Postoperative Fever: To What Is the Body Really Responding?

Ballestas, Helen C.

doi:10.1016/j.aorn.2007.08.018

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Volume 86, Issue 6 , Pages 983-992, December 2007

Postoperative Fever: To What Is the Body Really Responding?

Article Outline

ABSTRACT

THE PRESENCE OF A POSTOPERATIVE FEVER is not always indicative of an infectious process. Mild temperature elevation may be transient in nature and may arise from the body's response to tissue injury. Fevers that present from two to more than seven days after a surgical procedure may be caused by other physiological responses.

PERIOPERATIVE NURSES can target nursing assessments according to the postoperative day on which the fever presents. AORN J 86 (December 2007) 983–988. © AORN, Inc, 2007.

Mr B is in the second postoperative day after an intestinal rupture repair secondary to a small bowel obstruction. During morning report, the night-shift nurse relayed that Mr B had an oral temperature of 101.4° F (38.5° C) at 6 AM, though she noted no other immediate postoperative complications. The nurse administered 600 mg of acetaminophen by mouth at 6:30 AM. When the day-shift nurse reassessed Mr B at 10:30 AM, his oral temperature was 100.8° F (38.2° C). Prompt identification of the fever's etiology is warranted, particularly because Mr B is a postoperative patient.

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Significance of Postoperative Fevers

A study conducted by Vermeulen et al¹ indicates that, contrary to conventional thought, body temperature elevations are not always primary indicators of wound infection after surgery. In fact, fevers are common after tissue manipulation. Mild temperature elevations may be transient in nature. Most fevers are only indicative of infectious processes if they occur on postoperative day five or later.²

Factors that may increase body temperature include an increase in metabolism secondary to tissue repair or hypothalamic dysfunction, which alters the set point of thermoregulation in humans.³ Furthermore, there may be an increased incidence of fevers among patients undergoing abdominal surgery. Nevertheless, generally speaking, the presence of fever requires investigation.

Fevers usually occur when an infectious agent or toxin mediates an inflammatory response or when pyrogens are released as a result of the tissue manipulation and trauma that occurs during surgery. Pyrogenic release stimulates various cells such as monocytes, macrophages, and endothelial cells to release pyrogenic cytokines. This leads to increased heat conservation via vasoconstriction and involuntary muscular contractions that increase internal heat production. This internal heat is measurable and rated. Temperatures greater than 100.4° F (38° C) on two separate occasions at least four hours apart constitute true core body temperature elevation.⁴

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Postoperative Nursing Management

Prompt nursing interventions are indicated when a patient demonstrates a variation in vital signs—most specifically, temperature. Common causes of temperature elevation that are related to infectious processes include wound infections, urinary tract infections, pneumonia, catheter-related infections, or infections of prosthetic devices such as hip replacements.⁵ Temperature elevations also may occur

•if the patient is in alcohol detoxification,

•in response to medication therapies, or

•if there is a developing deep vein thrombosis.

It is important to note that fevers occurring during certain time frames in the postoperative recovery period give valuable clues to the origin of the fever.

Postoperative day two

As early as postoperative day two, patients may begin to experience surgical complications that cause fever. Respiratory complications usually are the culprit of fevers during this early period. Nursing assessment includes auscultation of the lung fields and monitoring for signs and symptoms of respiratory compromise, such as

•dyspnea,

•presence of adventitious breath sounds,

•shortness of breath, and

•sputum production.

Prior nursing history should include a history of any respiratory compromise, chronic obstructive pulmonary disease, smoking, alcohol use, diabetes, or obesity.

Prompt nursing interventions include teaching the patient to cough and deep breathe at least four times an hour while splinting his or her incision (ie, firmly pressing hands against a pillow placed on the incision) to aid in productive coughing. The nurse also should encourage the patient to use the incentive spirometer at least 10 times each hour while awake. The nurse should ensure that the patient is helped to ambulate by at least the first postoperative day if ordered and to ambulate frequently thereafter. The nurse also should ensure that pain is managed appropriately by administering adequate quantities of pain medication, and the nurse should instruct the patient on the importance of taking adequate medication because it helps to manage pain, prevent secretion stasis, and increase physical mobility.

Postoperative days three through five

Postoperative days three through five may bring on fevers that arise from urinary tract infections. Nursing assessment includes urinary intake and output, urine color and odor, and results of urine cultures. Promptly removing an indwelling catheter, ensuring proper hydration, and assisting with ambulation will help reduce the incidence of urinary tract infections, which if not readily identified and treated, can lead to sepsis. Maintaining asepsis during routine nursing care and ancillary care is crucial in minimizing bacterial colonization.

Postoperative days four through six

During the fourth to sixth postoperative day, the patient may develop a fever secondary to deep vein thrombosis (DVT). Nursing assessment includes inspection of lower extremities for redness, tightness, or pain, and the presence of a positive Homan's sign. Reduced ambulation because of pain or fear are factors that can contribute to the development of a DVT. The nurse should encourage the patient to use thromboembolic device (TED) stockings, use sequential compression devices if ordered, and ambulate early and frequently. The nurse also should administer ordered anticoagulation medication promptly and accurately.

Additionally, pulmonary emboli may form and can present with or without a fever. If the patient is exhibiting changes in hemodynamics or exhibits respiratory distress, the nurse should consider the presence of pulmonary emboli.

Postoperative days five through seven

It is during postoperative days five through seven that wound infections surface. The nurse should monitor the patient for traditional signs and symptoms of wound infection, including:

•redness,

•tenderness,

•purulent drainage, and

•odor.

If the patient exhibits an elevation in body temperature with an increase in pulse and blood pressure, the nurse should seriously consider the presence of infection. The nurse should use strict aseptic technique when changing wound dressings and should anticipate the need to culture the surgical wound in order to identify the offensive pathogen to determine effective antimicrobial therapy. In caring for the patient, the nurse must be aware that

•timely antibiotic therapy is required,

•prompt attention to obtaining laboratory values is warranted, and

•frequent overall assessments of the patient's general condition are essential.

Postoperative fevers after seven days

Fevers that present after postoperative day seven may be caused by medications. This is known as “drug fever.” Culprit medications include vancomycin, penicillin, and streptomycin. Some medications cause an inflammatory response as evidenced by changes in vital signs (eg, rifampin, tetracycline, erythromycin). Other medications can cause hypersensitivity reactions that cause an elevation in body temperature (eg, captopril, hydrazaline, labetalol). Some medications release pyrogens as part of their medication action (eg, cimetidine, ranitidine). Interferon stimulates endogenous pyrogens, thus causing an inflammatory response—hence the name drug fever. The nurse should evaluate all medications that the patient is taking and have a working knowledge of each medication's side effects and therapeutic effects.

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Special Considerations for Oncology Patients Undergoing Surgery

When caring for surgical patients, the nurse must give special consideration to oncology patients. Oncology patients often are immunocompromised because of their disease process and the effect of therapies (eg, chemotherapy, radiation). Untreated fevers in cancer patients may be associated with increased morbidity and mortality rates.⁶

Fevers presenting in these patients may lead to rapid sepsis.⁶ If the fever is not treated expeditiously within 48 hours, systemic effects may ensue (eg, rigors, hypotension, changes in mental status, acute renal failure). According to Chang et al, “untreated infections in neutropenic patients are associated with significant morbidity and mortality.”⁶^(p75) Chang and colleagues further observed that administering antipyretics, such as acetaminophen, may be an incorrect action because it delays essential medical intervention.

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What happened to Mr B?

At 10:30 AM, Mr B's body temperature remained elevated. In a quick review of the initial nursing assessment, the nurse noted that Mr B did not have a diagnosis of cancer or a history of cancer, so the nurse determined that it was safe to medicate the patient with an antipyretic as ordered. The nurse determined that prompt physician notification also was warranted.

The nurse performed a pulmonary assessment of the patient, which demonstrated crackles bilaterally without sputum production. With further investigation, the nurse determined that the patient was

•in pain and did not want to ambulate and

•not using the incentive spirometer as often as instructed.

Considering the postoperative day, it is very likely that Mr B was developing postoperative respiratory complications. The nurse instructed Mr B to cough and deep breathe at least four times an hour and reminded him to splint his incision to aid in productive coughing. The nurse also encouraged Mr B to use the incentive spirometer 10 times every hour while awake.

Nursing Care Plan for Surgical Patients at Risk for Postoperative Fevers

Diagnosis	Nursing interventions	Interim out-come criteria	Outcome statement
Risk for postoperative fever related to potential for respiratory complications (postoperative day two)	•Assesses respiratory status. •Obtains prior medical and surgical history. •Monitors for signs and symptoms of respiratory compromise. •Teaches the patient to cough and deep breathe at least four times an hour while splinting his or her incision. •Encourages the patient to use the incentive spirometer at least 10 times each hour while awake. •Ensures that the patient is helped to ambulate by at least the first postoperative day if ordered and to ambulate frequently. •Assesses the patient's preoperative pain, previous experiences of pain, and cultural and value components related to pain and pain management. •Ensures appropriate pain management by administering adequate quantities of pain medication. •Evaluates the patient's response to respiratory care and pain management interventions.	The patient's respiratory status remains uncompromised throughout the perioperative period. The patient reports pain in a timely fashion and demonstrates adequate pain management throughout the perioperative period.	The patient demonstrates respiratory status consistent with or improved from baseline levels established preoperatively. The patient's clinical and nonverbal signs remain stable, indicating adequate pain control.
Risk for postoperative fever related to potential for urinary tract infection (post-operative days three through five)	•Assesses urinary system for signs indicating urinary tract infection. •Promptly removes an indwelling catheter, if present. •Ensures proper hydration. •Ensures that the patient is helped to ambulate frequently. •Maintains asepsis during routine nursing care and ancillary care. •Evaluates the patient's response to urinary care interventions.	The patient's urinary tract remains free of signs of infection throughout the perioperative period.	The patient is free from signs and symptoms of urinary tract infection.
Risk for postoperative fever related to potential for developing deep vein thrombosis (DVT) (postoperative days four through six)	•Assesses lower extremities for redness, tightness, or pain, and the presence of a positive Homan's sign. •Ensures that the patient ambulates frequently. •Ensures that the patient's pain is managed adequately. •Obtains order for thromboembolic device (TED) stockings and sequential compression devices as appropriate and ensures that the patient uses them consistently. •Administers ordered anticoagulation medication promptly and accurately. •Notifies the surgeon immediately if the patient exhibits changes in hemodynamic status or exhibits respiratory distress. •Evaluates the patient's response to DVT prevention management interventions.	The patient's peripheral vascular system remains free of signs of DVT throughout the perioperative period.	The patient is free from signs and symptoms of DVT.
Risk for postoperative fever related to potential for developing a surgical wound infection (postoperative days five through seven)	•Assesses the patient preoperatively for susceptibility to infection (eg, chronic diseases, weight, laboratory values, skin integrity). •Helps minimize length of intraoperative phase by planning and anticipating care. •Monitors the patient for traditional signs and symptoms of wound infection (eg, elevation in body temperature with increased pulse and blood pressure, incisional redness or tenderness, purulent drainage, odor). •Implements, monitors, and maintains aseptic technique (eg, changing wound dressings). •Anticipates the need to culture the surgical wound. •Administers prescribed antibiotic therapy at appropriate times. •Promptly reports laboratory results to the surgeon. •Frequently reassesses the patient's general condition. •Evaluates the patient's response to infection-prevention and management interventions.	The patient's surgical wound remains free of signs of infection and the patient remains normothermic throughout the peri operative period.	The patient is free from signs and symptoms of infection.
Risk for postoperative fever related to potential for “drug fever” (postoperative days seven and later)	•Evaluates all medications that the patient is taking, particularly the “culprit” medications (eg, vancomycin, penicillin, streptomycin). •Assesses the patient for an inflammatory response as evidenced by changes in vital signs. •Assesses the patient for hypersensitivity reactions that cause an elevation in body temperature. •Notifies the surgeon immediately if the patient exhibits inflammatory or hypersensitivity responses.	The patient does not exhibit an inflammatory response or hypersensitivity reaction throughout the perioperative period.	The patient is free of signs and symptoms of drug fever.

The nurse assisted Mr B in taking a walk around the unit, and during that time she reminded him of the importance of ambulating frequently to prevent respiratory complications. She suggested that she return in about an hour to walk with him again. After that Mr B would probably be able to ambulate without assistance.

The nurse administered additional doses of antipyretics and antibiotics as ordered and reminded Mr B of the importance of taking pain medications to help manage pain, prevent secretion from building up in his lungs, and increase his physical mobility.

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Targeting the System Causing the Fever

Early postoperative fevers should not always be assumed to be the beginning of infectious processes.¹ Although it is true that infections may cause changes in body temperature, so can other physiological changes or responses to therapy occurring in the body during the postoperative period. It also is important to note that fevers may be transient in nature. Considering this information, the nurse may be able to target the specific system causing the temperature elevation depending on the postoperative day in which the fever occurs.

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Examination

Purpose/Goal

To educate perioperative nurses about how to target the specific system causing temperature elevation in postoperative patients depending on the postoperative day in which a fever occurs.

Behavioral Objectives

After reading and studying the article on postoperative fevers, nurses will be able to

1.define postoperative fever,

2.identify causes of postoperative fevers, and

3.describe nursing care of postoperative patients with fever.

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Questions

1.Body temperature elevations are always indicators of infection after surgery.

a.true

b.false

2.True core body temperature elevation exists if, on two separate occasions at least four hours apart, the patient exhibits temperatures greater than

a.99° F (37.2° C).

b.99.9° F (37.7° C).

c.100° F (37.8° C).

d.100.4° F (38° C).

3.Common causes of temperature elevation that are related to infectious processes include

1.catheter-related infections.

2.infections of prosthetic devices.

3.tissue trauma.

4.pneumonia.

5.wound infections.

a.1 and 3

b.2 and 4

c.1, 2, 4, and 5

d.1, 2, 3, 4, and 5

4.Obtaining a prior nursing history to monitor for a respiratory cause of postoperative fevers should include ascertaining history of

1.alcohol use.

2.chronic obstructive pulmonary disease.

3.diabetes.

4.obesity.

5.respiratory compromise.

6.smoking.

a.1, 3, and 5

b.2, 4, and 6

c.1, 2, 4, 5, and 6

d.1, 2, 3, 4, 5, and 6

5.Nursing interventions appropriate when a patient may have a urinary tract infection include

1.assessing for the presence of a positive Homan's sign.

2.assessing urinary intake and output, urine color and odor, and urine cultures.

3.encouraging use of the incentive spirometer.

4.ensuring proper hydration.

5.promptly removing an indwelling catheter, if applicable.

6.maintaining asepsis during routine nursing care.

1.1, 3, and 5

2.2, 4, and 6

3.2, 4, 5, and 6

4.1, 2, 3, 4, 5, and 6

6.If the patient exhibits changes in hemodynamic status or respiratory distress, the nurse should consider the presence of

a.pulmonary emboli.

b.deep vein thrombosis.

c.urinary tract infection.

d.wound infection.

7.Fevers caused by wound infections are most likely to occur on postoperative

a.day two.

b.days three through five.

c.days four through six.

d.days five through seven.

8.A likely cause of fevers that present after postoperative day seven are

a.medications.

b.respiratory complications.

c.urinary tract infections.

d.wound infections.

9.When an oncology patient develops a fever, the nurse should immediately administer an antipyretic, such as acetaminophen.

a.true

b.false

10.When educating Mr B in the case study, the nurse instructed the patient to

1.ambulate frequently.

2.cough and deep breathe at least four times an hour while awake.

3.splint his incision to aid in productive coughing.

4.take pain medications as ordered.

5.use the incentive spirometer 10 times every hour while awake.

a.1 and 2

b.3, 4, and 5

c.1, 2, 3, and 5

d.1, 2, 3, 4, and 5

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Answer Sheet

Postoperative Fever: To What Is the Body Really Responding?

Event #07126

Session #8468

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Learner Evaluation

Postoperative Fever: To What Is the Body Really Responding?

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This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

Purpose/Goal

To educate perioperative nurses about how to target the specific system causing temperature elevation in postoperative patients depending on the postoperative day in which the fever occurs.

Objectives

To what extent were the following objectives of this continuing education program achieved?

1.Define postoperative fever.

2.Identify causes of postoperative fevers.

3.Describe nursing care of postoperative patients with fevers.

Content

To what extent

4.did this article increase your knowledge of the subject matter?

5.was the content clear and organized?

6.did this article facilitate learning?

7.were your individual objectives met?

8.did the objectives relate to the overall purpose/goal?

Test Questions/Answers

To what extent

9.were they reflective of the content?

10.were they easy to understand?

11.did they address important points?

Learner Input

12.Will you be able to use the information from this article in your work setting?

1.yes

2.no

13.I learned of this article via

1.the Journal I receive as an AORN member.

2.a Journal I obtained elsewhere.

3.the AORN Journal web site.

14.What factor most affects whether you take an AORN Journal continuing education examination?

1.need for continuing education contact hours

2.price

3.subject matter relevant to current position

4.number of continuing education contact hours offered

What other topics would you like to see addressed in a future continuing education article? Would you or someone you know be interested in writing an article on this topic?

Topic(s): ______________________________________________________________________________________________________________________

Author names and addresses: ___________________________________________________________________________________________________

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References

Vermeulen H , Storm-Versloot MN , Goossens A , Speelman P , Legemate DA . Diagnostic accuracy of routine postoperative body temperature measurements . Clinical Infect Dis . 2005;40(10):1404–1410
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Dellinger EP . Should we measure body temperature for patients who have recently undergone surgery? . Clin Infect Dis . 2005;40(10):1411–1412
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- CrossRef

Woodrow P . Taking tympanic temperature . Nurs Older People . 2006;18(1):31–32
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- MEDLINE

Smeltzer SC , Bare BG , Hinkle JL , Cheever KH . Brunner & Suddarth's Textbook of Medical-Surgical Nursing . 11th ed.. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2007;
- View In Article

Rudra A , Pal S , Acharjee A . Postoperative fever . Indian J Crit Care Med . 2006;10(4):264–271
- View In Article

Chang A , Hendershot E , Colapinto K . Minimizing complications related to fever in the postoperative pediatric oncology patient . J Pediatr Oncol Nurs . 2006;23(2):75–81

indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages 989–990 and then completing the answer sheet and learner evaluation on pages 991–992.You also may access this article online at http://www.aornjournal.org.The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as a potential conflicts of interest in publishing this article.This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.