nursing care plan for fever Care plan. Altered body temperature, secondary to infectious process, as evidenced by temperature greater than 100.5 degrees F, malaise, chills, lethargy. Nursing interventions are to provide fever reducing medications, cool compresses and oral fluids, and review progress notes and lab results. (You’re looking for a CBC, cultures, sputum cultures possibly and chest x ray if applicable. ) Your interventions are assessed as evidenced by normal body temperature, lack of chills.
What is a nursing diagnosis for
fever?
A fever (or pyrexia) is indicative of infection. As a general rule, a temperature in excess of 37.4C is considered above normal and therefore, a fever.
However, not all fevers (high temperatures) can be considered equal. For example, it’s a well known fact that pre-menstrual women experience a rise in temperature with accompanying uncomfortable symptoms such as sweating, flushes and sleep disturbances.
A viral infection will generally exhibit a high temperature but may well resolve within 48 hours with conservative management such as paracetamol, additional oral fluids and bed rest.
If a high temperature is prolonged and in excess of 38C, bacterial infection is suspected requiring prompt action – blood cultures & specimen analysis along with aggressive antibiotic treatment is the first course of action. Usually intravenous antibiotics will be commenced and gradually tailed down to an oral dose for the course remainder.
Rule of Thumb! Fevers are indicative of an underlying cause. Never ignore, treat the most apparent suspects first but always be aware that something life-threatening may be going on.
How do nurses diagnose a fever in patients?
Since this is providing diagnoses under the guise of us being nurses, what we really need first and foremost is some data to get us to come up with the hyperthermia diagnosis.
To start with, you need to ask your client if they might be feeling any hot lately. That feeling of warmth is our best sign and subjective data that tell us something is not right in the temperature. Probably a very nice alternative that you might hear is that they might feel like the room would be a bit stuffy.
Once that’s established, we need to assess further and get our own data from the client. And obviously, measuring the temperature comes first to confirm your hard objective numbers. Other observations like dryness of the skin helps in rounding up the symptoms.
In formulating the diagnosis, it normally requires that you take note of the symptoms you’ve gathered since those would more or less be indicated as your related factor in the diagnosis. And if you happen to have a medical diagnosis from the physician, you can connect that as well (“Hyperthermia related to [symptom] secondary to [medical diagnosis]).
This basically solidifies the philosophy behind the nursing diagnosis as a way to describe clients’ responses to illness, NOT illness per se. So in effect, we are responsible for managing such responses until they are stabilized, working our way from a somewhat indirect way to hopefully affect and possibly improve the outcome of the actual illness/es clients have.