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Nursing Care Plan for Fever


Nursing Care Plan for Fever: Nursing Diagnosis for Fever (Hyperthermia)| Definition of Fever; Related Factors of Fever

Definition of Fever

  • Body temperature elevated above normal range


Defining Characteristics of Fever

  • Fever

  • Flushed, warm skin

  •  Increased heart and respiratory rate

  • Seizures

Related Factors of Fever

  • Anesthesia

  • Decreased perspiration

  • Dehydration

  • Exposure to hot environment

  • Inappropriate clothing

  •  Increased metabolic rate

  • Illness

  • Medications

  • Trauma

  • Vigorous activity

Nursing Care Plan for Fever | Assessment Focus of Fever


Nursing Care Plan for Fever | Assessment Focus of Fever; Expected Outcomes of Fever; Suggested NOC Outcomes of Fever

Assessment Focus of Fever (Refer To Comprehensive Assessment Parameters.)

  • Fluid and electrolytes

  • Pharmacological function

  • Physical regulation

  • Neurocognition

  • Respiratory function

  • Tissue integrity

Expected Outcomes of Fever

The patient will

  • Remain afebrile.

  • Maintain balance of intake and output within normal limits.

  • Maintain urine specific gravity between 1.005 and 1.015.

  • Exhibit moist mucous membranes.

  • Exhibit good skin turgor.

  • Remain alert and responsive.

Suggested NOC Outcomes of Fever

Hydration; Infection Severity; Thermoregulation; Vital Signs

 

Nursing Care Plan for Fever | Nursing Interventions of Fever


Nursing Diagnosis for Fever | Nursing Interventions of Fever and Rationales

Nursing Interventions of Fever and Rationales

  • Monitor heart rate and rhythm, blood pressure, respiratory rate, LOC and level of responsiveness, and capillary refill time every 1–4 hr to evaluate effectiveness of interventions and monitor for complications.

  • Determine patient’s preferences for oral fluids, and encourage patient to drink as much as possible, unless contraindicated. Monitor and record intake and output, and administer intravenous fluids, if indicated. Because insensible fluid loss increases by 10% for every1.8 0F (1 0C) increase in temperature, patient must increase fluid intake to prevent dehydration.

  • Take temperature every 1–4 hr to obtain an accurate core temperature. Identify route and record measurements.

  • Administer antipyretics as prescribed and record effectiveness. Antipyretics act on hypothalamus to regulate temperature.

  • Use nonpharmacologic measures to reduce excessive fever, such as removing sheets, blankets, and most clothing; placing ice bags on axillae and groin; and sponging with tepid water. Explain these measures to patient. Nonpharmacologic measures lower body temperature and promote comfort. Sponging reduces body temperature by increasing evaporation from skin. Tepid water is used because cold water increases shivering, thereby increasing metabolic rate and causing temperature to rise.

  • Use a hypothermia blanket if patient’s temperature rises above 103 0F (39.4 0C), if ordered. Monitor vital signs every 15 min for 1 hr and then as indicated. Prolonged hyperthermia may lead to complications such as seizures. Turn off blanket if shivering occurs. Shivering increases metabolic rate, increasing temperature.

  • Report lack of responses to interventions to physician to prevent complications.

Suggested NIC Interventions of Fever

Environmental Management; Fever Treatment; Fluid Management; Temperature Regulation

Nursing Care Plan for Fever | Definition of Fever; Related Factors of Fever; Nursing Interventions of Fever and Rationales