Care of Neonates with Fever (Nursing knowledge II)

Introduction

Quite often, mothers of new born babies undergo through extreme emotional pain;   they breakdown when their babies cry as nurses struggle to insert I/V lines. Many a times, duration of stay of mothers and neonates in the hospitals are prolonged since neonates develop fever, although the mother are fit and ready to be discharged. Consequently, this has implication on the scarce human and material resources.

There fore, the problem deserves closer scrutiny.  Remedies do not seem out of reach.  The fever can be prevented or mitigated, and the duration of hospital stay can be shortened by managing the fever professionally.  This will enable us to direct the resources on managing more serious and urgent cases. Gentamycin injection need not be the only solution for bringing down the temperature of the neonates. This study there fore, focuses on introduction of evidence-bases practice in the areas of (a) health facility, (b) nursing colleagues and, (c) clinical practices. It makes suggestions to bridge the gap in nursing knowledge and concludes that could and should make clinical decision involving other alternatives, interventions and precautions based on the evidence-based practice (EBP).

I. Objective/Aim

This study aims to find out the best methods of care and management of neonates with fever; and other alternative nursing cares which may be given to the neonates. It intends to argue that putting neonates on intravenous (I/V) injections is the least desirable option, and hence, may be resorted to it only when all other remedies are exhausted.  This is to prevent poking the neonates several times to establish an I/V access for single episode of rise in temperature, and; prevent nurses from mechanically or impulsively resorting to invasive procedures, if and when other less invasive methods are available.  It explores ways to manage the fever by looking at the other probable causes that lead to rise in body temperature of the neonates, such as, cleanliness of the delivery rooms and the maternity wards; and the ways the nurses, parents and relatives handle the babies. It explores best practices to reduce nosocomial infections and better care of neonates during sickness and in health.

Secondly, increasing number of health services are embracing the EBP concept.  It is essential to educate all stakeholders in health care about the concept since it is no more considered to be researchers’ domain solely. There is now the need to implement and evaluate evidence in clinical practices and nursing cares. Nurses, accordingly need to be informed and educated about the concept through education programs on EBP, though they are not readily available in developing countries like Bhutan; there are barriers in accessing and implementing evidence in clinical practice, such as, resource constraints and traditional healthcare practices.  

II. Literature Review

It is essential to review literature on the subject matter to find out what are the best practices for nursing care for neonates and effective management of neonates with fever. There is not only shortage of doctors and nurses trained or specialized in this area, but there is complete lack of written or published literature in Bhutan on the subject matter. Accordingly, the author has relied heavily on electronic or online literature.

Websites, such as, http://www.joannabriggs.edu.au, http://www.cinahl.com and http://www.ovid.com though informative are not comprehensive. It is indicated that although it may be rational to start injections at the earliest to prevent from serious bacterial infection (SBI), yet it is not wise to expose the child to ‘an invasive work-up unnecessarily’ (file://E:\URGENT CARE.htm). It is also important to ensure that the neonates are not bundled up leading to increase in temperature. One of the recommendations on management of asymptomatic hypoglycaemia in healthy term neonates for nurses and midwives states that it is very important to keep the body temperature of the neonates within normal limit to prevent from hypoglycaemia, which can even lead to death if not managed on time (http://www.joannabriggs.edu.au/pdf/BPISEng_3-3.pdf). However, it is found that there is no specific studies  carried out on management of fever in neonates though many researches are carried out on treatment of fever in children, such as  giving  paracetamol versus  reduction of fever physically by “tepid sponging, removing cloths and cooling environments” (Purssell, 1999).

The website of the Scottish Intercollegiate guidelines Network, http://www.sign.ac.uk/ and Centre for Evidence-Based Child Health, http://www.ich.bpmf.ac.uk/ebm/ebm.htm  throw some light on the evidence-based practices.  The literature review on comparative study of proper site, method and frequency of measuring temperature and its recordings was essential.  The temperature is to be measured from axilla, as the, “use of rectal thermometer predisposes to irritation of rectal mucosa” (The Lippinccott Manual of Nursing Practice, 1996, p.1021). The temperature measurement of the normal neonate is to be done twice daily (Dutta, 1997, p. 465).      

III. Methodology

A comparative study of deliveries was conducted to find out how many numbers of neonates were given injections, their mode of deliveries and the indication for injections, for the period between June 2007 to November 2007 at the Samtse District Hospital.  Accordingly, all the case-sheets of the studies were studied carefully.

IV. Findings/Outcomes

The study revealed that a total of 257 babies were delivered within six months out of which 106 were delivered by Caesarian Section (CS), that is, both elective and emergency.  151 were delivered through Spontaneous Vaginal Delivery (SVD), that is, breech, vacuum, forceps and normal. The study revealed that 34.91% of the total babies delivered by CS and 25.17% of SVD were given I/V antibiotics (please see Appendix I).

Perusal of individual cases indicates that all most all the babies delivered by CS develop fever by the 2^nd to 3^rd post-operative day and is the sole indication for initiating I/V antibiotics. Indication varied from muconium stained liquor to premature rupture of membranes in case of SVD babies. The most probable cause of fever in CS neonates is the cross-infections in the wards since they have to be retained in the hospital for comparatively longer period than the SVD neonates, who are discharged after 24 hours of delivery.

A prominent finding of the study is that the nurses are poor in keeping records; no notes were written by nurses in most of the case-sheets. It is found that they put the baby on I/V antibiotics based on a single episode of fever or a temperature of 99 degree Fahrenheit.  Non-invasive procedures, such as, cold sponging was not tried or possible causes were not ruled out. No other possible causes of rise in temperature were suspected, as evident from the little or no remarks of the nurses on the case-sheets. The case-sheets hence do not reflect the actual nursing care provided – in most case it is unrecorded, and hence unreported and unacknowledged. In other words, there is no adequate evidence of the procedures performed and care provided.

The study also revealed that babies who had received treatment along with the mothers were not admitted or shown in the indoor-register. This, there fore did not reflect the actual number of patients treated or admitted in the hospital; nor is there separate case-sheets or files maintained for the babies. Remarks are made on the same documents without clear separation between that of the mothers and babies. Since the care provided to the babies are often uncounted and not reflected on the case-sheets there is negative effect on the output of the nurses – their services go acknowledged and unrewarded.  Most importantly, no standard and true data can be generated   from the case-sheets for planning and researches.

V. Suggestions - Bridging the Gaps in Nursing Knowledge

There are many problems which nurses face during management of neonates with fever. Firstly, nurses hardly know or attempt to know the possible causes of the fever. They think that their duty is only to inform the doctors and administer injection to the babies. Some nurses are not even competent in administering injections; they inflict unnecessary pains to the babies since they can not establish I/V access and poke neonates many times; or the babies end up receiving intra-muscular injections.

Samtse district hospital has no pediatrician or staff trained in neonatal or pediatric nursing. The survival of the babies, therefore, depends mostly upon the individual general doctors, nurses and parents, on several occasions. Secondly, nurses are overburdened. A nurse on duty, for instance, has to take care of the neonates, sputum positive Tuberculosis patients, dress wounds, etc., in the same ward, at the same time.  There fore, lack of specialists and requisite facilities to keep the neonates in separate wards may be contributing towards nosocomial infections.

The purpose of this study was not to ascertain the correctness of the doctors’ orders in advising I/V antibiotics, but to enable the nurses to make independent decisions in ruling out other causes/possibilities to prevent neonates from infections. It is found that nurses need to go beyond executing doctors’ orders; they should analyze them critically before carrying them out. Nurses, for example, could arrange to maintain the optimum environmental hygiene, particularly in labor rooms and maternity wards.  The current practices and level of hygiene in the hospital may not fulfill the criterion of standard precautions. Accordingly, in the current settings, nosocomial infections can not be ruled out in quite a few numbers of hospitals in the country.

Nurses need to be educated on the importance and value of record keeping and relate it to the EBP concept. The records will not only serve as evidence in cases of litigations for alleged medical negligence and  malicious prosecution, but will show the path trodden by the patients, including neonates, in terms of treatment received during stay in the hospitals. The knowledge of nurses on recording and reporting needs to be improved; they should be given special courses in this area, to achieve both medical and legal ends. The writing of nurses’ notes has to be made compulsory and consistent.  Telephonic orders from doctors need to be promptly reduced to writing. Uncommon abbreviations need to be avoided to prevent miscommunications and errors in interpretations. The nurses’ notes should be written seriously and legibly, and not just for the sake of formality. This would not only prevent errors but will minimize the chances of being rejected by the court if tendered in evidence should there arise occasion to justify the procedures performed and treatment given.  

Nurses should contemplate over what they do, if not critically analyze them. Mechanical or ritualistic implementation of the doctors’ orders would relegate knowledge, skills and critical analyses to the back seats. There must also be refresher courses, trainings, workshops or studies to up-date their knowledge and hone their skills, based on the best practices.  This will go a long way toward fulfilling the demand for evidence-based care and critical thinking (Kumar & Grimmer, 2006).

In the current setting, nosocomial infection is the prime suspect of the cause of fever in neonates. There fore, the findings of this study will usher changes in  existing practices and reduce the risk for nasocomial infection by introducing the evidence based nursing in the following areas:

(a). Health Facility

Though difficult, it may not be impossible for the nurses to manage the fever in neonates resulting from nosocomial infections. However, this may not be achieved by nurse alone; it would require the assistance from many people, especially, that of the infection control team of the hospital. The infection control team should ensure that wastes are properly disposed and hygiene of the labor rooms and maternity wards in particular is maintained. The services of support staff, for instance, ward boys and sweepers are not less important in achieving this ends. Accordingly, they should be aware of the importance of cleanliness and the standard precautions, restriction of visitors into the wards, labor room, etc.

The hospital administration should also accordingly ensure consistent supply of floor mops and sanitary disinfectants required for maintaining cleanliness of the hospital wards.  It has been found that even placing an alcohol-based solution for rubbing the hands at the patient’s bed side can drastically improve hand hygiene of the healthcare workers thereby reducing the cross infections by the health workers (http://www.joannabriggs.edu.au/events/2005/convention). In this regard, hospital should in collaboration with Information Education and Communication for Health (IECH) bureau produce appropriate and adequate numbers of posters on hand washing techniques as a reminder for compliance of hand washing (Picheansathian, 2005). Similarly, relevant audio-visual materials would be effective in disseminating information on selected issues and practices.

It is found that the rate of nosocomial infection in neonates is high in developing countries where nurses mix intravenous solutions in the wards; this is due to minimum level of infection control in the wards (Macias et al, 2005 in http://www.ncbi.nlm.nib.gov/sites/entrez ). This  is eye-opening for Bhutanese  nurses since they have to resort to improvising pediatric intravenous solutions from adult I/V fluids like that of N/5 which is half strength normal saline. Given the sub-optimal ward environment, this type of procedures pose risk for causing fever in neonates.  

(b). Nursing Colleagues

There are many nurses who have the work experience of more than 25 years.  However, it is challenging to introduce evidence-based practice since they lack competence due to low level of academic qualification. Some nurses, for instance, mix gentamycin and ampicillin injections in the same syringe; they believe that there should be no problem since the two drugs are, after all, injected into the same blood stream.  

There fore, the EBP concept has to be introduced systematically; nurses must be convinced of the rationale behind the changes in the existing practices. Secondly, the degree of compliance for change would be high if the changes are introduced gradually rather than suddenly. For example, a female nurse may prolong the change of an indwelling catheter of male patients. However, if the frequency of the changes of male catheters is dictated by EBP, nursed would be obliged to comply without feeling uneasy.

Nurses should aim to cause less emotional trauma to the new mothers and less pain to the babies.  Nursing colleagues are expected to benefit from this study and be more critical when the mothers complain of rise in temperature of the neonates; they should check, for example, if the baby is not too much bundled up, assess room temperature - whether it is too hot or cold and, most importantly, they should be able to assess the general appearance of the baby and inform the doctors on time.

Nurses should discuss with the parents on how they can contribute in reducing the risk of babies from developing fever.  Care providers of the babies should be constantly reminded to take necessary precautions, such as proper ways of washing hands before handling the neonates. Nurses should be competent and culturally sensitive educators.  They should educate parents on care and safety of the neonates when they are in the hospital, as well as at home.

The practice of bathing babies twice or thrice a day in Bhutanese culture should be viewed critically. This practice is fraught with risk to the babies. Babies are likely to suffer from hypothermia since there are no means to ensure appropriate temperature for the babies in most Bhutanese homes. Some parents can not even afford clean and warm blankets and nappies for the babies.  Besides, excessive bundling of babies may not be encouraged to prevent rise in temperature.

(c). Clinical Practices

Like most Bhutanese nurses, the nurses of Samtse hospital have the foundation of clinical practice since it is a component of the curriculum of the Royal Institute of Health Sciences (RIHS), the country’s only medical/health institute. However, it falls in the lowest level of nursing practice, i.e., ‘tradition’ since they have been doing the way they have always done it for more than 25 years; they hardly got any refresher course since they left the training institute (Stetler, 1998 cited in Fitzgerald, & Clark, 2007).  For example, the site for measuring temperature is not consistent. Most nurses are not certain as to which site would give the accurate reading, though many nurses and parents prefer axillary method.   According to best practice, rectal temperature is considered as the most reliable one in comparison to other methods of temperature measurements (http://www.joannabriggs.edu.au/pdf/BPIEng_3_3.pdf ). However, it is not always safe to measure temperature from rectum as it may result in rectal perforation.  No such incidents have been reported in Bhutan though temperature is taken rectally as and when doctors order.

Evidence-based practice can contribute toward cost-saving, which is an important factor for a grant-dependant country like Bhutan.  We are not in position to afford incubators for the preterm babies in all the hospitals. Accordingly, ‘Kangaroo mother care’ can be introduced. It is one of the best practices for taking care of the preterm babies (www.kangaroomothercare.com). It is one of the evidence-based cares adopted by many countries.  It would be very useful for countries which lack adequate health infrastructure.

Conclusion

This study confirmed that nurses need to take individual decisions in reducing the nosocomial infection in the hospital. The health of the neonates not only depends on what doctors prescribe but on how and what nursing cares are given.  The role of the infection control team can not be undermined in reducing the risk of nosocomial infection. The study revealed deficiency in nursing knowledge and the errors which nurses tend to commit in the course of giving care to the neonates.

Besides, modern health facilities alone would not solve the problem at hand. It must be supported by appropriate nursing policies. This is an age of accountability. People expect more and more better services from the nurses.  Nurse have to be, there fore, able to demonstrate best nursing and midwifery practices and give evidence for clinical practices, alternatives and associated risk factors. Besides, the performance of nurses is increasingly evaluated based on the skills and activities supported by evidence for best practices.

It is our desire to provide an effective health service to our people. But this must be increasingly based on evidence and research findings. Accordingly, attention has to be given to the researches and develop appropriate methods and tools to support these objectives at the national and international level. The EBP concept has come to stay. Education programs have to be initiated to spread the knowledge and awareness of the nurses on the concept despite several barriers faced by developing countries in implementing it.  As this study proved, there is more than one way of dealing with neonates with fever. Nurses should explore alternatives before resorting to invasive procedures. 

Reference

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