Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Fever Control
FEVER CONTROL
A common presenting symptom in pediatrics and a cardinal sign of illness. Most fevers in children are seen in conjunction with an acute infectious process. Fever control is secondary to identification and treatment of its underlying cause.
There is controversy over whether all fevers should be actively treated. Fever is actually a protective measure and in itself is not harmful. Some experts contend that hyperpyrexia may be helpful in halting replication of a virus, and some studies have demonstrated that fever of a moderate degree can enhance immunologic response. High body temperatures, however, can diminish or reverse this effect, and a rapid increase in body temperature has been implicated as a triggering mechanism in febrile convulsions in susceptible children between 6 months and 5 years of age. Also, a child is generally more comfortable when fever is reduced. For these last three reasons, fevers of over 102F rectally should probably be treated once the etiology is established.
Elevation of temperature does not correlate with the severity of its cause (e.g., a neonate with sepsis may be hypothermic).
I. Subjective data
A. History of exposure
B. Diseases prevalent in the community
C. Fever pattern
1. Continuous
2. Remittent
3. Intermittent
4. Recurrent
D. Highest documented body temperature
E. Duration of fever
F. Accuracy of method used by parents in assessing temperature
G. Assessment of how sick the child appears
H. Any change in the level of sensorium
I. Other associated symptoms
1. Respiratory
2. Gastrointestinal
3. Genitourinary
4. Musculoskeletal
5. Central nervous system (CNS)
J. History of drug ingestion
K. History of decreased liquid intake
L. Treatment previously used and its effectiveness
II. Objective data
A. Complete physical examination to determine infectious etiology, including weight
B. Activity level
C. Level of sensorium
D. Assess state of hydration (see Appendix H, p. 534)
E. Toxicity
F. Laboratory tests as indicated by history and physical findings
1. Urinalysis and culture
2. Throat culture
3. CBC
4. Blood culture
5. CSF examination
6. Stool culture
III. Plan
A. Assess parent’s ability to take and interpret temperature correctly.
B. Oral temperature for most children 5 years of age and older
1. Place thermometer under tongue and leave it there for 4 minutes with lips closed.
2. If child has had anything to eat or drink or has been chewing gum, wait for 10 minutes before taking temperature.
C. Rectal temperature: Lubricate rectal thermometer with K-Y jelly or petroleum jelly, and gently insert 2.5 cm into rectum. Leave in place for 3 to 4 minutes.
D. Axillary temperature: Place thermometer high in axilla and hold arm close to body; remove shirt so that skin surfaces are touching. Leave in place for 4 to 5 minutes.
E. Normal temperature values
1. Oral: 98.6F ± 0.4F to 0.5F
2. Rectal: 99.4F ± 0.4F to 0.5F
3. Axillary: 97.6F ± 0.4F to 0.5F
F. Fever peaks at about 6 PM and is at its lowest point at about 4 AM.
G. With temperature elevation, for each degree of fever
1. Pulse increases by 10 beats/min. The increase may be higher in bacterial infections. Increased intracranial pressure, meningitis, and salmonellosis are associated with a decreased pulse rate.
2. Respiration increases by 2 cycles/min. Increased intracranial pressure, pulmonary disease, and acid-base disturbance produce greater elevations.
H. Hydration
1. Encourage liquids to prevent dehydration; clear liquids are easiest to retain.
2. Give small amounts frequently.
3. Try tea, cola, ginger ale, Popsicles, ice chips, Jell-O, ices, halfor full-strength juices.
I. Sponging or bathing
1. Every 2 hours if necessary for 30 minutes maximum
2. Use tepid water that feels comfortable to the parent’s wrist. Do not use alcohol or ice water. Chilling effect can cause shivering, which can increase body temperature. Rubbing with alcohol can cause toxicity through inhalation of fumes.
3. Rub skin briskly with a washcloth or towel to dry. Brisk rubbing increases skin capillary circulation and heat loss.
4. Cold sponging is generally recommended only for heat illness (hyperthermia).
J. Clothing
1. Clothe lightly to enhance heat loss through skin by radiation.
2. Avoid overdressing or covering with blankets, which will decrease radiation and cause further elevation of temperature.
K. Activity: Encourage rest; activity can increase body temperature.
L. Antipyretics for rectal temperatures over 102F
1. Use with caution.
2. Can mask fever
3. Will not cure disease
4. Do not use if child is dehydrated.
5. Acetaminophen
a. 10 to 15 mg/kg every 4 hours
b. Do not exceed 60 mg/kg/d. Give adequate dose for weight.
c. Acetaminophen half-life is significantly prolonged in infants and newborns. Use at a reduced dosage and with caution.
6. Pedia Profen or Children’s Advil Suspension (100 mg/5 mL)
a. 5 mg/kg every 6 to 8 hours for fevers 102.5F or less
b. 10 mg/kg every 6 to 8 hours for fevers over 102.5F
c. Maximum daily dose: 40 mg/kg
d. Do not use for infants under 6 months.
M. Thermometers
1. Digital: Reading takes approximately 30 seconds; as accurate as glass
2. Glass: Record more slowly; parents may find it more difficult to read; may no longer be available because of mercury concerns
3. Ear: Rapid recording (about 2 seconds); accurate with reliable instrument (not all instruments are reliable)
4. Tempa-Dot: Single use, paper thermometers; accurate, safe, easy to use for oral and axillary readings
IV. Follow-up
A. Dependent on degree of fever and etiology. With no established diagnosis, telephone contact should be maintained every 12 to 24 hours. Even if child does not seem sick, parents may be anxious without definitive diagnosis.
B. Child should be reevaluated if fever continues beyond 24 hours, if signs of toxicity occur, or if any signs or symptoms of infection occur.
V. Consultation/referral
A. Fever persisting over 5 days (fever of undetermined origin)
B. Acute high fever or prolonged highor low-grade fever
C. Infants under 6 months of age
D. Children with stiff neck, petechiae, swollen or inflamed joints, or dehydration
E. Tachypnea out of proportion to temperature elevation
F. Fever associated with seizure