Introduction
The article “Non-infectious causes of fevers in adults” by Steele, Franco-Paredes, and Chastain (2018) outlines the non-infectious causes of fever in adults. Fever is usually a symptom of infectious diseases, but Steele et al. (2018) recommend considering non-infectious etiologies. Because fever is a presenting symptom for many etiologies, clinicians often prescribe broad-spectrum antibiotics for the nonspecific symptoms. However, Steele and associates indicate that this approach is ineffective because the presence of fever is not predictive of a positive culture result, and its absence is also not indicative of pathogen absence.
The second risk caused by fever as a presenting symptom for many etiologies is that it can lead to over-prescription, causing pathogen resistance to antibiotics. According to Steele et al. (2018), pathogens resistant to antibiotics resistant to antibiotics cause at least 2 million diseases and 23,000 deaths in 2011. Additionally, the authors indicate that the assumption that infectious diseases cause all fevers causes extensive workup, prolonging hospitalization periods. Therefore, the authors conducted the study to help practitioners identify non-infectious causes of fever. The findings of this study will provide clinicians with adequate clues for identifying fever caused by non-infectious reasons.
Pathophysiology
The average body temperature is usually 37.10C but it may fluctuate between 0.50C and 1° C. This variation is considered normal and caused by physiological processes such as metabolism, physical activity, and hormonal variability. Fever is characterized by a body temperature of ≥ 38.3° C, while temperatures above 41° C define hyperthermia (Balli & Sharan, 2020). Fever occurs when endogenous pyrogens respond to invasive pathogens that cause hypersensitivity reactions, malignancy, or autoimmune diseases. Endogenous pyrogens are natural substances that originate from inside the body to mediate febrile responses against exogenous pathogens.
At the cellular level, leukocytes, tissue macrophages, and large granular lymphocytes engulf pathogens that enter the bloodstream or tissues. Endothelial cells and myeloid release cytokines such as the interleukin-1, IL-6, interferon (IFN)-gamma, IFN-alpha, and tumor necrosis factor (TNF)-alpha in the process (Steele et al., 2018). These cytokines induce fever by acting on the thermosensitive neurons located in the hypothalamus. When the cytokines are released, they bind to their specific receptors in the epithelial, vascular system. The binding processes produce prostaglandin-E2, a mediator responsible for many febrile-related responses.
In the brain, the prostaglandin-E2 stimulates the hypothalamus to increase the body temperature. The released cytokines bind to their specific receptors in the epithelial, vascular system, releasing prostaglandin-E2, a mediator responsible for many febrile-related responses (Balli & Sharan, 2020). The cytokines act on the hypothalamic thermosensitive neurons, upgrading the setpoint temperature via the prostaglandins. This action on hypothalamic thermosensitive neurons causes vasoconstriction, which, in turn, pulls blood from the periphery to internal organs to preserve heat.
The body reacts to this process by increasing heat production and reducing heat loss until the elevated setpoint temperature is reached. The heat production is achieved through sympathetic stimulation, thyroxine discharge, and shivering. Unlike hyperthermia, fever maintains a controlled temperature elevation, allowing the general functioning of body organs (Balli & Sharan, 2020). This controlled temperature elevation makes fever a protective body process. Hyperthermia, on the other hand, causes the temperature to increase beyond the setpoint temperature. Simply put, hyperthermia will cause an uncontrolled body temperature increase, causing the temperature to exceed the body’s capacity to lose it. It is worth mentioning that not all fever effects benefit the host, especially during cytokine overproduction. Some fever effects can be harmful and lethal, e.g., they can cause septic shock and fulminate infections.
Patient-Centered Medical and Nursing Management
The primary goals of fever management are normothermia achievement and maintenance and relieving patients of the discomfort associated with fever (Terrie, 2018). Healthcare providers must also identify and address the underlying causes to achieve optimal health outcomes. “Accessible Point-of-Care Tests” (POCTs) such as biomarker assays and pathogen-specific tests can help healthcare providers detect systemic responses to febrile illnesses. On the other hand, a comprehensive physical and history examination can help practitioners identify specific clinical clues for non-infectious etiological causes of fever.
Diagnosis #1: Fever Caused by Non-infectious Factors
The patient presents to the clinic with complaints of altered body temperature triggered by non-infectious reasons as evidenced by the following signs and symptoms:
- Lack of chills, rigors, lactic acidosis, and hemodynamic instability;
- The patient’s fever remains above 38.30C most of the time;
- The patient frequently experiences pulse temperature dissociation;
Treatment Goals
- Reduce the discomfort associated with fever.
- Keep the patient’s body temperature below 38.30C
Intervention
Nonpharmacologic intervention: The patient should be kept at a comfortable room temperature, wearing lightweight clothing. The patient can drink water to manage the dehydration caused by sweating. The patient’s temperature can be kept below 38.30C by an automatic cooling endovascular automatic cooling device.
Rationale
Fever patients also experience discomfort, including chills, flushed face, headache, malaise, sweating, myalgia, etc. (Terrie, 2018). The automatic endovascular cooling device is efficient in maintaining normothermia and reduces nurse workload. Reducing the patient’s body temperature and keeping them comfortable will improve their wellbeing.
Follow-up Evaluation
Healthcare practitioners can monitor patients’ orientation, consciousness, and neurologic responses and reaction to external stimuli by rechecking vital signs. These health indicators will indicate the patient’s response to the intervention (Doyle & Schortgen, 2016). The patient should be advised to use thermometers to measure their temperature instead of feeling their forehead with hands. Using the same thermometer is strongly recommended because readings may vary depending on the thermometer type.
Diagnosis #2: Infectious Cause
The patient presents to the clinic with complaints of altered body temperature caused by an infectious disease as evidenced by:
- Frequent chills and rigors
- Continuous fever is infrequent
- Increased respiratory rate even in the absence of evidence for an infectious process
- Pulse temperature dissociation is infrequent
Treatment Goal
Reduce body temperature from 38.60C to 36.30C
Intervention
Initiate antipyretics such as acetaminophen and nonsteroidal anti-inflammatory drugs to reduce the fever.
Rationale
Empirical research supports the use of antipyretics to reduce fever and its physiologic effects (Doyle & Schortgen, 2016).
Evaluation
The patient’s temperature will reduce to desired threshold hour after intervention implementation. Healthcare providers should educate patients on the importance of adhering to the manufacturer’s recommendation, proper medication use, including administration and dosing and potential side effects.
Application to Nursing Practice
As a practicing professional, I will always encounter patients with fever as a cardinal sign. This article has taught me that infectious diseases and non-infectious factors such as drug use, trauma, inflammatory infections, and autoimmune diseases can cause fever. It has improved my knowledge of effective fever treatment and management. It allowed me to understand why I need to identify the fever etiology before prescribing any medication to my patients. According to Steele et al. (2018), this approach will prevent ineffective treatment approaches such as over-prescription and extensive workup, reducing the patient’s hospitalization period. The article provides an evidence-based rationale for why I will always conduct a detailed physical and history examination to obtain sufficient evidence for fever etiology. If I suspect an alternative diagnosis without clinical evidence for sepsis, I will avoid prescribing antibiotics until the actual diagnosis is made.
References
Balli, S., & Sharan, S. (2020). Physiology, fever. StatPearls Publishing. Web.
Doyle, J. F., & Schortgen, F. (2016). Should we treat pyrexia? And how do we do it?Critical Care, 20, 1–10. Web.
Steele, G. M., Franco-Paredes, C., & Chastain, D. B. (2018). Non-infectious causes of fever in adults.The Nurse Practitioner, 43(4), 38–44. Web.
Terrie, Y. C. (2018). Managing and treating fever: A guide to nonprescription antipyretics.Pharmacy Times, 84(2), 1–5. Web.