Elsevier Logo

Careplan

Fever (Adult ED)

Dec.08.2020

Fever (Adult ED)

Clinical Description

  • Care of the Emergency Department patient seeking treatment for an elevated body temperature.

Key Information

  • Fever is a beneficial physiologic mechanism for fighting an infection; however, the degree of fever does not always correlate to the severity of the presenting illness.
  • Oncology patients and those with febrile neutropenia require prompt evaluation and initiation of antimicrobial therapy. Avoid rectal temperatures in neutropenic patients undergoing cancer therapy.
  • Presence of fever (greater than 38.3 degrees Celsius orally or 2 consecutive measurements greater than or equal to 38.0 degrees Celsius, each lasting over 1 hour) combined with an absolute neutrophil count of less than 500 neutrophils per microliter is a medical emergency. If not treated promptly, rapid deterioration, sepsis and death may result.
  • Sustained fevers over 41 degrees Celsius are typically related to neurologic dysfunction, rather than infection, and can lead to neurologic damage. Prompt cooling techniques and antipyretic agents are recommended.
  • A CRP (C-reactive protein) and procalcitonin measurement may provide a better indicator of serious infection than WBC (white blood cell) counts.

Threats to Life, Limb or Function

  • advanced age
  • bacteremia
  • chronic illness
  • febrile neutropenia
  • meningitis
  • petechiae or purpura
  • sepsis
  • sustained fever
  • toxic appearance; rapid deterioration

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Goal: Acute Signs/Symptoms are Managed

  • Goal: Acceptable Pain Level Achieved

    Correlate Health Status

    • Correlate health status to:

      • history, comorbidity
      • age, developmental level
      • sex, gender identity
      • baseline assessment data
      • physiologic status
      • response to medication and interventions
      • psychosocial status, social determinants of health
      • barriers to accessing care and services
      • health literacy
      • cultural and spiritual preferences
      • safety risks
      • family interaction
      • plan for transition of care

    Fever

    Associated Documentation

    • Fever Management

    Presentation

    • chills, rigors
    • confusion, delirium
    • elevation in body temperature
    • skin flushed
    • lethargic
    • mental status altered
    • seizures

    Associated Signs/Symptoms

    • anorexia
    • arthralgia, myalgia
    • breath sounds altered
    • extremities cool
    • cough
    • cyanosis
    • diaphoresis
    • diarrhea
    • headache
    • malaise
    • nuchal rigidity
    • peripheral perfusion altered
    • petechiae
    • rash
    • seizures
    • signs of dehydration
    • tachycardia
    • vomiting
    • work of breathing increased

    Potential Causes

    • central nervous system alteration (poststroke, intracranial hemorrhage)
    • dehydration
    • environmental exposure; overdressed
    • immune system disorder
    • infection or infectious disease
    • inflammatory or noninfectious disease (pulmonary embolism, malignancy)
    • medication reaction, drug ingestion
    • metabolic disorder (hyperthyroid, thyroid storm, adrenal insufficiency)
    • preexisting medical condition (autoimmune, rheumatologic disorder, sickle cell)
    • vascular inflammation

    Initial Assessment

    • breath sounds
    • fluid status
    • focal site of potential infection (throat, abdomen, bladder, soft tissue)
    • general appearance
    • hemodynamic status
    • neurologic status
    • oxygen saturation
    • respiratory rate, pattern, effort
    • skin characteristics

    History

    • allergies
    • comorbidities
    • immunization status
    • last menstrual period (females of child bearing age)
    • medications
    • fever onset and pattern
    • mental and behavioral changes
    • pain presence and location
    • recent illness or exposure
    • recent procedure or surgery
    • recent travel
    • treatment prior to presentation

    Laboratory Studies

    • CBC (complete blood count) with differential
    • CRP (C-reactive protein)
    • cultures (urine, wound, sputum, joint fluid)
    • ESR (erythrocyte sedimentation rate)
    • procalcitonin level
    • urinalysis

    Diagnostics

    • chest x-ray

    Potential Additional Testing

    • abdominal ultrasound
    • antigen panel
    • ABG (arterial blood gas)
    • bilirubin
    • bone scan
    • chemistry panel
    • CSF (cerebrospinal fluid) evaluation
    • CT (computed tomography) scan abnormal
    • culture, blood
    • fluorodeoxyglucose-positron emission tomography
    • hepatic transaminase enzymes
    • nuclear imaging
    • pregnancy test (females of childbearing age)
    • viral swab

    Problem Intervention

    Provide Respiratory Support

    • Assess and monitor airway, breathing and circulation; maintain close surveillance for deterioration.
    • Maintain open and patent airway with use of positioning, airway adjuncts and secretion clearance.
    • Position to minimize the risk of aspiration, ventilation-perfusion mismatch and breathlessness.
    • Minimize oxygen consumption and demand.
    • Provide oxygen therapy judiciously; titrate to prevent hyperoxemia.
    • Implement noninvasive or invasive positive pressure ventilation to support oxygenation and ventilation, as well as relieve respiratory distress.

    Problem Intervention

    Monitor and Manage Fluid and Electrolyte Balance

    • Assess fluid status; provide oral or intravenous fluid therapy.
    • Monitor intake, output and laboratory value trends.
    • Evaluate patient response; advocate for adjustment in treatment with imbalance.

    Problem Intervention

    Minimize and Manage Infection

    • Assess for presence of infection and signs of early sepsis.
    • Initiate precautions to prevent the spread of infection.
    • Obtain cultures prior to initiation of antimicrobial therapy, when possible.
    • Anticipate antimicrobial therapy administration; do not delay in the presence of high suspicion or clinical indicators.
    • Anticipate hospitalization for life-threatening illness, if source of fever is not determined or the patient is immunocompromised.

    Problem Intervention

    Promote Comfort and Manage Pain

    • Use a consistent pain assessment tool; evaluate pain and treatment response at regular intervals.
    • Involve patient and family in the management plan.
    • Provide nonpharmacologic strategies, such as adjusting room temperature, removing excess clothing and providing oral care.
    • Consider pharmacologic measures, such as an analgesic or antipyretic agent.
    • Anticipate aggressive treatment of fever in patients with limited cardiopulmonary or metabolic reserve.

    Problem Intervention

    Facilitate Procedures

    • Initiate and maintain NPO (nothing by mouth) status.
    • Prepare for, or assist with, procedure to determine source of fever, such as lumbar puncture, ear examination, pelvic examination, urinary catheterization or suprapubic tap.
    • Anticipate and prepare for surgical intervention.

    Education

    General Emergency Education

    Teaching Focus

    • symptom/problem overview

    • risk factors/triggers

    • self-management

    • assistive device

    • diagnostic test

    • diet modification

    • medical device/equipment use

    • medication administration

    • opioid medication management

    • orthopaedic device

    • safe medication disposal

    • smoking cessation

    • wound care

    Population-Specific Considerations

    Forensics and Legal

    • Utilize local, state/province, federal requirements and hospital policy and protocols to manage patient care involving forensics, protective services, workman’s compensation and mandatory reportable events and illness.

    Human Trafficking

    • Human trafficking victims most frequently seek healthcare services from Emergency Departments. Healthcare professionals, alert to signs of trafficking, can guide supportive care for victims.
    • Trafficked individuals may be male or female and engaged in sex work or other forced labor. High-risk signs requiring more direct questioning about exploitation include, among others, current employment in a high-risk industry, prior sexually transmitted infections, recent immigration, undocumented immigrant status and other vulnerable and minority populations.

    Geriatric

    • A serious bacterial infection should be presumed if older adults present with a fever or subnormal temperature, especially if they are also immunosuppressed.
    • The baseline temperature for an older adult is lower than in a younger adult.
    • In the presence of a severe infection, fevers may be mild or absent due to an impaired ability to initiate an elevation in body temperature.
    • A decline in functional, cognitive and physical status may signal an infection.
    • Fragile skin, weakened cough and gag reflexes, impaired urinary elimination and an impaired immune system predispose the older adult to infections.

    Pregnancy

    • Beyond 20 weeks gestation, supine position should be avoided. Maternal position should be lateral or lateral tilt to prevent compression of the inferior vena cava and aorta by the pregnant uterus.
    • Maternal stabilization and resuscitation are the primary priorities.
    • Assessment of fetal status, a secondary assessment, should include fetal heart rate, contraction activity and presence of maternal-fetal hemorrhage.
    • Maternal overheating during pregnancy can also result in fetal overheating. Congenital anomalies can result, particularly in the first trimester.
    • There is a higher risk for volume depletion due to heat stress during pregnancy.

    Quality Measures

    • NQF 0497. Admit Decision Time to ED Departure Time for Admitted Patients
      Median time from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient.
      Steward: Centers for Medicare and Medicaid Services
      Care Setting: ED, Hospital
      National Quality Forum-endorsed measure
      Last Edited: 10/11/2017
    • NQF 0496. Median Time from ED arrival to ED Departure for Discharged ED Patients
      Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department.
      Steward: Centers for Medicare and Medicaid Services
      Care Setting: ED, Hospital
      National Quality Forum-endorsed measure
      Last Edited: 10/11/2017
    • NQF 0495. Median Time from ED arrival to ED Departure for Admitted ED Patients
      Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the facility from the emergency department.
      Steward: Centers for Medicare and Medicaid Services
      Care Setting: ED, Hospital
      National Quality Forum-endorsed measure
      Last Edited: 10/11/2017

    References

    • American Heart Association. (2016). Advanced cardiovascular life support provider manual. USA: American Heart Association. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0495. Median Time from ED Arrival to ED Departure for Admitted ED Patients. Source[Quality Measures,Clinical Practice Guidelines]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0496. Median time from ED arrival to ED departure for discharged ED patients. Source[Quality Measures,Clinical Practice Guidelines]
    • Davidson, A. C.;Banham, S.; Elliott, M.; Kennedy, D.; Gelder, C.; Glossop, A.; Church, A. C.; Creagh-Brown, J. W. D.; Felton, T.; Foëx, B.; Mansfield, L.; McDonnell, L.; Parker, R.; Patterson, C. M.; Sovani, M.; Thomas, L.. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax. 2016;71(Suppl 2), ii1-ii35. [Quality Measures,Clinical Practice Guidelines]
    • Davis, M. D.; Walsh, B. K.; Sittig, S. E.;Restrepo, R. D.. AARC clinical practice guideline: Blood gas analysis and hemoximetry. Respiratory Care. 2013;58(10), 1694-1703. [Quality Measures,Clinical Practice Guidelines]
    • DeWitt, S.; Chavez, S. A.; Perkins, J.; Long, B.; Koyfman, A.. Evaluation of fever in the emergency department. American Journal of Emergency Medicine. 2017;35(11), 1755-1758. doi:10.1016/j.ajem.2017.08.030 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • DeWitt, S.; Chavez, S. A.; Perkins, J.; Long, B.; Koyfman, A.. Evaluation of fever in the emergency department. American Journal of Emergency Medicine. 2017;35(11), 1755-1758. doi:10.1016/j.ajem.2017.08.030 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2020). Sweet, V.; Foley, A (Eds.), Sheehy's Emergency Nursing Principles and Practice. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2020). Sweet, V.; Foley, A (Eds.), Sheehy's Emergency Nursing Principles and Practice. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Epstein, E.; McDougall, M.; Thomas, P.. Intravenous fluids in hospital: Practical approaches. British Journal of Hospital Medicine. 2017;78(4), C50-C54. doi:10.12968/hmed.2017.78.4.C50 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Fletcher, T. E.; Bleeker-Rovers, C. P.; Beeching, N. J.. Fever. Medicine. 2017;45(3), 177-183. Source[Quality Measures,Clinical Practice Guidelines]
    • Fletcher, T. E.; Bleeker-Rovers, C. P.; Beeching, N. J.. Fever. Medicine. 2017;45(3), 177-183. Source[Quality Measures,Clinical Practice Guidelines]
    • Fletcher, T. E.; Bleeker-Rovers, C. P.; Beeching, N. J.. Fever. Medicine. 2017;45(3), 177-183. Source[Quality Measures,Clinical Practice Guidelines]
    • Fletcher, T. E.; Bleeker-Rovers, C. P.; Beeching, N. J.. Fever. Medicine. 2017;45(3), 177-183. Source[Quality Measures,Clinical Practice Guidelines]
    • Greenbaum, J.. Identifying victims of human trafficking in the emergency department. Clinical Pediatric Emergency Medicine. 2016;17(4), 241-248. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Hammond, B. B.; Zimmermann, P. G. (2013). Sheehy's manual of emergency care. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Hammond, B. B.; Zimmermann, P. G. (2013). Sheehy's manual of emergency care. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Hooten, M.; Thorson, D.; Bianco, J.; Bonte, B.; Clavel Jr., A.; Hora, J.; Johnson, C.; Kirksson, E.; Noonan, M. P.; Reznikoff, C.; Schweim, K.; Wainio, J.; Walker, N.. (2016 [updated 2017, Aug]). Pain: Assessment, non-opioid treatment approaches and opioid management. (pp.160). Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). Source[Quality Measures,Clinical Practice Guidelines]
    • Liang, S. Y.. Sepsis and other infectious disease emergencies in the elderly. Emergency Medicine Clinics of North America. 2016;34(3), 501-522. doi:10.1016/j.emc.2016.04.005 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Liang, S. Y.; Theodoro, D. L.; Schuur, J. D.; Marschall, J.;. Infection prevention in the emergency department. Annals of Emergency Medicine. 2014;64(3), 299-313. doi:10.1016/j.annemergmed.2014.02.024 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Link, M. S.;Berkow, L. C.;Kudenchuk, P. J.;Halperin, H. R.;Hess, E. P.;Moitra, V. K.;Neumar, R. W.;O'Neil, B. J.;Paxton, J. H.;Silvers, S. M.;White, R. D.;Yannopoulos, D.;Donnino, M. W.. Part 7: Adult advanced cardiovascular life support. Circulation. 2015;132(18 suppl 2), S444-S464. doi:10.1161/CIR.0000000000000261 [Quality Measures,Clinical Practice Guidelines]
    • Long, B.; Koyfman, A.. Best clinical practice: Blood culture utility in the emergency department. Journal of Emergency Medicine. 2016;51(5), 529-539. doi:10.1016/j.jemermed.2016.07.003 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • National Institute for Health and Care Excellence. (2013 [Updated 2017]). Intravenous fluid therapy in adults in hospital . Source[Quality Measures,Clinical Practice Guidelines]
    • O'Driscoll, B. R.; Howard, L. S.; Earis, J.; Mak, V.; British Thoracic Society Emergency Oxygen Guideline Group. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017, Jun;72(Suppl 1), ii1-ii90. [Quality Measures,Clinical Practice Guidelines]
    • Registered Nurses' Association of Ontario. (2013). Assessment and management of pain. Source[Quality Measures,Clinical Practice Guidelines]
    • Rhodes, A.; Evans, L. E.; Alhazzani, W.; Levy, M. M.; Antonelli, M.; Ferrer, R.; Kumar, A.; Sevransky, J. E.; Sprung, C. L.; Nunnally, M. E.; Rochwerg, B.; Rubenfeld, G. D.; Angus, D. C.; Annane, D.; Beale, R. J.; Bellinghan, G. J.; Bernard, G. R.; Chiche, J. D.; Coopersmith, C.; De Backer, D. P.; French, C. J.; Fujishima, S.; Gerlach, H.; Hidalgo, J. L.; Hollenberg, S. M.; Jones, A. E.; Karnad, D. R.; Kleinpell, R. M.; Koh, Y.; Lisboa, T. C.; Machado, F. R.; Marini, J. J.; Marshall, J. C.; Mazuski, J. E.; McIntyre, L. A.; McLean, A. S.; Mehta, S.; Moreno, R. P.; Myburgh, J.; Navalesi, P.; Nishida, O.; Osborn, T. M.; Perner, A.; Plunkett, C. M.; Ranieri, M.; Schorr, C. A.; Seckel, M. A.; Seymour, C. W.; Shieh, L.; Shukri, K. A.; Simpson, S. Q.; Singer, M.; Thompson, B. T.; Townsend, S. R.; Van der Poll, T.; Vincent, J. L.; Wiersinga, W. J.; Zimmerman, J. L.; Dellinger, R. P. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Medicine. 2017;43(3), 304-377. doi:10.1007/s00134-017-4683-6 [Quality Measures,Clinical Practice Guidelines]
    • Sterling, S. A.; Miller, R.; Pryor, J.; Puskarich, M. A.; Jones, A. E. The impact of timing of antibiotics on outcomes in severe sepsis and septic shock:  A systematic review and meta-analysis. Critical Care Medicine. 2015;43(9), 1907-1915. [Metasynthesis,Meta-analysis,Systematic Review]
    • Troiano, N. H.; Witcher, P. M.; McMurtry Baird, S.. (2019). AWHONN: High-risk & critical care obstetrics. Philadelphia: Wolters Kluwer. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • U. S. Department of Health and Human Services. (2017). Human trafficking webinar for health care providers: SOAR to health and wellness. Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Wastfelt, M.; Cao, Y.; Strom, J. O.. Predictors of post-stroke fever and infections: A systematic review and meta-analysis. BMC Neurology. 2018;18(1) doi:10.1186/s12883-018-1046-z [Metasynthesis,Meta-analysis,Systematic Review]
    • White, L.; Ybarra, M.. Neutropenic fever. Hematology/Oncology Clinics of North America. 2017;31(6), 981-993. doi:10.1016/j.hoc.2017.08.004 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • White, L.; Ybarra, M.. Neutropenic fever. Hematology/Oncology Clinics of North America. 2017;31(6), 981-993. doi:10.1016/j.hoc.2017.08.004 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • White, L.; Ybarra, M.. Neutropenic fever. Hematology/Oncology Clinics of North America. 2017;31(6), 981-993. doi:10.1016/j.hoc.2017.08.004 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]

    Disclaimer

    Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

    ;