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HOME MANAGEMENT OF PEDIATRIC FEVER:
THE WILSON EDUCATIONAL MODEL FOR
THE FAMILY NURSE PRACTITIONER
By

Kim D. Wilson

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE
College of Nursing

1999

ABSTRACT

HOME MANAGEMENT OF PEDIATRIC FEVER:
THE WILSON EDUCATIONAL MODEL
FOR THE FAMILY NURSE PRACTITIONER

By

Kim D. Wilson

Recent studies suggest that 20-3 0% of emergency room visits and approximately
30% of outpatient visits include fever as part of a chief complaint. Although all children
experience fever, caregivers remain frightened and unsure of appropriate home
management of the fever. This scholarly project describes the development of the Wilson
Educational Model (WEM) for the family nurse practitioner (FNP) as an intervention for
caregivers of young children. The Health Belief Model provides the theoretical
framework for its development. The WEM includes: (a) a review guide for the FNP on
fever, (b) written literature for caregivers in the form of an educational pamphlet on home
management of pediatric fever, (c) a demonstration module on the technique for taking an
axillary temperature, (d) suggestions for alternative educational and community
resources, and (e) a pediatric follow-up call sheet. The WEM is based on scientific
knowledge and research and should assist the FNP in assuming a leadership role as an
educator in the primary care setting. Implications for practice, research, and education

are examined.

Copyright© by
Kim D. Wilson
1999

ACKNOWLEDGEMENTS

As my chairperson Joan Wood once said, “This will be an evolving project”. My
special thanks and appreciation to Joan who has guided, counseled, encouraged, and
endured through this project’s long evolution. Joan’s excellent communicative and
editorial skills motivated and inspired me. Thanks too, for the guidance and direction
from my committee members Susan Wheeler and Billie Gamble. I truly appreciated their
support and assistance with this project.

A very personal thanks to my husband Mark and children, Brent, Ryan and Julie,
who sacrificed so much in order for me to complete my graduate degree. Their love,

patience, understanding and support made achieving my Masters degree possible.

iv

TABLE OF CONTENTS

List of Figures ................................................................................. vi
Introduction ................................................................................... 1
Statement of Problem ........................................................................ 1
Purpose and Significance ................................................................... 2
Conceptual and Operational Definitions .................................................. 2
Family Nurse Practitioner .................................................................. 2
Home Management ................................................................. 4
Pediatric Fever ....................................................................... 5
Educational Model .................................................................. 6
Theoretical Framework .................................................................... 7
Application of the Health Belief Model .................................................. 10
Literature Review ............................................................................ l3
Pediatric Fever ...................................................................... 14
Home Management of Pediatric Fever ........................................... 18
The Family Nurse Practitioner in the Role of Educator ....................... 27
Development of the Model ................................................................. 29
The Wilson Educational Model ............................................................ 31
Educational Objectives ............................................................ 32
Fever Review Guide for the FNP ................................................. 33
The Educational Pamphlet ......................................................... 36
Demonstration Model for taking an Axillary Temperature .................. 40
Alternative Educational Resources ............................................... 44
Implications ................................................................................... 48
Research .............................................................................. 49
Practice ............................................................................... 51
Education ............................................................................ 53
Conclusion .................................................................................... 54
List of References ............................................................................ 56
Appendix A-The WEM for the FNP: Home Management of Pediatric Fever ...... 1-11

LIST OF FIGURES

Figure1.The Health Belief Model ............................................................... 9

Figure 2. The HBM as Applied to Caregiver Home Management of Pediatric Fever... 11

Figure 3. Fever Review Guide for the FNP .................................................... 34
Figure 4a. Educational Pamphlet ................................................................. 37
Figure 4b. Educational Pamphlet ................................................................ 38
Figure 5. Demonstration Mode] on taking an Axillary Temperature ....................... 41
Figure 6. Alternative Educational Resources .................................................. 46
Figure 7. Pediatric Follow-up Call Sheet ....................................................... 47

Introduction

In the pre-antibiotic era Sir William Osler once said “Humanity has but three
great enemies: Fever, Famine, and War. Of these, by far the greatest, by far the most
terrible, is Fever. (Atkins, 1984). In the twentieth century, fever is rarely considered as
gravely as it was by Osler. Still, few symptoms prompt a caregiver more concern than a
child’s fever. Recent studies suggest that 20-30% of emergency room visits and
approximately 30% of out-patient visits include fever as part of a chief complaint for
children (Murphy, 1972; D’Auria, 1997). Many caregivers often express fear and anxiety
over the presence of fever, which sometimes may be difficult to control. In addition,
caregivers lack knowledge on fever control and selected aspects of its management
(Kelly, Morin, & Young, 1996).

Statement of the Problem

Despite the availability of over the counter antipyretics and the mass advertising
concerning fever control, caregivers continue to demonstrate a lack of understanding and
confusion about fever. Mismanagement of pediatric fever has lead to heightened anxiety
on the part of caregivers, increased visits to the pediatrician or the emergency
department, and the overdosing of antipyretics. Health care providers and in particular
family nurse practitioners can play a significant role in enabling caregivers to make
appropriate health care decisions regarding the home management of a child’s fever.
However, there is nothing available in the current literature to guide the family nurse
practitioner in the education of caregivers on the pathology of fever, the appropriate

assessment of a child with fever, and the home management of fever.

Purpose and Significance

Health education is one of the family nurse practitioner’s most significant roles in
the era of managed care. Today’s caregivers are lacking specific education on the
management of pediatric fever. Due to time and staffing limitations facing nurses today,
more creative types of educational approaches which capitalize on teaching opportunities
at all points of entry into the health care system are needed. These include, but are not
limited to, a broad variety of practice settings, such as primary care offices, emergency
department waiting rooms, parenting classes, post-partum and pediatric hospital units. In
addition, this would include utilizing a variety of educational mediums, i.e., written
discharge instructions, HMO newsletters, follow-up calls, educational pamphlets,
educational video tapes and the use of return demonstrations.

Thus, the purpose of this scholarly project is to develop an educational model for
the family nurse practitioner on the home management of pediatric fever thus enabling
caregivers to appropriately care for their child at home. The product, the Wilson
Educational Model, is based on scientific knowledge and research and includes defining
symptoms, treatment options, referral and follow-up recommendations.

Conceptual and Operational Definitions

The review of literature provided guidance in the identification and definitions of
the conceptual and operational concepts discussed throughout this project. The concepts
include: family nurse practitioner (FNP), educational model, home management, and
pediatric fever.

Famin Nurse Practitioner (ENE)

Historically, clinical nurse specialists (CNS) and nurse practitioners (NP) had

separate councils within the American Nurses Association (ANA) structure, i.e., the
Council of Clinical Nurse Specialists, and the Council of Primary Health Care Nurse
Practitioners. As the roles of the CNS and the NP developed, the differences between the
~ roles appeared less clear. Nurse practitioners working essentially in primary care settings
began moving into acute care settings, and clinical nurse specialists working mainly in
the acute care setting began moving into primary care sites (Snyder & Yen, 1994). The
overlap of roles between the NP and the CNS has added confusion for the public and for
the nursing profession. Therefore, the roles of NP, CNS, and APN will be reviewed.

The role of the nurse practitioner (NP) was developed in 1965 at the University of
Colorado when a program for the education of the pediatric nurse practitioner (PNP) was
developed (Bryzynski & Fenton, 1993). The PNP role evolved and developed as well as
other NP roles including the family nurse practitioner (FNP) and the adult nurse
practitioner (ANP). The new NP roles increased client access to primary health care in
the out-patient setting, addressed physician shortages, and focused on direct patient care.
The NP possesses a broad knowledge base related to diagnosis, treatment and prevention,
i.e., performing physical examinations, ordering laboratory studies, developing diagnostic
treatment plans and making referrals (Page & Arena, 1994).

Currently, the American Academy of Nurse Practitioners offers certification for
the ANP and the FNP while the American Nurses Credentialing Center (ANCC) provides
specialty examination and certification in five areas: adult, family, school, pediatrics, and
gerontology. The purpose of certification is to assure various publics that an individual
has mastered a body of knowledge and has acquired skills in a particular specialty

(Snyder & Yen, 1994).

The clinical nurse specialist (CNS) role was developed in 1954 at Rutgers
University and was broadly defined as a nurse who holds a masters degree in a specific
area (Bryzynski & Fenton, 1993). The CNS role was developed as a hospital based role
which emphasized improving the quality of care delivered to patients by educating those
who give direct patient care and keeping the expert specialized nurse at the hospital
bedside (Page & Arena, 1994).

In 1992, the American Nurses Association (ANA) proposed the role of advanced
practice nurse (APN) as a general term to describe several roles of nurses with advanced
education, preparation, and degrees. Currently, the role Of the APN includes the CNS, the
NP, the certified registered nurse anesthetist (CRNA), and the certified nurse midwive
(CNM). Thus, APN is a general term, which describes a variety of nurses with advanced
preparations and degrees, and does not distinguish between the difl‘erent roles.

For the purpose of this project the APN role of interest is the family nurse
practitioner (FNP) and is defined as a nurse who is masters prepared and certified in the
family specialty area. The FNP focuses on providing primary health care and health
education to individuals and their families.

Home Management

Caregivers are responsible for the health and well being of their children. In
today’s managed care environment, medical care has become more complicated. The
American Institute for Preventative Medicine (1994) describes health care conditions
which caregivers can manage prior to seeking medical attention by using self-care
guidelines as home management.

Kaiser Pennanente Medical Centers published a patient educational guide in

1996; it describes patient education as a skill-building process which enables patients to
take responsibility for their decisions of learning, when, how, and even why to make a
change. Managing the family’s health care as much as possible at home empowers
clients and their families.

For this project, home management refers to the ability of the family/caregivers to
provide self-health care at home prior to seeking health professional advice. Self-health
care is based on health guidelines, which help caregivers decide when to treat or manage
the fever at home and when to seek the advice of the health care provider.

Pediatric Fever

Normal body temperature of infants and children varies, but generally stays
within a range of 36.2 degrees (°) to 380° centigrade (C), i.e., 970° to 100.4° farenheight
(F) (Yaffe, 1980).

Fever is one of the body’s natural defense mechanisms against disease and not
merely an uncomfortable side effect of disease (Kilmon, 1987). The elevation of body
temperature activates body defenses to increase T cell production and increase the
effectiveness of interferon in combating viral infections (F ruthaler, 1985; Tierney,
McPhee, & Papadakis, 1997; Uphold & Graham, 1998).

Fever, as defined by Brennan, Falk, Rothrock, & Kerr (1987), is greater than
100°F orally, greater than 100.4°F rectally or greater than 99.4°F axillary. Uphold &
Graham (1998) define fever as oral temperatures greater than 37.8°C (100°F), rectal
temperatures greater than 38°C (100.4°F), and axillary temperatures greater than 372°C
(99°F)

Uphold & Graham’s (1998) definition of fever has been selected for this project.

An elevation of body temperature greater than 100°F orally, 100.4°F rectally, or greater
than 99°F axillary.
Edugtional Model

The review of the literature identified several concepts that have many similarities
and are used interchangeably. The main concepts of patient education, health instruction,
health educational module, and educational model require definition.

Patient education as defined by Rankin & Stallings (1990) is a process of
influencing behavior and generating changes in attitudes, knowledge, and skills required
for maintaining or improving health. Fedor & Dalis (1989) define health instruction as a
plan prepared for the sequential arrangement of learning designed to positively influence
health, values, practice, attitudes, and cognitive capabilities conductive to the optimum
development of the individual, the family, and the community. For health instruction to
be effective, a systematic plan or lesson plan, is necessary. According to the authors, this
plan would include several steps: (a) identification of the relationships among health
areas, themes, questions and generalizations; (b) instructional Obj ectives; and (c) teaching
strategies (F edor & Dalis).

According to Lorig (1996), a health educational module is defined as any set of
organized activities designed to improve health behaviors and/or health status. Modules
or plans, give clear detailed directions, and a systematic way of communicating the
educational process.

The review of the literature did not provide a specific definition of educational
model. However, according to Webster’s Dictionary (1996), education is defined as the

process of training and developing the knowledge skill, mind and character by formal

schooling, teaching or training. Educational, as an adjective, refers to the giving of
instruction or information. Model is defined as a pattern, a plan, form or design.

Therefore, the definition for this project of ‘educational model’ is specific
instruction formalized into a plan or design with the identification of instructional
objectives and teaching strategies.

Theoretical Framework

The Health Belief Model (HBM) has been selected to guide this project.
Understanding the determinants of health protecting behavior is critical for the
development of effective interventions that health professionals can use to assist parents
in altering their behaviors, attitudes, and beliefs about their child’s health. The HBM is an
example of a theoretical explanation for health protection that has been proposed and
modified by Becker & Janz (1984) and empirically tested (Rankin & Stallings, 1996;
Pender, 1996). It was originally developed by social psychologists to predict the
likelihood of a person taking recommended preventive health action and to understand a
person’s motivation and decision-making about seeking health services.

The model attempts to identify compliers and non-compliers by looking at six
factors. The factors considered important to health care decisions are: (a) perception of
the severity of the illness, (b) perception of susceptibility to illness and its consequences,
(c) perceived threat of the illness, ((1) value of the benefits of treatment, (e) consideration
of the barriers to treatment, such as degree of social support, expense, regimen,
complexity, length of treatment, and side effects, the cost of treatment in physical and
emotional terms, and (t) cues which stimulate action for treatment of illness, such as,

illness in family or fiiends, television, or other media presentation-films, newspapers,

stories, or health pamphlets

Demographic variables such as age, gender, socioeconomic status and ethnicity
are believed to modulate a person’s perceptions about the seriousness of health conditions
and the need to take action for those conditions. (Becker, 1974, 1979; Janz & Becker,
1984; Becker & Janz 1985; Pender, 1996).

The model, as modified by Becker & Janz (1984) and illustrated in Figure 1.,
includes: 1). An Individual’s Perceptions, i.e., one’s perceived susceptibility to disease
and/or perceived seriousness or severity of disease; 2) Modifying Factors, i.e.,
variables of demographics such as socio-psychologic and structural variables, as well as
cues to action, which indirectly affect action tendencies through their relationship with
perception of threat; and 3) Likelihood of Action, i.e., the perceived benefits of
preventive action minus perceived barriers to preventive action. Janz and Becker (1984)
concluded through numerous studies that perceived barriers was the most powerful of the
HBM dimensions in explaining or predicting various health behaviors and the likelihood
of taking preventive action. In other words, the HBM relates components of a socio-
psychologic theory of an individual’s decision making to the HBM dimensions, i.e.,
susceptibility, severity, threat, benefits, and barriers, and cues to action.

The Health Belief Model has frequently guided nursing research in an attempt to
increase knowledge of health related behaviors (Thomas, 1995). The literature shows a
wide range of use of the HBM, e. g., predicting behavior of adherence to exercise
programs with cardiac patients (Mirotznik, Feldman & Stein, 1995), examining the
relationship of behaviors to cigarette smoking behavior (Galvin, 1992), utilizing

mammography (Stein, Fox, Murata & Morisky, 1992), participating in breast cancer

 

 

Individual Perceptions Modifying Factors Likelihood of Action

 

Demographic
variables

    

 

    

 

age, sex, ethnicity
Socio-psychologic
variables 5—. ...a L- L
Perceived benefits
Structural variables of preventive action
Minus

 

._m _ _ 9 Perceived barriers
Perceived to preventive action
susceptibility

to disease X

 

 

 

 

 
       

 

 

 

 

 

 

Perceived Perceived threat
seriousness of disease X
E (severity) ' . .
: taking
recommended
preventive
health action

 

 

 

a Cues to action

 

Figu_re 1. The Health Belief Model. Modified by Becker & Janz (1984)

 

screening (Fulton, et al., 1991), conducting self breast exams (W yper, 1990), adhering to
diabetes education (Hurley, 1990), and increasing compliance of emergency department
patients (Jones, Jones & Katz, 1988).

Although the application of the HBM in research is often for compliance
prediction, Rankin & Stallings (1996) found it to be useful in understanding caregivers’
motivation to provide health care services for their children. However, present research
using the HBM as the theoretical framework for predicting caregiver motivation is
limited.

Application of the HBM to
Caregiver Home Management of Childhood Fever

Applying the HBM in predicting behaviors of caregivers for their children with
fever could enable the PNP to make the most appropriate educational interventions and
ultimately promote or enhance the child’s health and well being in the future.

A modified HBM, Figure 2., The HBM as Applied to Caregiver Home
Management of Pediatric Fever, reflects specific appropriate questions and issues noted
in the literature which need to be considered. The literature review and model
development sections expand on these areas, however a brief summary is included in this
section.

The HBM component, individual perceptions, includes the concepts of
perceived susceptibility, perceived seriousness, and perceived threat as related to fever in

children as a universal concern to most caregivers. As stated previously, it is one of the

10

 

Individual Perceptions

 

Modifying Factors

 

 

Perceived
susceptibility
to fever
Parental assessment
of child How sick
does the child
appear? Could the
fever be caused by:
increased exercise,
warm weather, warm
clothing, warm food
or drink?
Perceived
seriousness
of fever
(Common myths and
misconceptions of
fever; What causes
it?, What is it?, Must
it always be treated?
Is fever common in
childhood?

 

 

H uhgrt‘ “it: “at ”fir-4‘5,”

F gure 2 The HBM as Applied to Caregiver Home Management of Pediatric Fever

(Wilson, 1999).

/ \ Likelihood of taking

Cues to action
Teaching interventionsfi'om FNP on
the home management quediatric
fever via written instructions return
demanstrations, videos, jbllow-up , '
. calls and canttma'ng support and
ethicatim

)4,» Tu mg. .a
L .

Likelihood of Action

    

 

 

 

Demographic 33:21:05
variables + .
Socio-psychological p reventrve
variables (Conx'fillgf’I fever
”0335332382,? making the child
y. income, lack’of comfortable,
education, lack of avatdrlngfitrther
familial support, lack of comg:::m)
care-grvrng experience) —-> Perceived
l barriers of
perceived action
. (Lack of
Perceived threat of fever [mowedge about
(Fever in childhood is fever, when ’0
usually not harmfid S/S may treat, treatment
2 include mild dehydration & options, how 10
discomfort. Yet, perceptions correctly take an
of rare febrile seizures & axillary
febrile delirium persist. temperature, What
Caregivers fear the is proper
condition of the child may medication to
worsen & escalation of 38160! and What
higher temps will cause dosage,
brain damage. This leads to availability of
“fever phobia ” ) medichtion.)

 

 

 

 

 

appropriate and
recommended fever
control treatment is
increased with
increased cues to
action with
interventions
impacting perceived
barriers.

 

11

 

 

most common complaints that children are treated for in pediatric ambulatory care
settings and pediatric offices (Robinson, Schwartz, Magwene, Krengel, Tambutello,
1989; Kelly, Morin & Young, 1996; Schmitt, 1980, 1984, 1993). Caregivers worry that,
if uncontrolled, the fever may spiral upwards to a fatal outcome (Parks, 1986). Caregivers
and professionals alike are alarmed by the threat of febrile convulsions or seizures
causing irreversible brain damage. Schmitt (1980, 1984,1993) described this
‘phenomena’ of unfounded fears concerning fever as fever phobia. While many
caregivers would likely intervene and give an antipyretic or another intervention in an
attempt to decrease their child’s fever, other caregivers, do nothing or panic and rush
their child to the nearest doctor’s office or emergency room. Prevailing myths and
misconceptions of fever, the cause of fever, treatment or non-treatment, and the
commonness in childhood may influence the caregiver’s perception of the seriousness of
fever. In order to understand why certain caregivers take initial action and others do not,
the modifying factors need to be identified.

Becker & Janz (1984) identified modifying factors as demographic variables,
i.e., age, sex, race, ethnicity, etc., and socio-psychologic variables, i.e., personality, social
class, peers and reference group pressure. The literature review for this project identified
these variables as young caregivers (<16 years old), unmarried, low income, lack of
education, lack of familial support, lack of care-giving experience.

According to the authors, cues to action may include teaching interventions fiom
the FNP via written instructions, return demonstrations, videos, follow-up calls and
continuing support. All are relevant interventions, which may impact cues to action.

Each of these variables has an impact on a caregiver’s perceived susceptibility and

12

seriousness and thus, perceived threat of fever. The focus of this project will be directed
towards the cues to action with the Wilson Educational Model incorporating the
educational interventions previously identified.

The likelihood of action component includes the concepts of perceived benefits
of preventive action minus the perceived barriers of taking preventive action. Perceived
benefits appear obvious: (a) control of the fever, (b) making the child comfortable, (0)
avoidance of filrther complications. Perceived barriers are often very subjective and
include: (a) lack of knowledge about fever, (b) when to treat or not to treat, (c) treatment
options, (d) how to take a temperature correctly and what does it mean or what really
constitutes a fever, (e) availability, cost, and proper dosage of medications, (e) which
medication to choose, i.e., Tylenol vs. ibuprofen vs. aspirin.

As Figure 2. illustrates, the various perceptions and influencing factors can have
either a direct or indirect impact on the predicted likelihood a caregiver will use
appropriate fever control interventions when treating their child’s fever.

Janz & Becker (1984) suggested that perceived barriers were the most prominent
factor associated with preventive health practices or maintenance of health regimes. This
project identifies these barriers and provides an educational model for the FNP to
implement with caregivers for the home management of pediatric fever. It is anticipated
that implementation of such a model would increase the likelihood of the caregiver taking
the appropriate action at home in the management of their child’s fever.

Literature Review
The following review of the literature discusses the issue of pediatric fever,

current protocols and management of pediatric fever, and the family nurse practitioner

13

(FNP) in the role of the educator. The review of the literature revealed that the majority
of research on pediatric fever and caregiver assessment and management took place
during the 1970s and 1980s and that little specific research has been done in these areas
during the 19905.

Pediatric Fever

Fever is one of the most common problems that children experience (Kilmon,
1987). In fact, almost all families have to cope with this problem at some time (Schmitt,
1980, 1984, 1993). As stated previously, 20-30% of all pediatric emergency visits and
30% of out-patient visits have fever as part of the chief complaint (Murphy, 1992;
D’Auria, 1997). However, many parents frequently assess and manage febrile illnesses
at home, often without consulting a health professional (Ames, Hayden, Campbell &
Lohr, 1982).

Caregiver knowledge of what constitutes fever and appropriate management of
fever has been studied since the early 1980’s. Generally, caregiver knowledge has been
assessed either when caregivers sought medical interventions because a child was ill
(Banco & Veltri, 1984; Kramer, Naimark, & Leduc, 1985) or when the child was seen for
routine health maintenance (Anderson, 1988; Casey, McMahon, McCormick,
Pasquariello, Zavrod & King, 1984; Kilmon, 1987; Schmitt, 1980). Analysis of these
studies’ findings revealed that caregivers are unaware of what level of temperature
indicates fever. In addition, caregivers often select inappropriate fever management
strategies. Studies conducted by Casey, et al., and Kelly, Morrin & Young (1996) found
that many caregivers exhibit a great deal of concern and many misconceptions about

fever and its management. Approximately 75% of parents could not define fever

14

accurately or the temperature at which harm could occur to the child. In addition, the
majority did not know when to start antipyretic therapy, the correct dosage, or the
appropriate frequency for checking temperatures and administering subsequent doses. A
substantial minority (26.5%) voiced opinions that reflected considerable concern about
fever and it’s significance, as well as a sense of helplessness in the management of fever
(15.1%).

The focus and preoccupation on an objective measurement of body temperature to
determine fever can interfere with a caregiver’s ability to accurately observe that their
child may look and act normally despite the fever. This over concern with body
temperature and fever has been termed by Schmitt (1980, 1984, 1993) as “fever phobia”
and may actually prevent caregivers from observing more serious manifestations of the
child’s illness. This can lead to an indiscriminate usage of anti-pyretic medication to
treat fever. The indiscriminate usage of anti-pyretics is contrary to the belief that fevers
without other manifestations is the body’s natural protection against disease and may
actually benefit from allowing the fever to ‘run it’s course’ (Rosenthal & Silverstein,
1988)

Caregiver experience plays a significant role in predicting whether a caregiver
will choose appropriate medical interventions for a child. Caregivers who reported
successfully treating their older children at home for fever, expressed more self-efficacy
in their ability to care for the child and less fear about initiating the appropriate
interventions (Kilmon, 1987). A study done in 1980 by Kapasi, Lorin, Nirken &
Yudovich discovered that fifty-three percent of caregivers who felt they were

knowledgeable about antipyretics were unaware that an overdose of acetaminophen

15

(Tylenol) could be lethal or cause irreversible liver damage. Recent reports of
therapeutic excess of anti-pyretic medications and or acetaminophen overdosing, have
lead to liver failure and even death (Greene, Craft, & Grishan, 1983; McDonough, 1998;
Nogen & Brenner, 1978; Schiodt, Rochling, Casey & Lee, 1997). In addition, ibuprofen
toxicity can lead to severe agitation, hypothermia, metabolic acidosis, acute renal
insufficiency and death (Kapasi, Lorin, Nirken & Yudovich, 1980; Kim, Gazarian,
Verjee, & Johnson, 1995; Linden & Townsend (1987); Ritter & Eskin, 1998). The
literature review did not reveal a more recent caregiver knowledge study on the dangers
of anti-pyretic over dosage. However, an observation may be made; given the increased
recent literature on the consequences of specific cases of over-dosage of anti-pyretics,
caregivers may remain unaware of the dangers involved.

The literature review established the issue of the constant need for educating
caregivers on pediatric fever, but in general the studies focused on subject populations
who were relatively well educated and had small intact families. The majority of
caregivers participating in the studies were in their late twenties or early thirties with
more than a high school education and were seeing a physician with their only or eldest
child. Racial demographics ranged fi'om 50-60 % White, 20-40 % Black, and other, i.e.,
Indian, Hispanic, Asian; the latter did not significantly affect the statistical outcomes
(Robinson, et.al., 1989; Casey, et al., 1984). Interestingly, despite the obvious
advantages of education, having an intact family unit, and being older caregivers, this
group of caregivers still lacked the knowledge and many of the necessary assessment
skills to make appropriate decisions concerning their child’s fever (Kilmon, 1987; Kelly,

et al., 1996).

16

Social scientists have evaluated the breakdown of today’s families, the increase of
single parent homes, teenage mothers raising children, and the impact of lower income
and education on the health care decisions caregivers make regarding their children’s
health care. Scientists found that these have contributed to an increased lack of
knowledge regarding the children’s health and caregivers ability to care for them (Ames,
et al., 1982; Lindgren, 1990; Porter, 1990; E11, 1996).

Current social and environmental trends and the current ‘abandonment’ of
traditional family support systems have increased the family’s need for support fi'om the
health care system (Black, 1989; Porter, 1990). Fuller (1997) describes single parent
families as an unique challenge for health care providers since they may be the only
support system available to the single parent. This may account for many caregivers
having feels of inadequacy and powerlessness in dealing with their children’s illness at
home. In addition, low self esteem has been shown to be directly related to poverty, lack
of education, and lack of resources and motivation; these also have been identified as
predictors of health promotion/prevention behavior (F ord-Gilboe, 1997 ; Meurer, Meurer,
& Holloway, 1997).

Young adolescent mothers (less than sixteen years of age) were found to have
many of the negative burdens or barriers, i.e., poverty, lack of education, lack of family
support systems, and lack of parenting experience (Ames, et al.,1982; F ord-Gilboe,
1997). With no one to turn to for counseling or advice, many young mothers use the
emergency room and/or their primary care provider at alarming rates (Murphy, 1992).

Research on educational interventions has been somewhat limited to a few studies

(Casey, et al., 1984; McCarthy, Sznajderman, Lustman-Findling, Baron, Fink,

17

Czarkowski, Bauchner, Forsyth & Cicchetti, 1990; Robinson, et al., 1989). These studies
have shown an impact on caregiver’s knowledge and treatment of fever, but suggest that
more than a one time intervention is needed for knowledge retention and compliance
(Kelly, et al., 1996). McCarthy, et al., (1990) found in their research that teaching
caregivers to assess specific clinical information had its greatest effect on the reliability
and specificity of their judgements. Educational interventions which were shown to have
had the greatest impact on caregivers were a combination of reading instruction or
written material, modeling or demonstrations by the FNP, observing videos and follow-
up calls to reinforce the information (Kelly, et al. 1996).

To summarize, the issue of pediatric fever is a continuing problem for all
caregivers. Disadvantaged caregivers, i.e., those with low income, a lack of education,
and a lack of familial support and experience with children, face increased barriers which
add to the mixed dilemma of caring for the child at home with fever. Comprehensive
educational interventions can play a significant role in the home management of pediatric
fever by enabling caregivers to: adequately assess their child’s state of health, make
appropriate decisions at home, and impact the perceptions of severity and susceptibility
of disease. Educational interventions can also identify the barriers and costs/benefits of
treatment, increase provider acknowledgment and sensitivity to the various demographic
variables which influence all caregivers, and increase the cues to action which may
ultimately increase their likelihood of taking appropriate and recommended action.
Home Man_agement of Pediatric Fever

The review of the literature on the management of pediatric fever at home clearly

indicates the need for caregivers to be educated about fever (Schmidt, 1983; McCarthy, et

18

al., 1990; Kelly, et al., 1996). Effective home management of fever requires a basic
understanding of: (a) the pathology of fever, including a definition, the causes, and the
benefits and harmfirl effects, (b) caregiver assessment of fever, including, how to take a
temperature and the identification of other signs and symptoms the child is experiencing,
(c) the health care provider’s assessment and management including, past medical
history, when to call a health care provider, and application of current protocols and
specific recommendations for home management of fever. Each of these areas are filrther
explored.

Pathophysiology of fever

Fever is defined as a temperature above the normal range. A rectal temperature
above 38.0 degrees (°) Centigrade (C), i.e., 100.4°Farenheight (F), an oral temperature
above 37.8 ° C, i.e., 100° F, and an axillary temperature above 372°C, i.e., 99° F, are
considered to be fevers (Dubois, 1948; Schmidt, 1983). The body’s temperature can
average 37°C (98.6°F) and can fluctuate during the day fi'om a low of36.1°C (97.0°F) in
the morning to a high of 38°C (100.4°F) in late afternoon. Mild elevation ranging from
38 to 385°C (100.4° to 101 .2°F) can occur and be caused by exercise, warm clothing, hot
weather, or warm food or drink. Ifone of these causes is suspected, it should be
eliminated and the temperature should be retaken in one-half hour (Schmitt, 1984).

Infection is the most common cause of fever in children. Most infections are viral
in etiology and the onset of the fever indicates the start of the infection. Typically, the
disappearance of the fever signals the end of the illness or infection. Most fever
associated with viral illnesses range fiom 383°C to 40°C (101° to 104°F), and last for

two or three days (Schmitt, 1984). Uphold & Graham (1998) list other possible causes of

19

fever such as, hypersensitivity to drugs, recent immunizations with certain vaccines,
vascular occlusive and/or inflammatory events, acute hemolytic episodes associated with
acute autoimmune hemolytic anemia or sickle cell anemia, neoplasms, collagen-vascular
diseases, and central nervous system abnormalities. In general, the height of the fever
does not relate to the seriousness of the illness (Kilmon, 1987). According to Schmidt
(1983), how sick a child acts is what counts.

The pathogenesis of fever occurs when bacteria, viruses, toxins, or other agents
are phagocytosed by leukocytes. Then, interluekin—l and other chemical mediators
(previously referred to as endogenous pyrogens) are produced and activate the production
of prostaglandins. Prostaglandins act on the thermoregulatory mechanism in the
hypothalamus and upwardly readjust the body’s thermostat. Raising the hypothalamic
set-point initiates the process of heat production and conservation by increasing
metabolism, triggering peripheral vasoconstriction, and less frequently trigger shivering
which increase heat production from the muscles.

The possible benefits of fever have been only recently appreciated. Research has
documented that many human host defense mechanisms, e.g., the inflammatory response,
are enhanced by fever (Kluger, 1980; Rosenthal & Silverstein, 1988; D’Auria, 1997).
Evidence suggests that the lymphocyte transformation component of the human immune
system is enhanced within a range of slight temperature elevation. Enright & Hill (1996)
note that the role of fever may be one of enhancement of the body’s defenses, reduction
of viability of the infecting organism, or both.

In general, fever that a child usually experiences is not harmful (Schmidt, 1980,

1984,1993). However, a high fever, defined as greater than 40.5 °C (105°F) has direct

20

correlation with an increased likelihood of bacteremia (McCarthy & Dolan, 1976). It is
important to realize that fever by itself causes no brain damage or harm unless it reaches
at least 41°C (107° F). Fortunately, the brain’s thermostat keeps an untreated fever fiom
infection below this level. A fever does not climb relentlessly upward. According to
Schmidt (1980, 1984, 1993) all children experience fever, but only four percent will have
a febrile convulsion or seizure. According to Nelson & Ellenberg (1978) most common
side effects of fever in children are generally harmless. They include; mild dehydration,
discomfort, febrile delirium and simple febrile seizures. These symptoms are also
transient or treatable.

To summarize, all children experience fever and this can be viewed as the body’s
natural response to fighting off infection either viral or bacterial. Fever is usually
harmless and the overall condition of the child needs to be evaluated prior to treatment of
the fever.

Caregiver assessment of fever

The main purpose of taking a temperature is to determine whether a fever is
present or absent, not to chart its every move. In general, the temperature should be
taken once a day, in the morning, e.g.,. before noon, until the fever is gone (Schmitt,
1980,1984,l993)

In children too young to cooperate when their temperature is taken orally, axillary
temperatures are recommended at home (Schmitt, 1984). Rectal temperature taking is
fiightening and uncomfortable for many small children and their parents. It is also less
safe and occasionally leads to rectal perforation or broken thermometers (W olfson, 1966;

Frank & Brown, 1978; Schmidt, 1984). In addition, Morales, Rovira, Mongard, Sancho

21

& Bach (1983) described a rare case of intra-spinal foreign body, a clinical thermometer
bulb, which after perforating the rectum migrated through the second left sacral foramina
and sacral canal up to the epidural space at Sl-LS level.

As stated earlier, the main purpose of taking a temperature is to find out if fever is
present and not the exact level of the temperature. Schmidt (1984) recommends that
axillary temperatures are adequate for home screening. The accuracy of axillary
temperatures has some support in the pediatric literature. In a study by David (1983),
involving 77 infants and children, the axillary reading detected 93% of rectal fevers
between 38 and 389°C and 100% of fevers greater than 39 °C. Eoff and Joyce (1981)
found a mean difference of 049° C between rectal and axillary temperatures in 50
infants and preschool-aged children.

Alternative approaches used by parents include touching their child’s forehead,
plastic forehead strips, and the ear thermometer. A study by Banco & Veltri in 1982,
found that parents touching the forehead detected only 74% of all febrile children;
however 90% of the children with fever greater that 389°C (102°F) were detected. The
plastic forehead strips were found to be unacceptable substitutes for thermometers in
three studies; the Clini-temp failed to detect 57% to 72% of children with fever and the
Fever Scan failed to detect 21% to 33% of children with fever (David, 1983, Reisinger,
Kao & Grant, 1979; Scholefield, Gerber, Dwyer, 1982).

The ear therrnos-scan thermometer or the infrared tympanic thermometer (ITT) is
appealing to many caregivers as it offers a clean, rapid, convenient, painless and
noninvasive replacement for the rectal thermometer. However, it is subject to user error

and expensive to buy. Research done by Yaron, Lowensein, Koziol-McLane (1995)

22

showed the ITT missed a significant proportion of patients with fever. The authors also
stated that the errors in measurement may occur because of inadequate technique, wax in
the auditory canal, or device inaccuracy. Kelly, et al., (1996) concluded that many
parents weren’t aware that in order to obtain an accurate reading the scope must be
directed on the tympanic membrane and not be placed haphazardly in the ear canal.

As stated previously, the temperature should not be the sole determinant of the
need to treat a fever. Specific caregiver assessments and close observations concerning
the child’s state of health need to be explored. McCarthy, et al., (1990) found that careful
observation of the state of well-being of a child to be the most important assessment
component in identifying a seriously ill febrile child. Questions they identified to aid in
the caregiver’s assessment include: Is the child less than six months of age? Is the child’s
fever accompanied by seizures, chills, listlessness, abnormal breathing, stiff neck,
excessive irritability, confusion, ear pain, sore throat, vomiting or diarrhea, urinary pain
or rash on the skin? Is the child’s fever greater than 104°F?, Has there been no
improvement in the last seventy- two hours? Does the child suffer fi'om other chronic
diseases, a history of seizures or has the child recently received immunizations?
(American Institute of Preventative Medicine, 1994; Schmitt, 1984).

Health care provider’s assessment and management of Miatric fever

Management of fever in a child begins with careful observation of the child’s
state. For example, is the child active or lethargic? Does the child have a decrease in
appetite? Is the child fussy or has his/her mood changed? (Rosenthal & Silverstein,
1988). If the overall condition of the child does not appear to be affected by the fever,

research suggests allowing the fever to run its course (D’Auria, 1997; Upholt & Grahm,

23

1998). Comfort measures as simple as offering a child fluids every 15-60 minutes, having
the child wear light clothing, avoiding bundling a febrile child, reducing activity of the
child, providing additional rest, and encouraging light meals may be enough to give the
child relief from the discomfort of a fever (Schmidt, 1993; D’Auria, 1997; Uphold &
Graham, 1998).

The use of antipyretic medication can afford considerable relief of the associated
fever discomfort (Rosenthal & Silverstein, 1988). D’Auria (1997) describes general
fever management interventions for children without specific localized infection and in
children less than three months of age. Intervention included the use of antipyretics for
temperature of 39 to 394°C (greater than 102°F to 103°F) or if the child is
uncomfortable. Children with a history of febrile seizures, underlying chronic disease or
immune disorder may need earlier or more aggressive antipyretic schedules (D’Auria,
1997). Acetaminophen 15mg/kg per dose up to five doses in 24 hours was
recommended. McNeil Pharmaceuticals (1998), the maker of Children’s Tylenol,
recommends the following dosing: (a) Children 0-3 months or 6-11 pounds- Infant
Suspension or Original Tylenol drops containing 80mg/.08ml., or a ll/2 dropper of
Suspension or Elixir (160mg/5cc) 1/4 teaspoon (tsp); (b) Children 4-11 months or 11-17
pounds-1 dropper of Suspension or V2 tsp. of Elixir; (c) Children 12-23 months or 18-23
pounds- 1 1/2 droppers of Suspension or 3%: tsp. Elixir or 1 V2 tablets of Children’s Tylenol
Chewable Tablets containing 80 mg. each tablet (tab); ((1) Children 2-3 years old or 24-
35 pounds- 2 droppers of Suspension or Elixir 1 tsp. or 2 chewable tabs; (e) Children
ages 4-5 years old or 36-47 pounds- 1 1/2 tsp. Elixir or 3 chewable tabs; (0 Children 6-8

years old or 48-59 pounds- 2 tsp. Elixir or 3 chewable tabs; (g) Children 9-10 years old or

24

60-71 pounds- 2 1/2 tsp. Elixir or 5 chewable tabs; (h) Children 11 years old or 72-95
pounds- 3 tsp. Elixir or 6 tabs; (i) Children over 12 years old or over 96 pounds may take
2 Adult Tylenol tabs. (325mg/tab).

Alternative therapy proposed was ibuprofen in children between 6 months and 12
years of age for temperatures less than 39.2°C (less than 102.5°F) or ibuprofen 5mg/kg
per dose every eight hours. However, if the temperature is 39.2°C or higher (greater than
102.5°F), ibuprofen 10mg/kg per dose every eight hours (available in 100mg/5m1) was
suggested. For children, 12 years of age and older, one tablet (200mg) every four to six
hours was suggested. Ifthe fever does not respond to one tablet, the dosage may be
increased to two tablets. D’Auria (1997) stated that the number of tablets should not
exceed six tablets in a twenty-four hour period. Whitehall-Robins Healthcare (1998) a
division of American Home Products Corporation, makers of Advil (iburpofen) and
McNeil Pharmaceutical Corporation (1998) makers of Motrin (ibuprofen) recommend the
following medication dosing for the suspension of 100mg/5ml or 1 teaspoon: (a) Children
6-11 months of age or 12-17 pounds for fever at or under 102.5° F- 1/4 tsp, or fever over
102.5° F- V2 tsp; (b) Children 12-23 months or 18-23 pounds with fever at or under
102.5° F- 1/2 tsp. or over 102.5° F- 1 tsp; (c) Children 2-3 years old or 24-35 pounds-1
tsp; (d) Children 4-5 years old or 36-47 pounds- 1 1/2 tsp; (e) Children 6-8 years old or
48-59 pounds- 2 tsp; (0 Children 9-10 years old or 60-71 pounds- 2 1/2 tsp; (g) Children
11 years old or 72-95 pounds- 3 tsp.

Aspirin is contraindicated in children and adolescents with high fever due to the
association between aspirin and Reyes syndrome (Uphold & Grahm, 1998; D’Auria,

I997). Caregivers need to be aware of other over the counter medications which contain

25

aspirin such as Pepto-Bismol and to avoid giving these types of medications when their
children have fevers (Uphold & Graham, 1998).

Historically, other methods used by health care providers and caregivers have
included sponging the child with water and/or alcohol, or placing the child in a tepid bath
water. Sponging is unnecessary in the majority of febrile episodes and sponging with
alcohol is contraindicated (D’Auria, 1997; Uphold & Grahm, 1998). Sponging is
recommended only when the need for aggressive treatment of fevers is indicated, i.e., if
fever is extremely high or child has history of febrile seizures; for children with liver
disease who cannot take acetaminophen; for children with neurologic problems in which
temperature regulation mechanisms are abnormal may experience heat stroke; or in
environments with excessive temperatures. Using a tepid bath is not currently
recommended due to the increased discomfort children feel due to shivering which may
actually lead to an increase in body temperature (D’Auria, 1997; Uphold & Graham,
1998)

While most childhood fever is self-limiting and can be managed at home, the
caregiver needs a guideline for home management as well as for calling a health
professional. As stated previously in the caregiver assessment section, caregivers must
call their health care provider if any of the accompanying signs and symptoms are
associated with fever.

In summary, the literature review identified information to be included in a guide
for home management of pediatric fever based on scientific research; this information
guides the assessment of fever, the need for treatment, and the type of treatment options

available to caregivers and health providers.

26

The FNP in the Rgle of the Edugtor

As far back as Nightingale (1859), teaching has been recognized as a nursing
function. Today, the nurse practice acts in many states and the national guidelines from
the American Nurses Association (1979) and the American Hospital Association (1972)
mandate nursing’s obligation to help patients learn to take care of their health and self-
manage their illnesses. Leventhal and Johnson (1983) describe the nurse as the
professional who acknowledges the patient’s perception of illness, the personal impact of
their illness, and the strategies they use to respond to their illness experience.

Rankin and Stallings (1990) describe the relationship between patient education
and nursing practice as:

The most effective means of returning control to the patient by reducing feelings

of helplessness and enhancing the ability to be the chief decision maker in the

management of one’s health and illness problems. We view patient education as
the essence of nursing practice (p2).

It is the essence of nursing as described by Rankin and Stallings (1990) that
provides a foundation for preparing nurses for a generalist role as a registered nurse
(R.N.) which includes associate degree, diploma, and bachelor of science academic
preparation. However, the master’s prepared FNP expands this basic role of educator,
from the generalist (RN) to primary care provider (FNP). The latter incorporates patient
teaching and counseling acquired through graduate education which builds upon previous
practice and experience.

Rankin and Stallings (1990) identify the significance of the FNP as an educator in

clinical practice and emphasize this role in patient education. Routinely, the FNP

27

addresses four components in the plan of care: (a) Dx: Diagnostic test and consultation,
(b) Rx: Pharmacologic and other therapeutic interventions; (c) Pt. Ed.: Patient
Education; and, (d) F/U: Follow-up. Thus, the FNP is constantly reminded that patient
education is one of the four important parts of the management plan that should always
be considered and documented in the primary care setting. The follow-up portion of the
management plan presents an opportunity for the FNP to evaluate and document the
patient’s response.

An. added impact regarding the attention and detail towards patient education may
be that it sets FNP practice apart from other primary care providers. Research
demonstrates that in general, the quality of primary care provided by nurse practitioners
is equivalent to that provided by physicians and that patients are particularly pleased with
the health education provided by nurse practitioners (Mundinger, 1994).

Historically, the role of the CNS has had a strong component of team-building
and team support. .The CNS’s effectiveness was frequently measured by how effective
the team was in reaching mutual goals. It is not surprising, then, that many CNSs have
placed a high value on education and spent a large segment of their time performing the
educator role (Hart, Lekander, Bartels, & Tebbitt, 1987). Robichaud and Hamric (1986)
found that CNSs spent 27% of their time on staff, student and community education.

In general, advanced practice nurses are committed to filrther their own education,
but they also assume responsibility for providing continuing education for other nurses
(Sparks, 1995; Benner, 1984). Collaboration in the health care arena is essential and the
FNP needs to'work with other health care providers to assure the timely delivery of

education to meet the needs of the clients. The FNP role requires education, re-

28

education, collaboration and cooperation with their nursing colleagues in order to provide
the best opportunity for patient education (Sparks, 1995). Nurse practitioners have
identified the teaching-coaching firnction as one of the major areas of their practice
(Brykczynski, 1989).

In conclusion, the literature suggests that one of the most important and
significant roles of the APN, and in turn the FNP, is that of patient and colleague
educator.

Development of the Model

The literature review provides the essential elements in order to develop an
educational model for the FNP in the home management of pediatric fever. This section
reflects the author’s organization of the information for the educational model. As
mentioned earlier, the literature review did not reveal a previously developed model for
use by the FNP when educating caregivers on home management of pediatric fever.
Thus, this educational model, referred to as the Wilson Educational Model (WEM) is
based upon scientific evidence and research; it provides flexibility and guidance to the
FNP when developing a management plan for the child and educating the caregiver.

The WEM utilizes Knowles’ educational principles of adult learning. Knowles
(1980) recognized that adult patterns of learning are quite distinct from those used by
children. He suggested that adults, because of their more extensive backgrounds and
greater independence, bring more to a learning experience, and that the instructor should
serve as a facilitator with the opportunity to benefit from the exchange as much as the
learner. Knowles’ views on teaching adults are summarized in his four principles of

andragogy. In Knowles’ view, the approach taken in teaching adults is so different from

29

the approach used with children that a new term, andragogy, is needed to describe “the
art and science of helping adults learn.” (p. 43). A brief discussion describing these four
principles of adult learning follows.

1) Adults are independent learners. The process of moving from childhood to
adulthood is a process of moving from dependence to increasing independence. There is
a deep psychological need for adults to see themselves, as well as to have others see
them, as generally independent or self-reliant. The educator working with adult learners
must respect the independence and ability of the adult learner to control his/her own
learning. Adults are responsible for what is to be learned and take an active role in their
learning. The learning takes place between the learner and the material; the teacher
facilitates the exchange.

2) Adults ’past experiences are resources for learning. Unlike children, adults
have a reservoir of past experience, which can be a resource for learning. Whenever
possible, adult past experiences should be drawn upon to enhance the learning process.
Further, adult self-images are often defined, at least in part, by their past experiences and
they have a deep investment in their value. Ignoring these past experiences in current
learning can be interpreted as essentially rejecting a large part of the adult learner.

3) Adults’ readiness to learn emerges fiom life ’s developmental stages. The adult
learner’s readiness to learn develops from life’s tasks and problems. As the adult years
progress, there is a shift in career, social roles, personal responsibilities, etc. The
transitions which evolve during life create opportunities for learning as the individual
strives to better understand and cope. Such phases have been labeled as “teachable

moments.” The individual is both more highly motivated to learn and the information is

30

more readily understood when presented within this context.

4) Adults’ learning is task or problem oriented. Adults will seek out various
resources for specific learning (information skills) to help them in answering a question
or dealing with a problem. They are motivated in their learning to find answers or solve
problems. Learning experiences will be most effective when they respond to adult
learners’ perceived needs.

Hence, the WEM for the FNP in the home management of pediatric fever is
guided by these four basic principles of adult learning as applied to the FNP and to their
clients, the caregivers of pediatric patients.

The Wilson Educational Model

The Wilson Educational Model (WEM) contains a guide for the FNP to facilitate
the discussion on home management of pediatric fever with the caregiver. This includes
educational objectives and teaching strategies as well as a brief review for the FNP on
identifying those caregivers that may benefit most by an educational intervention. It also
includes the definition of fever, pathogenesis of fever, and the benefits and harmful
effects of fever. A caregiver assessment guide and an educational pamphlet outlining
appropriate home management of fever that the FNP can review with the caregiver is also
included. In addition, a demonstration model on the proper technique of taking an
axillary temperature is provided. Furthermore, a list of web site addresses, educational
videos, and alternative community resources to assist the FNP in a variety of educational
techniques is included. The WEM also offers a suggested follow-up call sheet that could
aid the FNP in providing reinforcement of the educational interventions and to evaluate

the educational model’s effectiveness.

31

The complete packet of the Wilson Educational Model: Home Management of
Pediatric Fever (WEM), is included as Appendix A. This is the product for use and
reference for the FNP in practice.

Educational Objectives

For health instruction to be effective, a systematic plan with specific instructional
or educational objectives and teaching strategies need to be identified (F edor & Dalis,
1989). The educational objectives for the FNP address the problem of pediatric fever.
Studies suggest that 20-3 0% of emergency room visits and approximately 30% of out-
patient visits include fever as part of the chief complaint for children (Murphy, 1972;
D’Auria, 1997). Despite the availability of over the counter antipyretics and the mass
advertising on fever control, caregivers remain confused and lack an understanding of
fever and appropriate home management (Casey, et.al, 1984). This has resulted in what
some experts perceive is “fever phobia” (Schmidt, 1980) on the part of caregivers. It
results in an increase in unnecessary visits to health care providers or emergency
departments and the overdosing of antipyretics.

Therefore, the educational objectives for the WEM are directed towards the
caregiver and the FNP. The goal or major outcome sought is the proper home
management of pediatric fever by caregivers. Thus, the result being a decrease in
unnecessary visits to the health care provider’s office and/or emergency room with fever
as the sole complaint. The following are the WEM objectives: (a) Caregivers will
demonstrate an improved knowledge of fever as evidenced by defining “fever”,
describing its cause and identifying the harmful and the beneficial effects associated with

fever; (b) Caregivers will verbalize appropriate home management of their child’s fever;

32

(c) Caregivers will demonstrate the technique for taking and reading an axillary
temperature; (d) Caregivers will state when they can manage the child’s fever at home
and appropriately identify when they must see a health professional; (e) Caregivers will
verbalize where to find appropriate dosing instructions about antipyretic medications and
recognize the dangers of over dosing of these over the counter medications;(f) Caregivers
will identify other comfort measures that they can initiate in caring for the child’s fever at
home; (g) The FNP will increase his/her knowledge of pediatric fever and enhance the
caregiver’s knowledge and management of fever through the use of the WEM; (h) The
FNP will identify alternative teaching strategies and resources available in his/her
community; and (i) The FNP will utilize the follow-up call sheet to evaluate the
effectiveness of the WEM.
Fever Review Guide for the FNP

In order for the FNP to make effective educational interventions, it is important to
include a review of the basics of fever, i.e., the definition, the pathogenesis, and benefits
and harmful effects. Furthermore, identification of caregivers that may benefit most from
an educational intervention is required. The ‘Fever Review Guide’ for the FNP
incorporates this information in an organized and logical sequence. It is formatted for
quick reference using bullets and bold print to identify major content areas and to aid
readability of the guide (Figure 3.).

The literature review established a definition of fever as an elevation of body
temperature greater than 100 °F orally, 100.4 °F rectally, or greater than 99° F axillary
(Uphold & Graham, 1998). Fever occurs when bacteria, viruses, toxins, or other agents

are phagocytosed by leukocytes. Interluekin-l and other chemical mediators are

33

Fever Review Guide for the Family Nurse Practitioner

What is a fever?
0 An elevation of body temperature greater than 100 °F orally. 100. 4 °F rectally, or greater than 99 °F
axillwy (Uphold cf: Graham. I 998).

What causes afever?

0 Infection is most common cause of fever in children with most infections viral in etiology and lasting
from two to three days (Schmitt, 1984).

o Other medical conditions and causes for fever include: Hypersens'tivity to drugs, recent
immunizations with certain vaccines, vascular occlusive and/or inflammatory events, acute hemolytic
episodes associated with acute auto-immune hemolytic anemia, neoplasms, collagen-vascular
diseases, and central nervous system abnormalities (Uphold & Graham).

0 Environmental causes of fever include; exercise, warm clothing or bundling, hot weather, or warm
food or drinks (Schnritt, 1984).

What is the pathology of fever?

Fever occurs when bacteria, viruses, toxins, or other agents are phagocytosed by leukocytes. Interluela'n-l
and other chemical mediators arreviously known as endogenous pyroxenes) are produced and activate die
production of prostaglandins. Prostaglandins act on the thermoregulatory mechanism in the hypothalamus
and upwardly readjust the body ’s thermostat. Raising the lmoothalamic set-point initiates fire process of
heat production and conservation by increasing metabolism, triggering peripheral vasoconstriction, and
less fi'equently by triggering shivering which increase heat production from the muscles (Uphold &
Graham, 1998).

What are the benefits and harmful efi’ects of fever?

0 Fever enhances die inflammatory response which results in a reduction of viabi lily of the infecting
organism, within a range of slight temperature elevation (D ’Auria, 199 7).

0 Children usually sufi’er no harmfirl effects and a fever by itself causes no brain damage or harm unless
it reaches 107 °F (McCarthy & Dolan, 1976).

0 Bacterial infections seem to be most usually linked with higher fevers 105 °F and greater (McCarthy &
Dolan, I 9 76).

o The most common side effects of fever are harmless and include mild dehydration. discomfort, febrile
delirium and simple febrile seizures (Nelson & Ellenberg, 1978).

Who may benq‘itfi'orn educational intervention on fever?
Caregivers who present to oflice or clinic with a child with fever and have not initiated treatment at
home prior to seeking professional advice.

0 Caregivers who have initiated inappropriate treatment prior to seeking profess‘onal advice.

0 Caregivers who appear anxious or unsure of appropriate home management of fever.

0 Caregivers who are <16 years of age, .n'ngle parent/caregiver, lack of caregiver experience, low
income, lack of familial support, low education.

Figt_rre 3. Fever Review Guide for the Family Nurse Practitioner

34

produced and activate the production of prostaglandins. Prostaglandins act on the
thermoregulatory mechanism in the hypothalamus and upwardly readjust the body’s
thermostat. Raising the hypothalamic set-point initiates the process of heat production
and conservation by increasing metabolism, triggering peripheral vasoconstriction, and
less frequently by triggering shivering which increases heat production from muscles
(Uphold & Graham, 1998).

Infection is the most common cause of fever in children. Most infections are viral
in etiology, have temperatures of 101° F to 104° F, and last from 2-3 days (Schmidt,
1984). Other conditions which may cause fever include; hypersensitivity to drugs, recent
immunizations with certain vaccines, vascular occlusive and/or inflammatory events,
acute hemolytic episodes associated with acute auto immune hemolytic anemia,
neoplasms, collagen-vascular diseases, and central nervous system abnormalities.
Different environmental causes of fever include; exercise, warm clothing or bundling, hot
weather, or warm food or drinks (Uphold & Graham, 1998).

A benefit of fever is the inflammatory response, which is enhanced by a fever and
appears to reduce the viability of the infecting organism (Kluger, 1980; Rosenthal &
Silverstein, 1988; D’Auria, 1997). The most common side effects that children
experience with fever include; mild dehydration, discomfort, febrile delirium and simple
febrile seizures; all of which are generally harmless, transient and treatable (Nelson &
Ellenberg, 1978). According to Schmidt (1980, 1984, 1993), all children experience
fever, but only four percent will have a febrile seizure. Brain damage secondary to high

fever does not occur unless the temperature reaches 107° F. Bacterial infections seem to

be mostly linked with higher fevers (>105° F) (McCarthy & Dolan, 1976).

35

As stated in the literature review, the caregivers that must overcome negative
burdens or barriers in order to make appropriate health care decisions for their children
were identified as young (< 16 years old), single and poor, and lacked education,
experience, resources and motivation (Ames, et al., 1982; Ford-Gilboe, 1997). However,
those caregivers that do not face these negative social burdens still lack knowledge of
what constitutes fever and what appropriate home management of fever includes. Studies
conducted by Casey, et al. (1984) and Kelly, Morin & Young (1996) found many
caregivers exhibit a great deal of concern and many misconceptions about fever and its
management. Schmidt (1980) developed the term “fever phobia” to describe the intensity
of caregivers’ unfounded fears concerning fever and its consequences. Therefore, it is
important that the FNP recognizes that all caregivers may actually benefit from fever
education. However, some caregivers may need more specific instruction than others.
Thus, the WEM enables the tailoring of the interventions according to the needs of the
caregiver and the situation.

The Educational Pamphlet

The educational pamphlet, C.A.R.E. (Figure 4.), summarizes the key factors that
promote appropriate home management of pediatric fever. It includes a brief review of
fever and its causes, reasons for reducing a fever, interventions to reduce a fever,
appropriate dosage of antipyretic medications, and when to contact and/or see a health
care professional.

This educational pamphlet provides the caregiver with written instructions that
compliment the verbal instruction given by the FNP during the educational intervention.

The information that patients and their families retain during a routine visit to a health

36

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38

care provider is no more than 50% (Falvo, 1994). This is due to anxiety, large amounts
of information conveyed, minimal medical knowledge, and personal intellectual level.
Supplemental written instruction should assist the caregiver to remember the provider’s
instructions when returning home (F alvo, 1994).

When developing an education pamphlet, Doak, Doak, and Root (1997) suggest
the following points be considered to ensure comprehension by people at all literacy
levels: (a) write how you talk, use active tense of verbs not passive; (b) use common
words; (c) avoid medical jargon; and (d) use 12pt font or larger print. Falvo (1994) states
that the material should be organized with clear and specific instructions that reinforce
what was discussed during the provider-patient-caregiver contact. Rankin & Stallings
(1996) recommend that pamphlets make points vivid, sequence information logically and
include the smallest amount of information possible. Barnes (1996) states that in order
for patient educational materials to be easily understood in the general population a sixth
grade reading level is a reasonable goal. The educational pamphlet for the WEM utilized
these suggestions and the final pamphlet was reviewed by an educational reading
specialist and by several sixth graders. The pamphlet was found to be easy to read and
understandable at the sixth grade reading level.

Based upon the review of the literature and current recommendations for the
home management of pediatric fever, the WEM’s pamphlet uses the acronym C. A. R. E.
(Figure 4.) for the sequencing of the home management of fever. It is a one page tri-fold.
pamphlet with print on all sides and offers the following definitions for the letters: C-

Check your child’s temperature. Ifyour child’s temperature is over 100° F orally or

99° F axillary your child has a fever (Uphold & Graham, 1998). A-Assess your child

39

for other symptoms. How does your child look and act? Is the child active or appear
sleepy? Is your child fussy or uncomfortable? Is your child eating and drinking? Has
your child ever had a seizure or convulsion? Does your child have other medical
problems? (Rosenthal & Silverstein, 1988). If your child is affected by the fever then,
R-Reduce the fever. Keep child lightly dressed, make sure your child drinks plenty of
cool liquids, encourage small light meals and snacks, give acetaminophen (Children’s
Tylenol) every 4-6 hours or ibuprofen every 6-8 hours.(See medication chart on back of
pamphlet for proper dose). If possible use the child’s weight to determine dose,
otherwise use age (Uphold & Graham, 1998). Sponge the child with luke warm water if it
makes your child more comfortable. DO NOT use rubbing alcohol or put child in a bath
or shower (Schmidt, 1993; D’Auria, 1997; Uphold & Graham, 1998). E-Evaluate your
child’s response. If your child does not respond to these measures or more sick see your
health care provider. In addition, the pamphlet includes a brief definition of fever, a
guide about when to contact a health care provider, and a dosing chart for acetaminophen
(Children’s Tylenol) and ibuprofen (Motrin or Advil).
The Demonsm'on Mme! for Im'ng an Axillag Temmture

The review of literature revealed that taking a child’s temperature via the axillary
route to be the safest and easiest in terms of accessibility and the caregiver’s comfort
level. The Axillary Temperature Demonstration Model for the Family Nurse Practitioner
(Figure 5.) is presented as a three page guide for the FNP. It combines role playing by
the FNP with step by step discussion points with the caregiver on the technique of taking
an axillary temperature (Novitt-Moreno, 1997). It also includes a return demonstration

and discussion guide.

40

Axillary Temperature Demonstration Model
For the Family Nurse Practitioner

This demonstration model can be used to provide background information for the
FNP or can be employed as a script and/or guide of conversation points for the FNP with
the caregiver. It can facilitate the discussion with the caregiver an axillary temperature
tala'ng and promote feedback fiom the caregiver. Included is a step by step
demonstration of the technique for properly taking and reading an axillary temperature
on a child The FNP should first discuss the importance of properly taking an axillary
temperature and then demonstrate the technique on the child with the caregiver. A
return demonstration by the caregiver with time allotted for questions should follow.

Introduction to taking an axillary temperature on a child

Choosing the Method

Babies and children younger than age four or five are too young to keep their
mouths closed for oral temperature readings, so their temperatures must be taken either
in the rectum or under the armpit (axilla).

You can usually take an older child ’s temperature orally (by mouth) if he is
mature enough and alert enough to be able to keep his lips closed tightly around the
thermometer. However, if your child has fiequent coughs or is breathing through his
mouth because of a very stufiy nose, he might not be able to keep his mouth closed long
enough for an accurate oral reading. If this is the case, it would be better to take his
temperature either in the rectum or under the arm. I recommend the armpit for taking
the temperature at home as the safest, easiest and least invasive way.

Temperature measured in the armpit (axilla) is called an axillary temperature
reading. It is an alternative to the rectal method for hymns and children younger than
age four or five. It is also useful in older children who are so upset or uncomfortable
fiom an illness that they can ’t cooperate in taking either a rectal or oral temperature.
However, this is the least accurate way of taking a temperature and is usually ’/:-I degree
lower than an oral reacting. T o adjust the reading just add 1/2-1 degree to determine if
child has a fever. Remember this is just to see if your child has a fever. You must always
evaluate the child ’s overall condition to see how sick the child really is!

Choosing the thermometer

Both glass mercury thermometers and digital thermometers will give you an
accurate reading. What ’3 most important is that you choose a thermometer that ’s easy to
use and read

The newest thermometers are the ear thermometers that quickly and easily
measure temperature inside the ear canal. Ihey are still fairly expensive compared with

41

the glass and electronic models, and learning how to use them correctly takes some

training.

Forehead thermometers are convenient and comfortable to use, but they are not
very accurate. lhey may be handy for quick screenings, but for exact readings use a
glass thermometer or a digital one. Glass thermometers can shatter and release the
harmful mercury inside, so handle them carefully. In fact, it is always wise to have a
spare glass thermometer at home in case of accidents.

Taking an axillm temperature (all ggesz

Use an oral thermometer for this method

Prepare the thermometer by washing it in cool (not hot) soapy water or
rubbing alcohol.

If using a glass thermometer, shake it down to below 96 degrees. Make sure
that you have a watch or clock nearby for timing the reading. If you are using
a digital thermometer, read the directions beforehand so that you know which
beep, or series of beeps, is a sign that the thermometer is finished reading.

T urn it on and check that the screen is clear of any earlier reading.

Insert the thermometer in you child’s armpit. F old your child ’s mm across
his chest, and hold the thermometer in place for 4 to 5 minutes before reading
it. Axillary temperature readings tend to be about ’/2 to 1 degree lower than
temperatures measured orally. Digital thermometers will automatically beep
when done. Make sure the thermometer end is up in the armpit with the skin
surrounding it and not in an air pocket in the space under the armpit. This
will ensure a more accurate reading.

For a glass thermometer, read and record the number at the end of the
colored line. For a digital thermometer, read and record the number on the
screen.

Always note the time of day that the reading was taken. Temperatures in the
morning we usually lower than in the late (y‘ternoon. Note also, what your
child was doing, where he was at, i. e., in the sun or shade, and what he was
wearing prior to taking the temperature. Remember activity, exercise, being
indoors or outdoors in excessive heat or cold and overadressing can all effect
a child ’s temperature. Assess the situation and your child ’s behavior prior to
deciding if a fever is present. If any of these “environmental ” elements occur,
have your child rest, un-dress, drink cool fluids, and re-take the temperature
later.

An axillary temperature of 99 degrees can indicate that your child has a fever
and may need to be treated See flow-chart for caregiver assessment

42

guidelines for home management of a fever.

0 After using the thermometer, clean with warm soapy water or with rubbing
alcohol and store in a safe cool place.

Demonstration of taking an axillm temperature

0 Show the client both the glass thermometer and the digital thermometer.

0 Demonstrate how to shake down the glass thermometer and how to turn on
the digital thermometer.

0 Demonstrate proper placement of the thermometer under the child 's armpit.
Stress the importance of the under arm skin contact to the end of the
thermometer and holding the child ’s arm tightly across his chest.
Demonstrate the “bear hug ” as a gentler way of holding the child ’s arm
across the chest and as a reassurance that this will not hurt the child

0 Reinforce the need to keep the thermometer under the arm for 4-5 minutes or
until the digital beep goes off Removing the thermometer before this time will
not give an accurate reading.

0 Demonstrate reading the glass thermometer by turning the thermometer in
your fingers until you can see the end of the colored line. Show the caregiver
the location of the reading display on the digital thermometer.

0 Demonstrate shaking down the glass thermometer and turning of the digital
thermometer. Discuss cleaning and proper storage of both thermometers.

0 Allow the caregiver to perform a return demonstration of the techniques
discussed

0 Allow for questions and continued reinforcement of the procedure.

0 Document on the child ’s chart that a demonstration of the technique of tala'ng
an axillary temperature was done and that the caregiver verbalized
undersumding of the procedure.

(Source: Moren-Novitt, 199 7)

Figure 5. Demonstration model on taking an axillary temperature
43

Demonstration is useful for cognitive and psychomotor learning. It is most often
used to teach skills and to present standards of performance. Demonstration may be done
in person or via videotaped programs. The sense of sight is used in learning by
demonstration, but hearing, smell, and taste may also be stimulated (Rankin & Stallings,
1996). According to Rankin & Stallings (1996) a demonstration should be performed
slowly and the teacher should be certain that the learner can see and hear well, and that
all equipment or supplies that will be used at home is available for the demonstration.
The authors continue that repetition and return demonstration are needed for teaching
procedures with multiple steps.

Role playing and return demonstration involve doing or practicing. They help the
learner to apply knowledge or skills, usually after the demonstration (Rankin & Stallings,
1996). When used appropriately, role play and return demonstration tailor the learning to
the individual’s past or present life experiences while the teacher is there to offer
feedback and advice. This incorporates the adult principles of learning that Knowles
(1980) advocates and which were discussed previously.

Alternative Educational Resoigces for Home Management of Pediatric Fever

Health education has become an integral part of patient empowerment and the
ability to apply the principles of home management and appropriate medical decision
making for caregivers and their children. Learning can and should be enjoyable.
Knowing how to use a variety of learning activities to meet educational objectives can
make patient education more interesting, challenging, and effective for both the FNP and
the learner. The WEM for home management of pediatric fever incorporates many

learning activities such as guided discussion, demonstration and role play, simulation,

44

and practice. These are reflected in Figure 6., Alternative Educational Resources for
Home Management of Pediatric Fever; and Figure 7., Pediatric F ollow-up Call Sheet.
Applying the use of creative mediums with learning activities not only enhances those
learning activities, but can make the educational experience more enjoyable. Rankin &
Stallings (1996) propose several forms of mediums available today which may strengthen
learning activities. These include the media, posters, displays, flipcharts and bulletin
boards, graphics, electronic media, objects, models, and demonstrations, community
resources, games and simulations, photographs and drawings, audio materials and
videotapes, and printed materials as pamphlets or bulletins. The authors further indicate
that no one medium is best suited to all purposes and that the application of media should
be consistent with learning objectives. Just as learning activities promote certain types of
behaviors, media are also chosen to coincide with objectives. The media chosen must be
compatible with the learning needs of the audience and the environment in which the
learning takes place (Rankin & Stallings, 1996).

Effectively incorporating patient education into the primary care setting is
particularly difficult. As Bonnel (1996) points out “the clock is ticking”, as a familiar
phrase in the primary care clinic. The author suggests several ideas that can maximize
the lO-minute teaching opportunity (Bonnel, 1996). These include: 1) good resources
readily available, 2) good quality educational video tapes that can be viewed while at the
health care setting or checked out and viewed at home, 3) instruction given to patients or
caregivers to seek feedback on questions or concerns either with bringing questions in at
another appointment time or by letting them know they can call a “phone nurse” to

answer questions, 4) access to a list of phone numbers for community resources and

45

Alternative Educational Resources for
Home Management of Pediatric Fever

Edrrcafional Videotapes:

The University of Wisconsin Medical School
Patient Education Video Tapes; Ihe Facts abflt Fever
Order number 020294F $19. 95 +tax and shipping

Milner and Fenwick Inc.
Patient Education Videos; When youL baby ’3 sick
$25. 95 +tax and shipping

Computer based patient education- Web sites:

www.medsch.wisc.edu/uwhosp/outreach/pohindex.html
www.ama.assn.org/kidshealth
www;pediatricneurology.com/febrile.html
www.drkoqp.com/adamépeds/tqp/OO3400.html
thmdflbqnuduwthks

 

 

 

 

 

 

Community Agencies/Parental Support Groups

 

Local Family Independence Agency or Department of Social Services:

 

Local Public Health Department:

 

Parental Support Groups:

 

Women Infants and Children (WIC) and Michigan Infants and Children WIC):

 

Red Cross:

 

Local Hospitals-Case Management Departments:

 

Figure 6. Alternative Educational Resources

46

Pediatric F ollow-up Call Sheet

Otild’s Name FNP Name

 

 

Caregiver’s Name andrelation tochild

 

Date ofvisit and educational intervention

 

Presented with do

 

 

How is child doing now?

Do you have questions regarding your child’s fever?

Explain how you would assess your child ’s physical condition when he is sick?

Describe how you would take an axillary temperature. What temperature

suggests your child has a fever?

How much acetaminophen (Tylenol) or ibuprofen (Motrin orAdvil) should you
giveyour childandhow oflen? Where wouldyou look tofindtheproper dose?

What are the risks that overdosing of these medications can cause?

Are you comfortable with when to manage you child at home with a fever and
when it is appropriate to see a health professional?

Is there anything else we can assist you with in the care of your child?

Figure 7. Pediatric Follow-up Call Sheet

47

support along with educational follow-up calls by the health provider, 5) identify all
moments with the patient as “reachable moments”, which at times may just be to capture
the patient’s interest and convey the importance of this content to their health by
supplying pamphlets and teaching materials, and 6) follow-up of patient teaching either
with a re-check appointment or a follow-up phone call.

The WEM provides for the essential elements of effectively incorporating
caregiver education in the primary care setting by the FNP by utilizing these suggestions.
The model includes a list of alternative resources and materials to enhance the proposed
learning activities while allowing flexibility on the part of the FNP to individually apply
the WEM to each caregiver’s educational need.

The follow-up call sheet can be a useful tool in evaluating caregiver learning
outcomes. According to Rankin & Stallings (1996), evaluation of patient education
involves collecting specific and descriptive data related to behaviors targeted as patient
learning objectives. The Pediatric Follow-up Call Sheet (Figure 7.) which is based on the
caregiver objectives, is meant to aid the FNP in evaluating the usefirlness of the WEM
and as an educational reinforcement on home management of pediatric fever.

Implications

As the FNP assumes a stronger role as a primary care provider it becomes
increasingly important to demonstrate the quality of care at reduced costs. Patient
education is one of the most significant ways to decrease health care costs by
empowering patients and their families to make appropriate health care decisions prior to
seeking professional advice and treatment which is often expensive. The following

discussion examines the implications of this project and its product for research, practice,

48

and education.
Rmch

The ultimate goal of any profession is to establish a base of knowledge that will
guide the practice of its members. As nursing has advanced, so has its members’
commitment to research. FNPs can and do play an integral role in identifying key
practice problems for which research is needed. An equally important role exists in the
utilization of research findings in practice.

Evaluation and research are very similar. Many designs used for research are also
applicable for evaluation studies, i.e., a pre-post test design may be used in research and
evaluation (Hampton & Snyder, 1995). However, distinctions between these two
processes exist. According to Hampton and Snyder (1995), research is conducted to
generate knowledge that can be generalized to many populations or settings. Evaluation
refers to studies in which a comparison is made to some standard of acceptability with
two types of evaluation, i.e., formative evaluation is focused on the process, while
summative evaluation is focused on outcomes.

Evaluation studies are common in practice settings and would be a necessary
component when considering the implications for research on the WEM. Continuous
Quality Improvement (CQI) requires ongoing evaluation of the product by the FNP. This
could include designing a quality improvement study, determining the methods of
measurement, and establishing standards. The FNP can provide input and promote
research. Examples of this type of CQI study could be a pre-post test for both the
caregiver, as well as the FNP about fever; its pathology, causes, treatment options, and

appropriate home management. This method could evaluate the effectiveness of the

49

model and identify the specific interventions that were most helpful or improvements
which need to be made. The post-test could be completed immediately after the
intervention and repeated at intervals following the instruction (Rankin & Stallings,
1996). The suggested follow-up call sheet included in the model (F igure7.) was designed
to be used not only as an educational reinforcement, but also as an outcome indicator.
Ideally, this should be done by the FNP that participated in the educational intervention
using the WEM so that the follow-up can be consistent with the actual teaching provided.
Data collection could be either qualitative or quantitative; due to the combination of
yes/no and descriptive questions, the latter could be categorized to facilitate the data
collection process.

The increasing emphasis on cost effectiveness in the delivery of health care makes
evaluation a paramount activity in health care institutions. Hampton & Snyder (1995)
state that several studies have demonstrated significant cost savings related to
interventions by FNPs. Implementing new teaching strategies require follow-up
evaluation of the cost effectiveness of the intervention. The question of whether the
WEM, by properly educating caregivers on fever, is cost effective can be evaluated in
several ways. Retrospective chart reviews on the number of visits in which the sole
complaint of fever is addressed prior to and again after the implementation of the WEM
at a particular setting can indicate whether the WEM may have impacted the number of
visits and thus, decreased health care resources and costs. Another retrospective chart
review could be done on the number of children admitted to the hospital for overdosing
of antipyretics prior to implementation of the WEM and after the model was instituted.

Clinical research could extend to identify treatment options and specific

50

combinations of interventions for fever. This includes education for caregivers in the
appropriate use of antipyretic suppositories and researching the use of alternating
acetaminophen and ibuprofen.

Practice setting research directed towards the ease of use of the WEM in a time
limited practice with data collected via questionnaires completed by the caregiver is
another appropriate implication for research and would be another indicator of cost
effectiveness in the clinical setting. Effectively incorporating patient education into the
primary care setting is particularly difficult. As Bonnel (1996) points out, “the clock is
ticking” and it is increasingly important to get the information to the caregiver in a
concise, understandable, flexible way to meet their needs. The FNP can quickly assess
the WEM for ease of use, conciseness, and flexibility.

£ra_ct_ic_e

Prior to the implementation and use of the WEM in practice a expert panel must
evaluate the model for accuracy and clarity. This expert panel would ideally comprise of
an experienced FNP, a Certified Pediatric Nurse Practitioner (CPNP), a health or patient
educational specialist, and a pediatrician. This would ensure the accuracy and the
credibility of the model and appropriate changes would be made prior to clinical use.

The development of the WEM on the home management of pediatric fever creates
a reference and intervention resource for the FNP. The model is evidenced based and
thus enhances the FNP’s role in practice. It will be necessary for the WEM to be updated
according to new advances in research. The FNP must keep current on new
developments in nursing, medicine, and patient education by attending conferences and

reading peer reviewed journals. It will also be important for the FNP to perform

51

evaluations of the effectiveness of the model by evaluating the various interventions to
determine those used most frequently, those items which are never used or used
infrequently, and ways of adding or improving the educational interventions. This may
be accomplished on an individual FNP basis or through the involvement of the
professional nursing organization. The role of evaluator will be utilized through the
development of quality outcome monitoring such as chart and follow-up call reviews.

By encouraging the family nurse practitioner to participate in creating an
educational model for individual practice, the role of change agent can be utilized. If the
individual practitioner participates in governing his/her practice by creating patient
education models that provide higher quality of care at lower costs, there will be a greater
positive recognition of the profession. The nursing profession will be able to further
justify the importance and necessity of the FNP role in primary care. Through the use of
the roles such as change agent and clinician, the FNP can utilize positive clinical outcome
indicators as leverage when negotiating reimbursement with third party payer as well as
showing the benefits of patient education.

The roles of collaborator and consultant can be utilized as the FNP develops a
scientific evidence based practice by development of educational models. This allows
the FNP to become a valued team member. The FNP can advise other members of the
team such as those in other clinics and offices on effective home management and
education for caregivers on pediatric fever. The information can be shared at advanced
practice nursing conferences as well as at health fairs and local nursing associations. The
WEM can be utilized within the hospital setting for education interventions by clinical

nurse specialists, nursing educators, and staff R.N.s on many different units. These could

52

include the emergency/urgent care departments, pediatrics, and post-partum units. The
educational pamphlet can be self explanatory and given to all caregivers of small children
on these units. However, its greatest impact may be in concert with the FNPs
instruction, demonstration and return demonstration.

The role of case manager is becoming more crucial in today’s managed care
environment. The use and effectiveness of the WEM, in its entirety or of its components,
on home management of pediatric fever prior to seeking expensive health advise should
be an invaluable vehicle for patient education. Educating caregivers on appropriate home
management of pediatric fever may reduce health care costs by decreasing the number of
inappropriate visits to primary care offices and emergency rooms. This could
consequently reduce the number of inappropriate hospital admissions by decreasing the
number of negative outcomes of inappropriate management of fever, i.e., over dosage of
antipyretics, dehydration, and febrile seizures.

In addition, the FNP as a case manager may identify those caregivers most at risk
as discussed in the literature review and pro-actively intervene with the WEM by
teaching parenting skills in the home management of a child’s fever. It is important that
the FNP be aware of and refer to the available community resources as needed for these
caregivers. Such services as the State of Michigan’s Family Independence Agency or
Department of Social Services, Parenting Support Groups, Catholic Social Services, the
American Red Cross, and the public health department may be able to provide the
caregiver and their family with financial assistance, medication assistance, shelter, food,

and other support services.

53

Education

The development of the WEM enhances the family nurse practitioner’s role as an
educator. As stated previously, the educator role is one of the most important and
significant roles of the FNP and encompasses education of patient and colleague alike. In
general, advanced practice nurses are committed to not only furthering their own
education, but also assume the responsibility for providing continuing education for other
nurses. It also has implications for educational use at the graduate level with the new
FNP as an educational tool guide.

The internet has become a virtual haven for educational tools and a web site
dedicated to educational interventions for the FNP has implications for not only the FNP,
but certainly for the general public who may access the information. The WEM could be
utilized in this way on the internet as a web site on pediatric fever and or as a web site on
educational models for use by the FNP.

As educational models are developed for use by the FNP in his/her practice, it is
likely they will reinforce the importance that education and health promotion have in the
FNP’s role as primary health care provider, as well as distinguishing advanced practice
nurses apart from other health providers.

Conclusion

Fever accounts for approximately 30% of the chief complaints presenting at out-
patient visits (Murphy, 1972). Furthermore, despite the availability of over the counter
antipyretics, caregivers continue to demonstrate a lack of understanding and confusion
about fever. The result has been increasingly inappropriate visits to primary care

providers’ offices and emergency departments. Over dosing of antipyretics has serious

54

consequences, and yet many caregivers are uninformed of the dangers. The development
of the Wilson Educational Model (WEM) on the Home Management of Pediatric Fever
provides the FNP with an evidenced based guide or lesson plan to effectively address
these issues with the caregivers of children. Implementation of the WEM has the
potential to promote positive patient outcomes by increasing caregiver satisfaction and
self care behaviors to decrease inappropriate use of primary care offices and emergency

departments, and to ultimately reduce health care costs.

55

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65

APPENDIX A

The Wilson Educational Model for the

Family Nurse Practitioner:

H ome Management of Pediatric Fever

Prepared by
Kim D. Wilson, RN, MSN
College of Nursing
Michigan State University
East Lansing, Michigan
1999

2

Educational Objectives

For the Caregiver:

Caregivers will demonstrate an improved knowledge of fever as
evidenced by defining “fever ” describing its causes and identr'fi/ing the
harmful and beneficial eflects associated with fever.

Caregivers will verbalize appropriate home management of their child’s
fever.

Caregivers will accurately demonstrate the taking and reading of an
axillary temperature.

Caregivers will state when they can manage the child ’s fever at home
and appropriately identzfv when they must see a health care professional.

Caregivers will verbalize where to find appropriate dosing instructions
about antipyretic medications and describe the dangers of over dosing of
these over the counter medications.

Caregivers will identify other comfort measures that they can initiate in
caring for the child ’s fever at home.

For the FNP:

The FNP will increase his/her knowledge of pediatric fever and enhance
the caregiver ’s knowledge and management of fever through the use of
the WEM.

The FNP will identrjy alternative teaching strategies and resources
available in his/her community.

The FNP will utilize the follow-up call sheet to evaluate the effectiveness
of the WEM.

Fever Review Guide for the Family Nurse Practitioner

What is a fever?
0 An elevation of body temperature greater than 100 °F orally, 100. 4 °F rectally, or greater than 99 OF
ara‘llary (Uphold & Graham, 1998).

What causes a fever?

0 Infection is most common cause of fever in children with most infections viral in etiology and lasting
fiom two to three days (Schmitt, 1984).

o Other medical conditions and causes for fever include: Hypersensitivity to drugs, recent
immunizations with certain vaccines, vascular occlusive and/or inflammatory events, acute hemolytic
episodes associated with acute auto-immune hemolytic anemia, neoplasms, collagen-vascular
diseases, and central nervous system abnormalities (Uphold & Graham).

0 Environmental causes of fever include; exercise, warm clothing or bundling, hot weather, or warm
food or drinks (Schmitt, 1984).

What is the pathology of fever?

Fever occurs when bacteria, viruses, tora'ns, or other agents are phagocytosed by leukocytes. Interluekin-l
and other chemical mediators (previously known as endogenous pporaenes) are produced and activate the
production of prostaglandins Prostaglandins act on the thermoregulatory mechanism in the hypothalamus
and upwardly readjust the body ’s thermostat. Raising the hypothalamic set-point initiates the process of
heat production and conservation by increasing metabolism, triggering peripheral vasoconstriction, and
less fi'equently by triggering shivering which increase heat production fi'om the muscles (Uphold &
Graham, I 998).

What are the benefits and harmful ejects of fever?
0 Fever enhances die inflammatory response which results in a reduction of viability of the infecting
organism, within a range of slight temperature elevation (D ’Auria, I 99 7).

0 Children usually sufler no harmful effects and a fever by i tself causes no brain damage or harm unless
it reaches 107 °F McCarthy & Dolan, 1976).

0 Bacterial infections seem to be most usually linked with higher fevers 105 °F and greater (McCarthy &.
Dolan, I 9 7 6).

o The most common s'de effects of fever are harmless and include mild dehydration, discomfort, febrile
delirium and simple febrile seizures (Nelson & Ellenberg, 1978).

Who may benefit from educational intervention on fever?
Caregivers who present to ofl‘ice or clinic with a child wrth fever and have not initiated treatment at
home prior to seeking professional advice.

0 Caregivers who have initiated inappropriate treatment prior to seeking professional advice.

0 Caregivers who appear anxious or unsure of appropriate home management of fever.

0 Caregivers who are < 16 years of age, single parent/caregiver, lack of caregiver experience, low
income, lack of familial support, low education.

r When your child has a

l fever. '
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1

Huh

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Home management guidelines for -
children with fever '

l l
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Educational Pamphlet: Home Management of Pediatric Fever

 

Axillary Temperature Demonstration Model
For the Family Nurse Practitioner

This demonstration model can be used to provide background information for the
PNP or can be employed as a script and/or guide of conversation points for the FNP with
the caregiver. It can facilitate the discussion with the caregiver on axillary temperature
taking and promote feedback from the caregiver. Included is a step by step
demonstration of the technique for properly taking and reading an axillary temperature
on a child The FNP should first discuss the importance of properly taking an axillary
temperature and then demonstrate the technique on the child with the caregiver. A
return demonstration by the caregiver with time allotted for questions should follow.

Introduction to taking an axillary temperature on a child

Choosing the Method

Babies and children younger than age four or five are too young to keep their
mouths closed for oral temperature readings, so their temperatures must be taken either
in the rectum or under the armpit (axilla).

You can usually take an older child ’5 temperature orally (by mouth) if he is
mature enough and alert enough to be able to keep his lips closed tightly around the
thermometer. However, if your child has fiequent coughs or is breathing through his
mouth because of a very stufiy nose, he might not be able to keep his mouth closed long
enough for an accurate oral reading. If this is the case, it would be better to take his
temperature either in the rectum or under the arm. I recommend the armpit for taking
the temperature at home as the safest, easiest and least invasive way.

Temperature measured in the armpit (axilla) is called an ara'llary temperature
reading. It is an alternative to the rectal method for infants and children younger than
age four or five. It is also useful in older children who are so upset or uncomfortable
from an illness that they can’t cooperate in taking either a rectal or oral temperature.
However, this is the least accurate way of taking a temperature and is usually l/2-l degree
lower than an oral reading. To adjust the reading just add ’/2-1 degree to determine if
child has a fever. Remember this is just to see if your child has a fever. You must always
evaluate the child ’s overall condition to see how sick the child really is!

Choosing the thermometer

Both glass mercury thermometers and digital thermometers will give you an
accurate reading. What ’s most important is that you choose a thermometer that ’s easy to
use and read

The newest thermometers are the ear thermometers that quickly and easily
measure temperature inside the ear canal. They are still fairly expensive compared with

the glass and electronic models, and learning how to use them correctly takes some
training.

Forehead thermometers we convenient and comfortable to use, but they we not
very accurate. They may be handy for quick screenings, but for exact readings use a
glass thermometer or a digital one. Glass thermometers can shatter wrd release the
harmful mercury inside, so We them cwefirlly. In fact, it is always wise to have a
spwe glass thermometer at home in case of accidents.

Taking an axillm temperature (all ages)

Use an oral thermometer for this method

0 Prepare the thermometer by washing it in cool (not hot) satmy water or rubbing
alcohol.

0 If using a glass thermometer, shake it down to below 96 degrees. Make sure that you
have a watch or clock newby for timing the reading. If you we using a digital
thermometer, read the directions beforehand so that you know which beep, or series
of beeps, is a sign that the thermometer is finished reading. T urn it on wrd check that
the screen is clew of any ewlier reading.

0 Insert the thermometer in you child ’s armpit. F old your child ’s wrn across his chest,
and hold the thermometer in place for 4 to 5 minutes before reading it Axillary
temperature readings tend to be about ’/2 to 1 degree lower than temperatures
measured orally. Digital thermometers will automatically beep when done. Make
sure the thermometer end is up in the wmpit with the skin surrounding it wrd not in
an air pocket in the space under the armpit. This will ensure a more accurate
reading.

0 For a glass thermometer, read wad record the number at the end of the colored line.
For a digital thermometer, read wad record the number on the screen.

0 Always note the time of day that the reading was taken. Temperatures in the morning
we usually lower than in the late afternoon. Note also, what your child was doing,
where he was at, i. e., in the sun or shade, and what he was wewing prior to taking
the temperature. Remember activity, exercise, being indoors or outdoors in excessive
heat or cold and over-dressing can all effect a child ’s temperature. Assess the
situation and your child ’s behavior prior to deciding if a fever is present. If any of
these “environmental” elements occur, have your child rest, un-dress, drink cool
fluids, and re-take the temperature later.

0 An axillary temperature of 99 degrees can indicate that your child has a fever wad
may need to be treated See flow-chart for cwegiver assessment guidelines for home
management of a fever.

0 After using the thermometer, clean with wwm soapy water or with rubbing alcohol
and store in a safe cool place.

Demonstration at taking an axillam temperature

0 Show the client both the glass thermometer and the digital thermometer.

0 Demonstrate how to shake down the glass thermometer and how to turn on the digital
thermometer.

0 Demonstrate proper placement of the thermometer under the child ’s wmpit. Stress
the importance of the under arm skin contact to the end of the thermometer and
holding the child’s arm tightly across his chest. Demonstrate the “bew hug ” as a
gentler way of holding the child’s wrn across the chest and as a reassurance that this
will not hurt the child

0 Reinforce the need to keep the thermometer under the arm for 4-5 minutes or until the
digital beep goes off Removing the thermometer before this time will not give an
accurate reading.

0 Demonstrate reading the glass thermometer by turning the thermometer in your
fingers until you can see the end of the colored line. Show the cwegiver the location
of the reading display on the digital thermometer.

0 Demonstrate shaking down the glass thermometer and turning off the digital
thermometer. Discuss cleaning and proper storage of both thermometers.

0 Allow the cwegiver to perform a return demonstration of the techniques discussed

0 Allow for questions wrd continued reinforcement of the procedure.

0 Document on the child ’s chart that a demonstration of the technique of taking an
axillary temperature was done wrd that the cwegiver verbalized understanding of the

procedure.

(Source: Moren-Novitt, 199 7)

Alternative Educational Resources for
Home Management of Pediatric Fever

Educational Videotapes:

The University of Wisconsin Medical School
Patient Education Video Tapes; The Facts about Fever
Order number 020294F $19. 95 +tax and shipping

MilnerandFenm’ck Inc.

Patient Education Videos; When ypur baby ’s sick
3 25. 95 +tax and shipping

Computer based patient education- Web sites:

wmr'. medsch. wise. edu "uwhosp “Outreach pohindex. html
www. ama. assn. org 'kidshealth

mm: pe ch am (ileum/(my. com febrile. html

lt'ml'. (tr/coop. com 'adom’pea's 'top- 003 J ()0. him!

Virtual Hospital web links

 

 

 

 

 

Community AgencieVParental Support Groups

Local Family Independence Agency or Depwtment of Social Services:

 

 

Local Public Health Depwtment:

 

 

Pwental Support Groups.-

 

Women Infants and Children (WIC) and Michigan Irfants and Children MC):

 

Red Cross:

 

Local Hospitals-Case Management Depwtments:

 

Pediatric F allow-up Call Sheet

Child’s Name FNP Name

 

Caregiver’s Name and relation to child

 

Date of visit and educational intervention

 

Presented with do

 

 

How is child doing now?

Do you have questions regarding your child’s fever?

Explain how you would assess your child’s physical condition when he is sick?

Describe how you would take an axillary temperature. What temperature suggests
your child has a fever?

How much acetaminophen (Tylenol) or ibuprofen Motrin or Advil) should you give
your child and how often? Where would you look to find the proper dose?

What are the risks that overdosing of these medications can cause?

Are you comfortable with when to manage you child at home with a fever and when it
is appropriate to see a health professional?

Is there anything else we can assist you with in the care of your child?

10

References

Barnes, LP. (1996). Evaluating the readability of patient education materials.
American Joumal of Matemal/Child Nursing, 21, 273.

D’Auria, J .P. (1997). Fever. In J. Fox (Ed), Primary health care of children. (pp.
770-776). New York: Mosby.

McCarthy, P.L., & Dolan, T.F. (1976). Hyperpyrexia in children. American Jourual
of Diseases in Children.130. 849-851.

McNeil Pharmaceutical Products Co. (1998) Pediaprofen; Hospital formulary
manual. Comprehensive drug information monograph. McNeil Consumer Products, Fort
Washington, P.A.: author.

McNeil Pharmaceutical Products Co.(1998). Tylenol; Hospital formulary manual.
Comprehensive drug information monograph. McNeil Consumer Products, Fort
Washington, PA.: author.

Moren-Novitt, A. (1997). Kids Health; Your child’s temperature. (On- line).
Available: http://206. 189. 190.10l/insight/h-focus/nemours/infectio/home/temp.htm.

Nelson, K.B. & Ellenberg, J .H.(1978). Prognosis in children with febrile seizures.

Pediatrics 61, 720-727.

 

Schmitt, B.D.(1984). Fever in childhood. Pediatrics 74 929-936.

 

Uphold, ca, & Graham, M.V. (1998). linical idelines in famil ractice (3rd
ed). Gainesville, FLA: Barmarrae Books.
Whitehall-Robins Healthcare (1998). Children’s Advil; Hospital formulary manual.

Comprehensive drug information. Whitehall-Robins Healthcare, Madison, NJ,

11

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