Nursing Care Plan for Fever

A nursing care plan for fever is a vital component in the proper management of fever in patients. A comprehensive assessment of the patient’s vital signs, medical history, and symptoms, as well as the diagnosis of the underlying cause of the fever, should be part of such a plan. The strategy should also include appropriate interventions such as administering antipyretic medication, providing proper hydration, and implementing temperature-lowering measures for the patient.

Nurses are essential in carrying out these interventions, assessing the patient’s progress, and changing the care plan as needed. Healthcare practitioners can effectively manage fever and achieve optimal patient outcomes with a well-crafted nursing care plan.

What is Fever?

Fever is a common symptom of many infections, including viral, bacterial, and fungal infections. Several drugs and immunizations also cause it as a side effect. It is a natural body’s immune response against infections or inflammation.
It is normally a controlled function of the body by the hypothalamus, a thermoregulatory center of the brain, thus it is transient in reaction to infection or inflammation and diminishes naturally when the infection or inflammation causes are removed from the body or destroyed.

Types of Fever Based on Body Temperature

1. Low-Grade Fever:

A low-grade fever is a mild fever with a body temperature of 100.4°F (38°C) to 101°F (38.3°C). It is frequently connected with minor diseases such as the common cold or flu and normally cures on its own within a few days.

2. Moderate Fever:

A moderate fever is defined as a body temperature between 101°F (38.3°C) and 102.2°F (39°C). It is frequently linked to more serious illnesses, such as pneumonia or a urinary tract infection. Depending on the underlying reason, a moderate fever may necessitate medical therapy such as antibiotics or antiviral drugs.

3. High Fever:

A high fever is defined as a fever with a body temperature greater than 102.2°F (39°C). It is frequently connected with life-threatening diseases such as meningitis or sepsis, and it can also occur as a side effect of some drugs. A high fever is dangerous and necessitates immediate medical attention, including medication to lower the fever and address the underlying cause.

4. Hyperpyrexia:

Hyperpyrexia is a severe kind of fever characterized by a body temperature above 106°F (41.1°C). It is a medical emergency with significant consequences such as seizures, brain damage, and organ failure. Hyperpyrexia necessitates prompt medical attention and may necessitate hospitalization as well as intensive therapy such as cooling measures and intravenous fluids.

Types of Fever Based on Pattern of Occurrence

1. Continuous fever: a fever that remains at a constant level without significant fluctuation for an extended period of time, often associated with bacterial infections.
2. Remittent fever: a fever that fluctuates over a wide range but does not return to normal, often seen in viral infections.
3. Intermittent fever: a fever that comes and goes, with periods of normal temperature alternating with periods of fever; there are three types:

• Quotidian fever (every day)
• Tertian fever (every 48 hours)
• Quartan fever (every 72 hours); is often seen in malaria.

4. Pel-Ebstein fever: a rare type of fever that occurs in some cases of Hodgkin’s lymphoma, following a pattern of periodic spikes lasting for several days or weeks, followed by a period of normal temperature.

Fever and hyperthermia are sometimes mistaken, but they are not the same thing. Now we’ll look at what hyperthermia is.

What is Hyperthermia

Hyperthermia, on the other hand, is a condition in which the body’s temperature regulating mechanism (Hypothalamus) fails and the body temperature increases above normal. Environmental factors, such as exposure to high temperatures or humidity, as well as specific drugs or medical disorders, can all cause hyperthermia. Hyperthermia, unlike fever, is not a natural response to infection and can be hazardous if left untreated.

Types of Hyperthermia Based on Severity

Heat cramps, heat exhaustion, and heat stroke are all examples of hyperthermia.
1. Heat Cramps: Heat cramps are the mildest form of hyperthermia, induced by electrolyte loss through sweating.
2. Heat exhaustion: It is a more severe form of hyperthermia that can occur when the body is repeatedly exposed to high temperatures. Dizziness, nausea, headache, and weariness are some of the symptoms.
3. Heat stroke: It is the most severe type of hyperthermia, and it can cause organ damage, brain damage, and even death. It occurs when the internal temperature of the body exceeds 104°F (40°C).

What is Malignant Hyperthermia?

Malignant hyperthermia (MH) is a rare but potentially fatal illness that can develop during anesthesia. It is caused by a genetic problem that alters how the body manages calcium in muscle cells. When someone with Malignant hyperthermia (MH) is exposed to certain anesthetic medicines, their muscles can contract excessively, resulting in a high fever, muscle rigidity, and other symptoms.

Malignant hyperthermia (MH) can cause major complications and even death if left untreated. Stopping the triggering medicine, slowing muscle contractions, and cooling the body to bring down the fever is all part of the treatment.

To lessen the risk of complications, people with a family history of Malignant hyperthermia (MH) or other risk factors should notify their healthcare practitioners before receiving anesthesia.

Nursing Assessment for Fever

• Take the patient’s vital signs, which should include his or her temperature, heart rate, respiration rate, and blood pressure.
• Determine the patient’s level of awareness, orientation, and cognitive function.
• Examine for dehydration symptoms such as dry mucous membranes, low skin turgor, and decreased urine production.
• Examine the infected site for any signs of infection, such as redness, swelling, and drainage.

Nursing Diagnosis for Fever

Altered Body Temperature more than normal related to an infectious process.

Outcome:

The patient will have a temperature of less than 38°C within 72 hours.

Nursing Interventions for Fever and Its Rationale

S.No.	Nursing Interventions	Rationales
1	Encourage the patient to drink plenty of fluids to prevent dehydration.	Fever increases fluid loss through sweating, which can lead to dehydration. Adequate hydration is important for maintaining normal body functions.
2	Implement cooling measures such as tepid sponge baths, cooling blankets, or fans as prescribed.	Educate the patient and family about the importance of hand hygiene and infection prevention measures to prevent the spread of infection.
3	Monitor the patient’s temperature every 4 hours or as indicated by the patient’s condition.	Frequent temperature monitoring helps to assess the effectiveness of interventions and identify any changes in the patient’s condition.
4	Administer antipyretics such as acetaminophen, aspirin, or ibuprofen as prescribed.	Antipyretics lower the fever and promote patient comfort.
5	Encourage the patient to rest and limit physical activity.	Rest reduces the metabolic rate, which can help to lower the body temperature and conserve energy.
6	Administer antibiotics as prescribed for bacterial infections.	Antibiotics are indicated for bacterial infections and can help to reduce fever by treating the underlying infection.
7	Educate the patient and family about the importance of hand hygiene and infection prevention measures to prevent the spread of infection.	Education can help to prevent the spread of infection to others and promote overall health and well-being.

Outcome Evaluation:

Within 72 hours of nursing interventions, the patient’s temperature should be less than 38°C, indicating effective management of the fever.

Continuation of Outcome Evaluation:

If the patient’s temperature is not controlled within 72 hours of nursing interventions, the nursing care plan must be reassessed. The nurse should work with the healthcare team to determine the underlying cause of the temperature and change nursing interventions as needed. If the patient’s fever has subsided, the nurse should continue to evaluate the patient’s vital signs, hydration status, and cognitive function to verify that the patient is healing properly and that no complications have arisen.

It is also essential to keep an eye on the patient for any side effects of the nursing treatments, such as gastrointestinal distress or allergic responses to drugs. If adverse effects occur, the nurse should notify the healthcare professional as soon as possible and change the nursing treatments as appropriate.

Additional Nursing Diagnoses Relevant for a Patient with Fever

• Risk for fluid volume deficit related to increased fluid loss through sweating, vomiting, or diarrhea.
• Risk for impaired skin integrity related to prolonged exposure to moisture from sweating or from the use of cooling measures.
• Risk for impaired thermoregulation related to an inability to regulate body temperature due to illness or medication side effects.
• Risk for ineffective coping related to the stress and discomfort of the fever.
• Risk for infection related to the presence of an underlying infection that is causing the fever.
• Risk for impaired gas exchange related to fever-induced respiratory distress.
• Risk for altered nutrition: less than body requirements related to loss of appetite, nausea, or vomiting.
• Risk for disturbed sleep pattern related to the discomfort of the fever and associated symptoms.
• Risk for falls related to the patient feeling weak or dizzy due to the fever and associated symptoms.

Risk for fluid volume deficit related to increased fluid loss through sweating, vomiting, or diarrhea.

Expected Outcome:

The patient will maintain adequate fluid balance, as evidenced by normal urine output, stable vital signs, and absence of signs of dehydration within 24 hours.

Fluid Volume Deficit Nursing Interventions and Rationale:

Nursing Interventions	Rationales
Monitor the patient’s fluid intake and output.	Monitoring fluid intake and output helps to assess the patient’s fluid balance and identify any imbalances.
Encourage the patient to drink plenty of fluids, such as water, oral rehydration solutions, or clear broths.	Adequate fluid intake can help to maintain fluid balance and prevent dehydration.
Monitor the patient’s vital signs, particularly blood pressure and heart rate, as they can indicate fluid volume deficit.	Vital signs can help to assess the patient’s fluid status and identify any changes.
Administer intravenous fluids as prescribed if the patient is unable to tolerate oral intake or is severely dehydrated.	Intravenous fluids can help to correct fluid imbalances and maintain fluid balance.

Evaluation:

If the patient maintains adequate fluid balance, has normal urine output, stable vital signs, and no signs of dehydration, the nursing interventions have been effective in preventing fluid volume deficit.

Risk for impaired skin integrity related to prolonged exposure to moisture from sweating or from the use of cooling measures.

Expected Outcome:

The patient’s skin will remain intact and free of breakdown or damage.

Impaired Skin Integrity Nursing Interventions and Rationale:

Nursing Interventions	Rationales
Assess the patient’s skin for any signs of redness, blistering, or breakdown.	Regular skin assessment can help to identify any areas of potential skin breakdown and prevent complications.
Keep the patient’s skin clean and dry.	Maintaining clean and dry skin can help to prevent skin breakdown and infection.
Use skin protectants, such as barrier creams or ointments, to prevent skin breakdown in areas prone to moisture exposure.	Skin protectants can provide a barrier to prevent moisture from damaging the skin.
Change wet clothing and bed linens promptly.	Prolonged exposure to moisture can increase the risk of skin breakdown.

Evaluation:

If the patient’s skin remains intact and free of breakdown or damage, nursing interventions have been effective in preventing impaired skin integrity.

Risk for impaired thermoregulation related to an inability to regulate body temperature due to illness or medication side effects.

Expected Outcome:

The patient’s body temperature will remain within normal limits, as evidenced by stable temperature readings and the absence of signs of hyperthermia or hypothermia.

Impaired Thermoregulation Nursing Interventions and Rationale:

Nursing Interventions	Rationales
Monitor the patient’s temperature regularly, as directed by the healthcare provider.	Frequent temperature monitoring helps to identify any changes in the patient’s body temperature and assess the effectiveness of interventions.
Administer antipyretics, such as acetaminophen or ibuprofen, as prescribed.	Antipyretics can help to reduce fever and promote comfort in the patient.
Implement cooling measures, such as tepid sponge baths, cooling blankets, or fans, as prescribed.	Cooling measures can help to lower the patient’s body temperature and promote comfort.
Monitor the patient’s response to medications that can affect thermoregulation, such as antipsychotics or antidepressants.	These medications can affect the body’s ability to regulate temperature and may require adjustment to prevent hyperthermia or hypothermia.

Evaluation:

If the patient’s body temperature remains within normal limits and the nursing interventions have effectively prevented hyperthermia or hypothermia, the nursing interventions for impaired thermoregulation have been effective.

Risk for infection related to compromised immune system function or invasive medical procedures.

Expected Outcome:

The patient will remain free of infection, as evidenced by normal vital signs, absence of signs and symptoms of infection, and negative cultures.

Risk for Infection Nursing Interventions and Rationale:

Nursing Interventions	Rationales
Use standard precautions, such as hand hygiene and appropriate use of personal protective equipment, to prevent the spread of infection.	Standard precautions are essential in preventing the transmission of infectious organisms.
Monitor the patient’s vital signs, particularly temperature, as it can be an early indicator of infection.	Vital signs can help to identify any changes in the patient’s condition and the need for further assessment or intervention.
Ensure that invasive medical procedures are performed with sterile technique to prevent contamination.	Invasive procedures can increase the risk of infection, so a sterile technique is necessary to prevent contamination.
Administer prophylactic antibiotics or antiviral medications as prescribed to prevent infection.	Prophylactic medications can help to prevent infection in patients at high risk, such as those with compromised immune systems or undergoing invasive procedures.

Evaluation:

If the patient remains free of infection, with normal vital signs, absence of signs and symptoms of infection, and negative cultures, the nursing interventions for risk for infection have been effective.

Risk for imbalanced nutrition: less than body requirements related to decreased appetite, nausea, vomiting, or diarrhea.

Expected Outcome:

The patient will maintain adequate nutritional status, as evidenced by stable weight, normal laboratory values, and the absence of signs of malnutrition.

Imbalanced Nutrition: Less than body Requirement Nursing Interventions and Rationale:

Nursing Interventions	Rationales
Monitor the patient’s weight regularly to assess for changes in nutritional status.	Weight can be an indicator of changes in nutritional status, and regular monitoring can help to identify any changes.
Assess the patient’s nutritional status and dietary preferences.	Assessing the patient’s nutritional status and dietary preferences can help to identify any deficiencies and develop an appropriate nutrition plan.
Offer small, frequent meals and snacks throughout the day to encourage adequate intake.	Offering small, frequent meals and snacks can help to increase the patient’s intake and prevent nausea and vomiting.
Administer antiemetics or other medications as prescribed to manage nausea and vomiting.	Managing nausea and vomiting can help to improve appetite and increase food intake.

Evaluation:

If the patient maintains adequate nutritional status, with stable weight, normal laboratory values, and absence of signs of malnutrition, the nursing interventions for risk for imbalanced nutrition: less than body requirements have been effective.

Risk for impaired gas exchange related to respiratory distress or compromised respiratory function.

Expected Outcome:

The patient’s respiratory status will improve, as evidenced by normal respiratory rate, oxygen saturation, and absence of signs of respiratory distress.

Impaired Gas Exchange Nursing Interventions and Rationale:

Nursing Interventions	Rationales
Monitor the patient’s respiratory rate, depth, and effort regularly to assess for changes in respiratory function.	Regular respiratory assessment can help to identify any changes in the patient’s respiratory status and the need for intervention.
Administer supplemental oxygen as prescribed to maintain adequate oxygenation.	Supplemental oxygen can help to improve oxygenation and prevent hypoxemia.
Encourage deep breathing and coughing exercises to promote lung expansion and improve ventilation.	Deep breathing and coughing exercises can help to improve lung function and prevent respiratory complications.
Monitor the patient’s response to medication, such as bronchodilators or corticosteroids, as they can affect respiratory function.	Medications can affect respiratory function, so monitoring the patient’s response to medication is necessary to identify any adverse effects or the need for further intervention.

Evaluation:

If the patient’s respiratory status improves, with normal respiratory rate, oxygen saturation, and absence of signs of respiratory distress, the nursing interventions for risk for impaired gas exchange have been effective.

Risk for fluid volume deficit related to fever, increased insensible losses, or decreased oral intake.

Expected Outcome:

The patient’s fluid balance will be maintained, as evidenced by stable fluid intake and output, normal vital signs, and the absence of signs of dehydration.

Fluid Deficit Nursing Interventions and Rationale:

Nursing Interventions	Rationales
Monitor the patient’s fluid intake and output regularly to assess for changes in fluid balance.	Monitoring fluid intake and output can help to identify any imbalances in fluid balance and the need for intervention.
Encourage the patient to increase fluid intake, such as water, clear broths, or electrolyte solutions, to prevent dehydration.	Increasing fluid intake can help to maintain hydration and prevent fluid volume deficit.
Monitor the patient’s vital signs, particularly blood pressure and heart rate, as they can be indicators of fluid volume status.	Vital signs can help to identify changes in fluid volume status and the need for further intervention.
Administer intravenous fluids as prescribed to maintain fluid balance.	Intravenous fluids can help to maintain fluid balance in patients with fluid volume deficits or those who are unable to maintain adequate fluid intake orally.

Evaluation:

If the patient’s fluid balance is maintained, with stable fluid intake and output, normal vital signs, and absence of signs of dehydration, the nursing interventions for risk for fluid volume deficit have been effective.

Summary

In summary, effective nursing care for fever involves comprehensive nursing assessment, accurate nursing diagnosis, appropriate nursing interventions, and frequent outcome evaluation. By implementing evidence-based nursing interventions, monitoring the patient’s response to treatment, and collaborating with the healthcare team, the nurse can help to manage fever and promote positive patient outcomes.

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