Postoperative Fever: To What Is
the Body Really Responding?
HELEN C. BALLESTAS, RN, MSN, CRRN
M
r 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.
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 hu-
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.
© AORN, Inc, 2007
1.4
mans.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
POSTOPERATIVE NURSING MANAGEMENT
Prompt nursing interventions are indicated when a patient demonstrates a
variation in vital signs—most specifically,
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.
DECEMBER 2007, VOL 86, NO 6 • AORN JOURNAL • 983
DECEMBER 2007, VOL 86, NO 6
The patient may develop a fever
secondary to deep vein thrombosis during
the fourth to sixth postoperative day;
therefore, the nurse should inspect the
patient’s lower extremities for
redness, tightness, or pain.
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
984 • AORN JOURNAL
Ballestas
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
Ballestas
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.
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
DECEMBER 2007, VOL 86, NO 6
Patients with cancer often are
immunocompromised because of their
disease processes and the effects of
therapy; fevers that are left untreated
may be associated with increased
morbidity and mortality.
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.
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
AORN JOURNAL •
985
Ballestas
DECEMBER 2007, VOL 86, NO 6
Nursing Care Plan for Surgical Patients
at Risk for Postoperative Fevers
Interim outcome criteria
Outcome
statement
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
demonstrates
respiratory
status consistent
with or
improved
from baseline
levels
established
preoperatively.
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.
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
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.
Diagnosis
Nursing interventions
Risk for
postoperative
fever related to
potential for
respiratory
complications
(postoperative
day two)
•
•
•
•
•
•
•
•
•
Risk for
postoperative
fever related to
potential for
urinary tract
infection (postoperative days
three through
five)
•
•
•
•
•
•
Risk for
postoperative
fever related to
potential for
developing
deep vein
thrombosis
(DVT)
•
•
•
•
986 • AORN JOURNAL
The patient
reports pain in a
timely fashion and
demonstrates
adequate pain
management
throughout the
perioperative
period.
The patient’s
clinical and
nonverbal
signs remain
stable,
indicating
adequate pain
control.
Ballestas
DECEMBER 2007, VOL 86, NO 6
Nursing Care Plan for Surgical Patients
at Risk for Postoperative Fevers
Diagnosis
(postoperative
days four
through six)
•
•
•
Risk for
postoperative
fever related to
potential for
developing a
surgical
wound
infection
(postoperative
days five
through seven)
•
•
•
•
•
•
•
•
•
Risk for
postoperative
fever related to
potential for
“drug fever”
(postoperative
days seven and
later)
Interim outcome criteria
Outcome
statement
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 infectionprevention and management interventions.
The patient’s
surgical wound
remains free of
signs of infection
and the patient
remains normothermic throughout the perioperative period.
The patient is
free from signs
and symptoms
of infection.
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.
Nursing interventions
•
•
•
•
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.
AORN JOURNAL •
987
Ballestas
DECEMBER 2007, VOL 86, NO 6
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.
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.
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. Consid-
ering 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.
REFERENCES
1. 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.
2. Dellinger EP. Should we measure body temperature for patients who have recently undergone surgery? Clin Infect Dis. 2005;40(10):1411-1412.
3. Woodrow P. Taking tympanic temperature. Nurs
Older People. 2006;18(1):31-32.
4. 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.
5. Rudra A, Pal S, Acharjee A. Postoperative fever.
Indian J Crit Care Med. 2006;10(4):264-271.
6. 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.
Helen C. Ballestas, RN, MSN, CRRN, is a
nursing instructor at New York Institute of
Technology, Old Westbury, New York.
Ms Ballestas has no declared affiliation that
could be perceived as a potential conflict of interest in publishing this article.
Chemotherapy May Lead to Long-Term Cognitive Impairment
T
he cognitive impairment experienced by 14% to
45% of patients after cancer treatment can be longlasting, according to a September 20, 2007, news release from Hurricane Voices Breast Cancer Foundation,
Concord, Massachusetts. For severely affected individuals, these cognitive impairments have led to significant problems at home and in the workplace.
From January to May 2007, researchers surveyed
471 male and female patients who were diagnosed
with an array of cancers, including
• breast,
• ovarian,
• lung,
• colorectal, and
• other cancers.
The findings indicated that long after their last
dose of chemotherapy, more than 40% of respon-
988 • AORN JOURNAL
dents reported moderate
• lack of concentration (ie, 55%);
• short-term memory loss (ie, 52%);
• difficulty with word recall (ie, 49%);
• inability to organize daily tasks (ie, 42%); and
• inability to multitask (ie, 44%).
In addition, 42% of the survey respondents described their physicians as dismissive or indifferent
in addressing their concerns. The researchers hope
that the results of this study will increase awareness among medical professionals to help them better assist patients struggling with cognitive impairments after chemotherapy treatment.
Cognitive deficits lead to “loss of self” among cancer patients [news release]. Concord, MA: Hurricane Voices Breast
Cancer Foundation; September 20, 2007.
Examination
1.4
Postoperative Fever: To What Is the
Body Really Responding?
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.
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
© AORN, Inc, 2007
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
DECEMBER 2007, VOL 86, NO 6 • AORN JOURNAL • 989
Examination
DECEMBER 2007, VOL 86, NO 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.
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.
990 • AORN JOURNAL
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
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.
Answer Sheet
1.4
Postoperative Fever: To What Is the
Body Really Responding?
Event #07126
Session #8468
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DECEMBER 2007, VOL 86, NO 6 • AORN JOURNAL • 991
1.4
Learner Evaluation
Postoperative Fever: To What Is the
Body Really Responding?
his 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.
T
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.
992 • AORN JOURNAL • DECEMBER 2007, VOL 86, NO 6
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: _______________
__________________________________________
__________________________________________
© AORN, Inc, 2007