light clothes
3. Tepid sponging
4. Unsure
(Adam & Stankov, 1994; Prebble, 1996)
22. Side effects of Panadol are:
(Please circle all appropriate responses)
1. Liver toxicity
2. Renal toxicity
3. Gastrointestinal irritability
4. Unsure
(Adam & Stankov, 1994), [Robertson, 2002 #920]
23. Decisions on how to treat a child’s fever should be made on the basis of:
(Please circle all appropriate responses)
1. Temperature readings
2. Physical examinations
3. Child’s health history
4. Unsure
[Thomas, 1995)
24. An increased temperature in children can also be the result of:
(Please circle all appropriate responses)
1. Overdressing
2. A warm bath
3. Exercise
4. Unsure
(Schmitt, 1993)
25. Febrile children have increased:
(Please circle all appropriate responses)
1. Oxygen consumption
2. Cardiac output
3. Caloric requirements
4. Unsure
(Thomas, 1995)
FEVER MANAGEMENT MAIN QUESTIONNAIRE ORIGIN OF ITEMS
4
SECTION 3: GENERAL OPINIONS ABOUT FEVER MANAGEMENT IN CHILDREN
Legend T = true; F = false; B/A = belief/attitude
Reference/s the question was developed from
T/F
1. Fever is the most common reason for taking a young child to the doctor
Thomas, 1995 T
2. Temperature, in children, is often unrelated to the severity of the illness
McCarthy, Lembo, Baron, Fink, &
Cicchetti, 1985
Bruhn, Lelyveld, & Ludwig, 1991
T
3. Moderate fever has beneficial effects for children
Bruce & Grove, 1992
Lorin, 1990
T
4. Children’s baseline temperature increases, as they grow older
This is related to children under 3 months of age
Herzog & Coyne, 1993 T
5. Fevers below 41° C may not be harmful to children
Shann, 1993
Lorin, 1990
T
6. High fever (>41° C) impairs the immune response
Lorin, 1990 T
7. The increased metabolic demands of fever may compromise children with cardiac or respiratory failure
Kluger, 1986 T
8. Fever causes an increased metabolic rate
Henker, 1999
Gildea, 1992
T
9. Many parents have a phobia about fevers van Stuijvenberg et al., 1999
Ipp & Jaffe, 1993
T
10. Many nurses have a phobia about fevers
B/A
11. Temperature alone is an indication for the administration of antipyretics
Ipp & Jaffe, 1993 F
12. Doctors generally recommend the use of antipyretics to reduce the temperature in a febrile child
Klein & Cunha, 1996 B/A
13 It is important to treat fever aggressively with antipyretics to prevent febrile convulsions.
(Schnaiderman, 1993) (Lorin, 1990;
Shann, 1991); (Rosenthal &
Silverstein, 1988); (Styrt, Mummaw, &
Stein, 1994)
F
14. I would waken a sleeping febrile child to administer an antipyretic
(Ipp & Jaffe, 1993)
(Reeves-Swift, 1990)
F
15. It is better to assess the severity of a child’s illness through clinical findings rather than temperature
(McCarthy et al., 1985)
T
16. Tympanic thermometers provide accurate measures of core temperature
Holtzcalw, 1992 T
17. External cooling is the management of choice for febrile children with liver damage
MIMS 1996-1999 T
18. Younger children, under 3 years of age, generally require less Panadol per kg than children older than 3 years of age
MIMS 1996-1999 F
19. It is generally better to administer Panadol to children with fever
Shann, 1993
Bruce & Grove, 1992
F
20. Children with a history of febrile convulsions should be given Panadol to reduce their fever
Kluger 1986 F
FEVER MANAGEMENT MAIN QUESTIONNAIRE ORIGIN OF ITEMS
5
21. Panadol should only be administered if the child’s temperature is greater than 38.3° C
Nurses are conditioned to this
Thomas, 1995
T
22. It is really better to use non-pharmacological measures to reduce a child’s temperature
(Prebble, 1996) T
23. To reduce shivering in a febrile child nurses should wrap the child’s extremities (Holtzclaw, 1993) T
24. Regular administration of Panadol may mask a fever indicative of a progressive infective process
Shann, 1993
Reeves-Swift, 1990
DeBuse, 1994
Klein & Cunha, 1996
T
25. The treatment of fever with antipyretics can cause an ‘overshoot’ of a child’s temperature to a subnormal range
Cunha & Bigamon-Beltran, 1984
Holtzcalw, 1992
T
26. Febrile convulsions generally occur within the first 24 hours of an febrile associated illness
Sagraves, 1999 T
27. Nearly one-third of the children who have a febrile convulsion will have another febrile convulsion within 6 to 12 months
Camfield & Camfield, 1997
Hirtz, 1997
Stenklyft & Carmona, 1994
Berg et al., 1992
T
28. Children who have a febrile convulsion have a greater likelihood of developing epilepsy at a later date
Poth & Belfer, 1998
Stenklyft & Carmona, 1994
Hirtz, 1997
Berg et al., 1995
T
29.
30.
31.
Risk factors for febrile convulsions include:
♦ a previous history of febrile convulsion
♦ a family history of febrile convulsions
♦ developmental delay or frank neurological abnormalities
Berg et al., 1997
Berg et al., 1997
Bethune, Gordon, Dooley, Camfield, &
Camfield, 1993
T
T
T
32. Neurological damage is common in a child who has had a febrile convulsion Berg et al., 1997 F
33. The first febrile convulsion is preventable
Reeves-Swift, 1990 F
34. Altered brain metabolism as a result of infection can lower the seizure threshold in children
Gildea, 1992 T
35. Antipyretics reduce fever by approximately 2° C
Schmitt, 1993 T
36. Fever reduction from Panadol generally lasts between 3 – 4 hours
Kelly, Morin, & Young, 1996 T
37. Antipyretic therapy should be administered to children older than 3 months for fevers greater than 38.3°C
Thomas, 1995
38. Panadol can be given to a febrile child every 4 hours during a 24 hour period MIMS 1996-1999 F
39. Maximum dose of Panadol for children under 40kgs shouldn’t exceed
90mg/kg/day
Shann, 1993
Reeves-Swift, 1990
T
40. The administration of Panadol is nurse initiated in paediatric settings
B/A
FEVER MANAGEMENT MAIN QUESTIONNAIRE ORIGIN OF ITEMS
6
41. Maximum dose of Panadol for children over 40kgs shouldn’t exceed 4 grams Shann, 1993 T
42. Antipyretic treatments have minimal effect in the prevention of recurring febrile convulsions
Schnaiderman, 1993
Van Esch et al., 1995
Sagraves, 1999
T
43. The antipyretic effect of Panadol is longer than that of Ibuprofen.
Cassidy & Dolgin, 1993 F
44. Tepid sponging causes a decrease in the child’s temperature by causing shivering Miller, 1993 F
45. External cooling methods, eg., sponging, fans, may increase the child’s temperature through shivering
Kelly et al., 1996 T
46. Fever may not be tolerated in children who have cardiac and/or respiratory disorders
(Shann, 1993; Thomas, 1995) T
FEVER MANAGEMENT MAIN QUESTIONNAIRE ORIGIN OF ITEMS
7
SECTION 4: PANADOL ADMINISTRATION TO FEBRILE CHILDREN
Legend: L = likely; U = unlikely
When you administer Panadol to a febrile child, how likely is it that the following consequences will occur?
This section is about how decisions are made
1. Increased comfort L
Antipyretics reduce the discomfort/pain associated with the illness rather than increase comfort per se
Styrt & Sugerman, 1990
DeBuse, 1994
Kramer, Naimark, Roberts-Brauer, McDougall, & Leduc, 1991
Shann, 1995
2. Increased activity U Reeves-Swift, 1990
Kramer et al., 1991
3. Increased appetite L Kramer et al., 1991
4. Reduced irritability U Kramer et al., 1991
5. Reduced temperature L Styrt & Sugerman, 1990
Thomas, 1995
6. Reduced risk of febrile convulsion U Schnaiderman, 1993
Shann, 1991
7. Reduced parental anxiety L Schmitt, 1980
8. Reduced temperature set-point L Thomas, 1995
9. How likely are you to administer Panadol when next caring for a febrile child?
How likely is it that the following people would expect you to administer Panadol to a febrile child?
Extremely
likely
Neutral Extremely unlikely 10. The child’s parent/guardian
11. Your nursing colleagues
12. The medical staff
How desirable do you feel each of the following consequences would be for a febrile child who received Panadol?
Extremely
desirable
Neutral Extremely undesirable 13. Increased comfort
14. Increased activity
15. Increased appetite
16. Reduced irritability
17. Reduced temperature
18. Reduced risk of febrile convulsion
19. Reduced parental anxiety
20. Reduced temperature set-point
In general, how likely are you to go along with the wishes of the following people in the administration of Panadol to febrile children?
FEVER MANAGEMENT MAIN QUESTIONNAIRE ORIGIN OF ITEMS
8
Extremely likely Neutral Extremely unlikely 21. The child’s parent/guardian
22. Your nursing colleagues
23. The medical staff
How much effect does each of the following factors have on your administration of Panadol to a febrile child?
A great deal Neutral None at all
24. Ward policy and expectations regarding the administration of Panadol to febrile children
25. The height of the child’s fever
26. The child’s reason for admission
27. History of previous febrile convulsions
28. The child’s characteristics (eg., age)
Please rate how much you agree with the following statements:
Strongly
agree
Neutral Strongly disagree 29. I intend to administer Panadol when next caring for a febrile child
30. Administering Panadol to a febrile children is within my control How often do you consider each of the following factors prior to the administration of Panadol to a febrile child?
Very
often
Neutral Not very often
31. Ward policy and expectations regarding the administration of Panadol to febrile children
32. The height of the child’s fever
33. The child’s reason for admission
34. History of previous febrile convulsions
35. The child’s characteristics (eg., age)
Extremely
easy
Neutral Extremely difficult 36. How easy is it for you to administer Panadol to a febrile child?
A great deal of control Neutral No control at all
37. How much control do you have in administering
Panadol to a febrile child?

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