Fever stages

In the fever course 3 stages or periods are distinguished: stage of the temperature elevation or augmentation stage, stage of high temperature maintenance or eruptive stage, and stage of temperature reduction.

Stage of the temperature elevation or augmentation stage is characterized by rapid (within several hours), slow (within several days), or very slow (within week) temperature elevation that caused by decreased emission of heat as a result of peripheral vascular spasm. Rapid temperature elevation is associated with a chill, headache, aching whole-body pain; observed at pneumonia, erypsipelatous inflammation, scarlatina, malaria, reverse typhus, more slow beginning is characteristic for typhoid fever.

Stage of high temperature maintenance or eruptive stage – is stage of elevated temperature level maintenance from several hours to several weeks. In this period heat production and heat emission are simultaneously intense. Patients complain on feeling of heat, general weakness; at the considerable increase of temperature there can be a delirium, hallucinations, sometimes patients can be in the irresponsible state. Reducing of blood pressure level, acceleration of the pulse rate and respiration rate are proportional to the level of body temperature elevation.

Stage of temperature reduction can flow with rapid lowering of temperature within few hours – critical falling, crisis (pneumonia, malaria) or gradual reduction within several days – lytic reduction, lysis (typhoid fever, scarlet fever). Lytic lowering of temperature is gradual and therefore safely for patient. Critical lowering of temperature can have unfavorable consequences; the fall-off of temperature which is accompanied abundant sweating can result in development of acute vascular insufficiency – collapse. The condition of patient is sharply worsened: a pulse becomes frequent, of weak filling, breathing becomes frequent superficial, consciousness is entangled; a patient is pale, covered a death-damp. If not to render the first aid, a patient can die.

After fever, at recovery period, reducing of temperature to subnormal level with absence of daily variations (monothermia) are often observed.

Care of the patient with fever

Care of patient at stage of the temperature elevation

1. Have patient lie down in the bed.

2. Cover by blanket.

3. Give patient hot drink (milk with honey, tea with raspberry, etc).

Care of patient at stage of high temperature maintenance

1. Apply cold compress on forehead for facilitation of headache.

2. Feed patient 6-7 times per day (even at night) by high-calorie, vitaminized liquid or semi-liquid meal (clear soup, mashed potatoes, milk, sour cream, kefir, fruit, berries).

3. To give a patient frequent but by small portions drink (decoction of wild rose, milk with honey soda, vegetable, fruit and baccate juices, alkaline mineral water) for excretion of toxic products from an organism.

4. After the reception of meal to rinse a mouth by boiled water.

5. In time change underwear after perspiration; to conduct treatment of skin.

6. To conduct the prophylaxis of bedsores, pneumonia, to watch that a patient will not be in the same position, especially on the back; turn him on a side, to give him half-sitting posture.

7. Regularly ventilate an apartment, but without drafts, preliminary cover a patient.

During all period of fever a patient must keep to the bed regime.

Care of patient with fever and deranged consciousness, hallucinations

NOTE! Be very attentive to the patient in delirium and hallucinations, because such patient can injure itself and circumferential.

1. At the first signs of impaired consciousness inform doctor and strengthen attentive behavior in the care of such patients.

2. To create for a patient complete rest and on possibility individual post of the nurse, junior nurse, or relatives of the patient.

3. To isolate the patient if possible.

4. To fix a patient in a bed by special belt.

5. On doctor’s order a nurse enter a patient medicines (intramuscular 50% Analgin 2 ml, 1% Dimedrol 1-2 ml, 2.5% Aminazin 2 ml).

6. To use physical methods of temperature decline: cold compresses, ice bag on a head, cold water bags on carotid and brachial arteries (at temperature that exceed 38 ˚С). These cooling methods can be used only after medications which remove spasm of skin vessels and influence on centers of thermoregulation; otherwise cooling will intense thermoproduction and increase hyperthermia.

Care of the patients at stage of temperature reduction

Care of the patients at stage of temperature reduction includes the same measures as in patients at stage of temperature elevation. Special attention should be paid to the condition of cardiovascular system in critical body temperature reduction: in intense sweating possible dehydration of the organism and development of collapse.

The first aid in collapse

1. Decline head end of the functional bed. Take away a pillow from under the patient’s head.

2. Elevate feet end of the bed on 30-40 cm. Call the doctor.

3. Give strong sweet tea or coffee to the patient.

4. Attach hot-water bottle to feet

5. On doctor’s order a nurse enter subcutaneously 10% caffeine-benzoate sodium solution 1 ml and 10% sulfokamfocaine 2 ml.

6. At improvement of patient condition change underwear and bed-linen.

Hypothermia is a condition in which core temperature drops below that required for normal metabolism and body functions which is defined as 35.0 C (95.0 F). Symptoms usually appear when the body's core temperature drops by 1-2 C (1.8-3.6°F) below normal temperature. If exposed to cold and the internal mechanisms are unable to replenish the heat that is being lost a drop in core temperature occurs.

Human life is only compatible with a narrow range of temperatures:

Temperature (C)	Symptoms
28	muscle failure
30	loss of body temp. control
33	loss of consciousness
37	normal
42	central nervous system breakdown
44	death*

Critically low body temperature in which restoration of organism function is possible is called “biological zero”. For humans such “biological zero” is body temperature 24-26˚С. Temperature somewhat higher than “biological zero” – 31-35˚C, that accompanied by decreased mobility and sensitivity is called “temperature of cold narcosis”.

Disturbance of thermal balance can be caused: a) by the considerable decline of external environment temperature and strengthening of heat emission; b) by significant reduction of thermoproduction; c) by connection of these conditions. The most frequent mechanism of hypothermia development is strengthening of heat emission, two phases are expressed here: adaptation (compensation) and break-down of compensation mechanisms (decompensation)

As body temperature decreases characteristic symptoms occur such as shivering and mental confusion. The signs and symptoms vary depending on the degree of hypothermia and may be divided by the three stages of severity.

Symptoms of mild hypothermia 32–35 C (90–95 F) may be vague with sympathetic nervous system excitation (shivering, hypertension, tachycardia, tachypnea, and vasoconstriction). These are all physiological responses to preserve heat. Cold diuresis, mental confusion, hyperglycemia, as well as hepatic dysfunction may also be present.

Moderate hypothermia. Body temperature of 28–32 C (82–90 F) results in shivering becoming more violent. Muscle mis-coordination becomes apparent. Movements are slow and labored, accompanied by a stumbling pace and mild confusion, although the victim may appear alert. Surface blood vessels contract further as the body focuses its remaining resources on keeping the vital organs warm. The victim becomes pale. Lips, ears, fingers and toes may become blue.

Severe hypothermia. Body temperature drops below approximately 28 C (82°F) shivering stops. Difficulty speaking, sluggish thinking, and amnesia start to appear; inability to use hands and stumbling is also usually present. Cellular metabolic processes shut down. Below 30°C (86 F), the exposed skin becomes blue and puffy, muscle coordination becomes very poor, walking becomes almost impossible, and the victim exhibits incoherent/irrational behavior including terminal burrowing or even a stupor. Pulse and respiration rates decrease significantly, but fast heart rates (ventricular tachycardia, atrial fibrillation) can occur. Major organs fail. Clinical death occurs. Because of decreased cellular activity in stage 3 hypothermia, the body will actually take longer to undergo brain death.

As the temperature decreases further physiological systems falter and heart rate, respiratory rate, and blood pressure all decreases. This results in an expected HR in the 30s with a temperature of 28°C (82 F).

Aggressiveness of treatment is matched to the degree of hypothermia. Treatment ranges from noninvasive, passive external warming, to active external rewarming, to active core rewarming. In severe cases resuscitation begins with simultaneous removal from the cold environment and concurrent management of the airway, breathing, and circulation. Rapid rewarming is then commenced. A minimum of patient movement is required as aggressive handling may increase risks of a dysrhythmia. Hypoglycemia is a frequent complicates and therefore needs to be tested for and treated. Intravenous thiamine and glucose is often recommended.

Degree	Rewarming technique
Mild: 32–35 C (90–95 F)	Passive rewarming
Moderate: 28–32 C (82–90 F)	Active external rewarming
Severe: < 28 C (82°F)	Active internal rewarming[30]

Rewarming can be achieved using a number of different methods including passive external rewarming, active external rewarming, and active internal rewarming.

Passive external rewarming. This involves the use of a person's own heat generating ability through the provision of properly insulated dry clothing and moving to a warm environment.

Active external rewarming. This involves applying warming devices externally such as hot water bottles or warmed forced air. In austere environments this is often done by placing a hot water bottle in both armpits. Another method is to place the person in a tub with hot water (of 44°C), and place their arms and legs outside of the tub/hot water.

Active core rewarming. This involves the use of intravenous warmed fluids, irrigation of body cavities with warmed fluids (the thorax, peritoneal, stomach, or bladder), use of warm humidified inhaled air, or use of extracorporeal rewarming such as via a heart lung machine.

As most people are moderately dehydrated due to hypothermia induced cold diuresis intravenous access and intravenous fluids are often helpful (250 - 500 cc 5 percent dextrose and normal saline is often recommended at a temperature of 40 -45 C).