Comparison between vinegar and cold water
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https://www.eduzhai.net International Journal of Nursing Science 2012, 2(4): 38-46 DOI: 10.5923/j.nursing.20120204.03 A Comparison of Vinegar Compresses vs. Cold Water& Water with Vinegar for treating of Fever at Tropical Hospitals Fathia Attia Mohammed1,*, Elsayeda Ibrahim Ahmed2 1Lecture of M edical Surgical Nursing, Faculty of Nursing Zagazig University 2Lecture of Nursing Administration, Faculty of Nursing Zagazig University Abstract Fever is a co mmon encounter in hospitalized patients & its management is integral aspects of nursing care. Research aimed to assess and compare the efficacy of v inegar,, cold water and cold water with vinegar compresses in the treatment of fever. Th is was a quasi-experimental study conducted in the Tropical Hospitals at Sharqia Governorate. The study was carried on 45 patients; divided to three group15 patient in each group, all of them were suffering fro m fever & suspected to have typhoid fever for investigation & ad min istered the same drug management. We used vinegar compresses with the first group, cold water co mp resses with second group & water with vinegar co mpresses with third one. A compress was done at the same time & locations. Body temperature was measured after one &two hours orally by using mercury thermo meter. Both co mpresses methods were effect ive in decreasing body temperature and vinegar was found to be more effective than cold water and cold water with Vinegar co mpresses (P ≤ 0.001). Vinegar co mpresses can be used in the treatment of fever when we needs to rapidly lo wering patient temperature. Keywords Vinegar, Medical Uses of Vinegar, Fever, Co ld Co mpress, Typhoid Fever 1. Introduction Vinegar is a liquid substance consisting main ly of acetic acid and water, the acetic acid being produced through the fermentation of ethanol by acetic ac id bacteria .. Vinegar, fro m the French vinegar, meaning “sour wine,” can be made fro m almost any fermentable carbohydrate source, including wine, mo lasses, dates, sorghum, apples, pears, grapes, berries, melons, coconut, honey, beer, maple syrup, potatoes, beets, malt, grains, and whey. Initially, yeasts ferment the natural food sugars to alcohol. Next , acetic acid bacteria (Acetobacter) convert the alcohol to acetic acid Not sure this is relevant White vinegar comes about by the process of oxid izat ion of any alcohol. There are several types of vinegars that are found like apple cider vinegar or balsamic v inegar and each of them provides several health benefits. It has been known to increase therefore leading to a stronger immune system .Relevance? as it is being used as compress not for in g es tio n . The Islamic Prophet Muhammad is reported to have said, "The best o f cond imen ts o r co nd iment is v in egar."  Avicenna, in his famous book "The Canon of Medicine", * Corresponding author: email@example.com (Fathia Attia Mohammed) Published online at https://www.eduzhai.net Copyright © 2012 Scientific & Academic Publishing. All Rights Reserved mentioned several beneficial med icinal uses for vinegar: it is a powerful clotting agent, it heals burns and skin inflammat ions, and it relieves headaches caused by heat. This is a really interesting reference but it would be important to reference scientific sources to support this. He also considers vinegar a good digestive supplement  .Bin Qayyim Al-Jawziyya also mentions the merits of v inegar in his book, Al Tabb al Nabawi (The Prophetic Medicine). In this book, he mentions that wine vinegar helps against gastric inflammat ion and bile, and prevents the effects of to xic med ications and poisonous mushrooms. He also notes that vinegar quenches thirst, acts as an appetite stimulant, and prevents tumours' from occurring as well as helps in the digestion process (5). This is a really interesting reference but it would be important to reference scientific sources to support this One of the main white vinegar health benefits is that it helps in the absorption of calciu m and other important minerals fro m the varied foods that are eaten. This is because vinegar contains acetic acid which has the ability of helping the body absorb the required minerals and calciu m (reference at the end ). It therefore not only helps in digestion, but also in making the bones stronger and thereby preventing osteoporosis. It has to be kept in mind that due to its acid content, vinegar must always be diluted before ingestion or it can cause heart burn. White vinegar uses are several and these include med icinal uses as well. Here are some of them: 1-It can be used as a form of treat ment for minor infect ions 39 International Journal of Nursing Science 2012, 2(4): 38-46 and skin burns. Dab a cloth in white v inegar and cover it over the infected area for a cooling effect and soothing of sunburned skin and therefore helps in provid ing effective skin care. 2-For infections, rashes, insect bites, dabbing of white vinegar with the help of a cotton swab can help clean the area and prevent further infections to the skin. 3-It is used as an effective remedy for sore throat. Adding a tsp of white vinegar to 8 ounces of water and then gargling with it followed by swallowing the mixture will help rid a person of throat problems. 4-Using wh ite vinegar in an inhaler and taking a steam of the same can be used as a decongestant for a blocked chest. 5-One of the main white vinegar skin benefits is that it helps to treat extremely dry skin. Using 2 tabs of v inegar in bath water will help mo isturize the skin naturally and help in curing itchy skin as well. 6-White vinegar can also cure dandruff. After a regular bath, simp ly pour a mixture of half cup vinegar diluted in 2 cups water. 7-White vinegar also helps in curing toenail fungus. Rub a cotton swab dipped in white vinegar over the infection many times in a day. 8-Soaking ones feet in vinegar helps in curing athletes foot, as well as an equal mixture of alcohol and vinegar helps to combat swimmer's ears [3 & 6]. Fever is a co mmon encounter in hospitalized patients and can cause morbid ity and mortality in crit ically ill patients & its management is integral aspects of nursing care .. About 5% of people who go to an emergency room have a fever . Fever (also known as pyrexia is a common medical sign characterized by an elevation of temperature above the normal range of 36.5– 37.5 °C (98–100 °F) due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.  A wide range for normal temperatures has been found. Fever is generally agreed to be present if the elevated temperature is caused by a raised set point and: Rectum temperature is at or over 37.5–38.3 °C (99.5–100.9 °F) [9,].Temperature measured through mouth is at or over 37.7 °C (99.9 °F) &Temperature measured under axillaries or thought otic route at or over 37.2 °C (99.0 °F)  A fever can be caused by many different conditions ranging fro m benign to potentially serious. There are arguments for and against the usefulness of fever, and the issue is controversial. With the exception of very high temperatures, treat ment to reduce fever is often not necessary; however, antipyretic med ications can be effective at lowering the temperature, which may improve the affected person's comfort. Infections are the most common cause of fevers, however as the temperature raises other causes become more co mmon. The regulation of body temperature involves a complex series of physiological responses. Temperature is u ltimately regulated in the hypothalamus. A t rigger of the fever, called pyrogens, causes a release of prostaglandin E2 (PGE2). PGE2 then in turn acts on the hypothalamus, wh ich generates a systemic response back to the rest of the body, causing heat-creating effects to match a new temperature level. In many respects, the hypothalamus works like a thermostat. When the set point is raised, the body increases its temperature through both active generations of heat and retaining heat. Vasoconstriction both reduces heat loss through the skin and causes the person to feel cold. If these measures are insufficient to make the blood temperature in the brain match the new setting in the hypothalamus, then shivering begins in order to use muscle movements to produce more heat. When the fever stops, and the hypothalamic setting is set lower; the reverse of these processes (vasodilatation, end of shivering and no shivering heat production) and sweating are used to cool the body to the new, lower setting.  When taken from a source each sentence should reference the source Pyrogens are a substance that induces fever. These can be either internal (endogenous) or external (exogenous) to the body. The bacterial substance lip polysaccharide (LPS), present in the cell wall of some bacteria, is an examp le of exogenous pyrogens. Pyrogenicity can vary: In extreme examples, so me bacterial pyrogens known as super antigens can cause rapid and dangerous fevers. Depyrogenation may be achieved through filtrat ion, distillation, chro matography, or inactivation . When taken fro m a source each sentence should reference the source Types of Fever - Prolonged fever lasting longer than about 10-14 days -Chronic Fever that lasts longer than three to four days; some researchers consider intermittent fevers that recur over months to years as "chronic" fevers -Intermittent: Fevers that either varies fro m normal to fever levels during a single day or may occur one day and recur in about one to three days - Re mittent: Fevers that come and go at regular intervals -Constant: Also termed continuous; usually low grade and does not change by much (by about 1 degree F over 24 h o u rs ) In continuous fever, temperature remains above normal throughout the day and does not fluctuate more than 1 °C in 24 hours, e.g. lobar pneumonia, typhoid, urinary tract infection, brucellosis, or typhus. A fever is usually acco mpanied by sickness behavior, which consists of lethargy, depression, anorexia, sleepiness, hyperalgesia, and the inability to concentrate. There are argu ments for and against the usefulness of fever, and the issue is controversial. Theoretically fever can aid in host defense. .Fever in children is believed to train the immune system and prevent asthma. White blood cells also rapidly proliferate due to the suitable environment and can also help fight off the harmfu l pathogens and microbes that invaded the body.  Research has demonstrated that fever assists the healing process in several important ways: Increased mobility of leukocytes, Enhanced leukocytes phagocytosis ,Endotoxin effects decreased ,Increased proliferation of T cells[16,17] Fathia Attia M ohammed et al.: A Comparison of Vinegar Compresses vs. Cold Water& 40 Water with Vinegar for treating of Fever at Tropical Hospitals Fever should not necessarily be treated. Most people recover without specific medical attention. A lthough it is unpleasant, fever rarely rises to a dangerous level even if untreated. Damage to the brain generally does not occur until temperatures reach 42 °C (107.6 °F), and it is rare for an untreated fever to exceed 105 °F (41 °C). So me limited evidence supports sponging or bathing feverish children with tepid water. The use of a fan or air conditioning may reduce the temperature and increase co mfort. If the temperature reaches the extremely h igh level of hyperpyrexia, aggressive cooling is required. In general, people are advised to keep adequately hydrated. Whether increased fluid intake improves symptoms or shortens respiratory illnesses such as the common cold is not known. Cold causes vasoconstriction (shrinkage of blood vessels), decreasing blood flow to an area, and slowing the body’s metabolism and its demand for o xygen A tepid sponge bath is a bath with water below body temperature, between 80_F and 95_F (26.6_C to 35_C). This type of bath may be ordered to reduce a client’s elevated temperature. The first effect of this water on the skin is blood vessel constriction. Sources of cold include ice packs, ice bags, cold collars, or co mmercial cold packs. If the client’s systemic temperature is elevated, cooling blankets or cooling tepid sponge baths can be used.  Typhoid fever is a systemic infect ion, caused mainly by Salmonella typhi found only in man. It is characterized by a continuous fever for 3-4 weeks, relative bradycardia, with involvement of ly mphoid tissue and considerable constitutional symptoms. Each year, wo rld over, there are at least 13-17 million cases of typhoid fever, resulting in 600,000 deaths.  With an estimated 16–33 million cases of annually resulting in 216,000 deaths in endemic areas, the World Health Organization identifies typhoid as a serious public health problem. Its incidence is highest in children and young adults between 5 and 19 years old.  Infection caused by S. typhus remains an important public health problem, particu larly in developing countries. Morbidity and mo rtality attributable to typhoid fever are once again increasing with the emergence and worldwide spread of S. typhi strains that are resistant to most previously useful antibiotics. The clin ical presentation of typhoid fever varies fro m a mild illness with low-g rade fever, malaise, and slight dry cough to a severe clinica l picture with abdomina l discomfort and mu ltip le co mp lications. . TF is characterized by the sudden onset of sustained fever, severe headache, nausea, abdominal pains and loss of appetite, constipation or sometimes diarrhea  Hu mans are the only natural host and reservoir. The infection is transmitted by ingestion of food or water contaminated with faces. Ice cream is recognized as a significant risk factor for the transmission of typhoid fever. Shellfish taken fro m contaminated water, and raw fruit and vegetables fertilized with sewage, have been sources of past outbreaks. The highest incidence occurs where water supplies serving large populations are contaminated with faces. [27, 28] People can transmit TF as long as the bacteria remain in their body; most people are infectious prior to and during the first week of convalescence, but 10% of untreated patients will discharge bacteria for up to 3 months. In addition, 2–5% of untreated patients will become permanent, lifelong carriers of the bacteria in their gall-bladder.  The definit ive diagnosis of typhoid fever depends on the isolation of S. typhi fro m blood, bone marrow or a specific anatomical lesion. The presence of clin ical symptoms characteristic of typhoid fever or the detection of a specific antibody response is suggestive of typhoid fever but not definit ive. Blood culture is the mainstay of the diagnosis of this disease.  The major routes of transmission of typhoid fever are through drinking water or eating food contaminated with Salmonella typhi. Prevention is based on ensuring access to safe water and by promoting safe food handling practices. Health education is paramount to raise public awareness and induce behavior change. Supportive measures are important in the management of typhoid fever, such as oral or intravenous hydration, the use of antipyretics, and appropriate nutrition and blood transfusions if indicated. More than 90% of patients can be managed at howith oral antibiotics, reliable care and close med ical fo llo w-up for co mplications or failure to respond to therapy. However, patients with persistent vomit ing, severe diarrhea and abdo minal d istension may require hospitalization and parenteral antib iotic therapy. [30, 31] There are two vaccines currently recommended by the World Health Organization for the prevention of typhoid: these are the live, oral Ty21a vaccine (sold as ''Vivotif Berna'') and the in jectable Typhoid polysaccharide vaccine (sold as ''Typhim Vi'' by Sanofi Pasteur and ''Typherix'' by GlaxoSmithKline). Both are providing 50% to 80% protective and are reco mmended for travellers' to areas where typhoid is endemic. Boosters are recommended every 5 years for the oral vaccine and every 2 years for the injectable form.  2. Objective To assess and compare the efficacy of vinegar co mpresses versus tape water & tape water with vinegar as hypothermic compresses \ agent 2.1. Research Question The main research question was what are the best compresses methods is more effect ive in reducing patient body temperature? 3. Research Methodology 3.1. Research Design 41 International Journal of Nursing Science 2012, 2(4): 38-46 This was a quasi-experimental study. We conducted the study in 45 subjects between Jun 2011 and October 2011 3.2. Sitting Tropical Hospital at Zagazig & Hehia city, Sharqia governorate, the tow mentioned hospitals are under the supervision of Ministry of Health at Egypt 3.3. Subject All ad mitted patients to the mentioned hospitals in the time of research application .The inclusion criteria for selected subject were only patients admitting suffer fro m high fever with a classic man ifestation of typhoid fever in the first day before administer drug therapy& suspected medical diagnosis is typhoid fever for investigation. All patients have under the same management strategies according to typhoid protocol management'. All patients haven’t past chronic illness' including both male & female patient in variety of age 3.4. Intervention 45 patients divided into 3 groups, each group included 15 patients. White vinegar, cold water & cold water with vinegar half to half co mpresses follo wed by measuring body temperature within first & second hours orally by using mercury thermo meter & documented in flow sheet for each patient. All comp resses were applied for Pt., under axillaries, above the forearm &under the Knee. When applied forehead compresses most of the patients were suffered fro m v inegar orders so, we excluded fro m all application in three groups. 3.5. Admi nistrati ve Design The written permission was obtained before conducting the study from hospital directors. The res earch objective was illustrated either for patients or their family & o rally consent was obtained The subjects characteristics are shown in table ( 1) indicates to the majority of subject age was either below than 20 or 40 year, nearly t wo third were male , more one third were uneducated while nearly half were student and nearly tow third were lived in rura l a rea. Percentage distribution of subjects body temp before & after comp resses in three method was illustrated in table ( 2 ) indicates that more than half have body temp more than 39 0C , nearly half have body temp in between 38.1- 39.1 & 60% have body temp in between 38.1- 39.1 before v inegar , vinegar with water & water co mpresses application res p ectiv ely . Table (1). Demographic charact eristics of st udied subject (No 45 pat ient) Variable Number % Age -10-20 ->20 -40 - > 40- 60 ->60 14 31.1 6 13.3 18 40 7 13.6 Sex male female Le vel of e ducation non educated primary secondary un iv ersit y Occu pa tion House-wife St uden t Self Employment Ret ired Address Urban Rural 29 64.4 16 35.5 17 6 9 13 37.8 13.3 20 28.9 7 15.6 19 42.2 5 11.1 14 31.1 17 37.8 28 62.2 4. Result Table (2). Percentage Distribution of subjects temp according to Compresses Methods (No 45) Temp value 37.6 - 38 c 38.1 - 38.5c 38.6 – 39.1c > 39.1c Tot al Vinegar Vinegar + water water B No\ % 0 0 2 13.3 5 33.3 8 53.4 15\ 100 A1h A2h No\ % 3 20 7 46.7 4 26.7 1 6.6 15\ 100 No\ % 13 86.7 1 6.6 1 6.6 0 0 15\ 100 B No\ % 0 0 2 13.3 7 46.7 5 33.3 15\ 100 A1h No\ % 1 6.6 8 53.4 5 33.3 1 6.6 15\ 100 A2h No\ % 6 46 5 33.3 4 26.7 0 0 15\ 100 B No\ % 0 0 2 20 9 60 4 26.7 15\ 100 A1h No\ % 0 0 3 19.9 8 53.4 4 26.7 15\ 100 A2h No\ % 0 0 4 26.7 10 66.6 1 6.6 15\ 100 Fathia Attia M ohammed et al.: A Comparison of Vinegar Compresses vs. Cold Water& 42 Water with Vinegar for treating of Fever at Tropical Hospitals S.O.V Between methods Within methods Tot al Significant (0.05) Table (3). Comparison the effectiveness of three compresses methods After 1 hour DF SS Ms F 2 3.07 1.53 After 2 hour DF SS Ms 2 11.02 5.51 42 5.24 0.13 12.27** 44 8.31 42 4.41 0.11 44 15.42 Table (4). Comparison of mean value of three compresses methods Met ho d Vinegar Vinegar + Water W at er )0.05 ( LSD )0.01 ( LSD After 1 hour Means 38.4 38.5 39.0 0.321 0.740 After 2 hour Means 37.6 37.9 38.7 0.294 0.678 F 52.48** 39.0 38.5 38.4 vinegar vinegar +water Water Figure (1). Represent the Mean Temp after Application of Compresses by Hour 38.7 37.9 37. vinegar vinegar + water Water Figure (2). Represent the Mean Temp after Application of Compresses by 2 Hours 43 International Journal of Nursing Science 2012, 2(4): 38-46 Fi gure (3). Histogram represent s the degrees of Temp changes Aft er Applicat ion of Compresses There was a difference in ultimate reduction of temperature between & within the three methods. It was compared by using F test & an ANOVA test and the result showed a statistically significant value (P<0.05) (table 3) To illustrate the significant d ifferent was regard ing wh ich methods, we used comparison of three means by using less significant difference test (LSD test) (table 4) that indicates that vinegar compression was rapidly effective in reduction fever followed by vinegar with water than only water compresses either after one & tow hours at difference means less than 0.05 wh ile no difference at 0.01 Figure (1, 2 & 3) shows the differences' between means of three co mpresses methods 5. Discussion We writ ing in methodology that the PT coming to tropical hospital suffer the same clin ical man ifestation of typhoid fever according to physician view & already send samples to lab to assure & start the same medical management s terateg ies One of the major weaknesses was not discussed here. The abstract states “suspected to have typhoid fever” It is very important to understand that diagnosis of he organis m is very important to the reliab ility of this study. Different organisms have different fever patters. There is an evidence that using antipyretic drugs or external cooling helps recovery, and as the review by Carey indicates they can cause discomfort and delay recovery, therefore their routine use should be discouraged. Larger studies are needed to establish the effects (or lack of them) of the impact of antipyretic drugs and external cooling (alone or in combination) on short-term recovery fro m illness and shortto mediu m term morb idity. Available evidence does not support routine administration of antipyretics to reduce duration of fever or illness (33). Several methods have been recommended to reduce fever in children, which include tepid sponging, fanning, alcohol sponging and antipyretics. However, controversy surrounds the use of tepid sponge for reduction of fever. The effectiveness of tepid sponging as a treatment alongside antipyretic varies between studies, with some finding that it is of no benefit and others suggesting that it is helpful (34) Nu merous non-pharmacological interventions for management of fever were detailed including environ mental changes (e.g. removing blankets, turning down thermostat, opening windows), physical cooling measures (e.g. ice packs, cooling blanket, bathing) and other interventions (e.g. mobilization, incentive Spiro meter use). Furthermo re, many interventions seen as useful by some participants (e.g. ice packs, cooling blankets, fans, etc.) were seen as problemat ic by others. The hypothermia b lanket is used cautiously to treat uncontrollable hyperthermia. Risk occurs because the cold interferes with the normal febrile (fever) response. Fever-producing pathogens cause the body’s temperature regulatory centre (the hypothalamus) to produce a new body Fathia Attia M ohammed et al.: A Comparison of Vinegar Compresses vs. Cold Water& 44 Water with Vinegar for treating of Fever at Tropical Hospitals temperature set point in the body’s effort to fight off the pathogen’s negative effects. Using a hypothermia b lanket during this response decreases the actual body temperature, moving it further away fro m the set point. This may cause an even more severe febrile react ion. In addition, fever sometimes is helpful, because it has the effect of destroying pathogens (35). Cold causes vasoconstriction (shrinkage of blood vessels), decreasing blood flow to an area, and slowing the body’s metabolism and its demand for o xygen. A cloth (padded gauze) is immersed in cold water and applied in area where we get large superficial vessels E.g. axilla and groin .Change the cloth when it becomes warm &applied fo r 15-20 min (36) Regardless of practice setting, interventions chosen by nurses were frequently based on trial and error or indiv idual conventions – ‘what works’– rather than ev idence-based practice. So me nurses’ accounts indicated use of interventions that were clearly contraindicated by the literature. Fever management is often left to the discretion of the individual p ractitioner because evidence-based guidelines are not explicit (37) Recent studies reveal wide variat ion in nursing practice and barriers to evidence-based fever management. In studies conducted separately in three different countries (US, Sweden and Australia), all authors noted a lack of consistency in the way nurses described fever and the management of fever (38). The gap between availab le evidence fro m patient outcomes research and data on bedside practice for fever management is a striking, widespread problem. Their participants reported using interventions not supported by literature such as alcohol, ice packs to the groin and opening the windows in the intensive care unit to treat fever. During the chill phase of fever, use of ice packs is likely to lead to increased shivering as the temperature set point has been raised and the body is working to increase the temperature to the new threshold (39). This concern is magnified when the ice is applied to the groin area which contains a large number of heat sensitive neurons. The use of alcohol to reduce fever is unclear efficiency. While Polderman suggests that a combination spray is efficacious (40) there is little published evidence to support its use. Moreover, alcohol can be drying to skin, and alcohol toxic ity has been reported with the use of 100% isopropyl or ethyl alcohol for sponge baths in both children and older adults (41), there is a need for research to evaluate the use of the alcohol and water sprays in fever manage ment. A tepid sponge bath is a bath with water below body temperature, between 80_F and 95_F (26.6_C to 35_C). This type of bath may be ordered to reduce a client’s elevated temperature. The first effect of this water on the skin is blood vessel constriction. Administration of cold water for fever has been practiced for years. Formally and informally, healthcare personnel have voiced opinion for and against the practice of cold water and questioned its relative effectiveness compared to other methods. Several methods have been recommended to reduce fever in children, which include tepid sponging, fanning, alcohol sponging and antipyretics. However, controversy surrounds the use of tepid sponge for reduction of fever. The effect iveness of tepid sponging as a treatment alongside antipyretic varies between studies, with some finding that it is of no benefit and others suggesting that it is helpful (42). Best practices in fever management are then essential to optimizing patient outcomes. Yet the topic of best nursing practices for fever management is largely ignored in the clin ical and research literature, wh ich can complicate the achievement of best practices.( 43) We observed that administration of v inegar co mpresses resulted in rapid temperature reduction in the initial 30-60 minutes as compared to water alone or co mbined with vinegar half to half ; however, by the end of 2 hours both groups had reduce degree of temperature in different range. There was a difference in ult imate reduction of temperature between the three groups. Client with the v inegar compresses group had a higher reduction of body temp than only water or water with vinegar group's figure (3). There wasn't other studies that support or to compare the present result with them In spit of many research encounter to use vinegar as a hypoglycaemic & as an anti-inf la mmatory. 6. Summary& Conclusions 6.1. Main Outcome Measures Reduction of body temperature was effective within used vinegar compress compared to other methods used. Results: The reduction of body temperature in the v inegar compress faster than cold water & cold water with vinegar half to half co mpress, however, by the end of 2 hours 6.2. Conclusions Using of vinegar co mpresses is more effective in reduction of body temperature for patient who suffer fro m fever 6.3. Recommendation - Applications vinegar co mpresses for patients who suffer fro m fever in all health institutions especially when needs to lower patient body temp fasting . - Further work needs to be conducted, particularly with regard to assess using of vinegar in management fever in health institution - Reapplication of our results using other samples would be helpful in ensuring the validity of these findings. - Further work needs to be conducted to illustrate which effect of vinegar on skin surface are as a vasodilators or evaporated or both 6.4. Li mitati ons - The study was undertaken at tropical hospitals only. 45 International Journal of Nursing Science 2012, 2(4): 38-46 - There aren't similar studies to support & compare with our study 381–387.  Craven, R and Hirnle, C. (2006). Fundamentals of nursing: Human health and function. Fourth edition. p. 1044 REFERENCES  Lewis, SM , Heitkemper, MM , and Dirksen, SR. (2007). 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