Fever Nursing Diagnosis & Care Plan

Fever, also known as hyperthermia or pyrexia, is a medical condition when the body’s thermoregulatory system fails. The patient’s temperature is usually measured above 37.5 degrees Celsius.

It results from the failure of the body’s thermoregulatory center, the hypothalamus to control the body temperature between the normal range of 36 to 37.5 degrees Celsius.

Signs and Symptoms of Fever

Signs and symptoms of hyperthermia can vary depending on the cause and severity, but some common indicators include:

• Elevated body Temperature: Increased body temperature is the common sign of fever.
• Poor skin turgor: When a person has an elevated body temperature, their skin turgor may be affected due to dehydration.
• Shallow breathing: Shallow breathing or rapid breathing (tachypnea) can be a symptom, particularly in severe cases or in people with underlying respiratory conditions.
• Profuse Sweating or heavy sweating
• Increased metabolic rate: The body is burning more calories than usual. This increased metabolic rate is part of the body’s response to fighting off an infection or illness.
• Elevated blood pressure: It is common for their blood pressure to be slightly elevated. This is due to a number of factors, including the body’s response to infection and inflammation.
• Joint pain
• Dry mouth

Causes for Fever

There are several possible etiologies or causes of hyperthermia, and the most common ones include an ongoing infection, trauma, exposure to hot environment, and increased metabolic rate due to extreme activity.

A higher than normal body temperature can also be triggered by intake of some medications, either as an adverse side effect (e.g. antibiotics, sulfa drugs, and chemotherapy agents), or as withdrawal symptom (e.g. fentanyl or heroin withdrawal).

Body temperature can be assessed by taking temperature from different routes, including tympanic, axillary, oral, and rectal. 

Malignant Hyperthermia

Malignant hyperthermia and heat stroke are serious heat-related illnesses that can cause significant health complications and extreme temperatures. Heat exhaustion is a less severe form of heat illness, but can still lead to more severe heat related illness if not addressed properly and can become life threatening.

Signs and symptoms associated with heat illness include an elevated body temperature, rapid heart rate, nausea, headache, dizziness, and confusion. Without treatment heat illness can be fatal. It is important to recognize heat illness early and take the necessary steps to reduce the risk of more serious heat-related illnesses. These steps include providing adequate hydration, fluid reuscitation, cooling blankets, and rest for recovery. If heat illness progresses to heat stroke, it can become life threatening.

Below are 5 nursing diagnosis that a nurse can consider in the care of a patient who has hyperthermia along with interventions and rationales.

Nursing Diagnosis for Fever

Fever Nursing Care Plan 1

Nursing Diagnosis: Hyperthermia related to upper respiratory tract infection (URTI) as evidenced by a high temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.

Desired Outcome: Within 4 hours of interventions, the patient will have a stabilized temperature within the normal range.

Fever Nursing Interventions

Monitor vital signs at least every 4 hours.  To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and antipyretic medications (e.g. Tylenol) administered.

Remove excessive clothing, blankets and linens. Adjust the room temperature / air conditioning.  To regulate the temperature of the environment and make it more comfortable for the patient.

Administer the prescribed antibiotic and anti-pyretic medications.  Use the antibiotic to treat bacterial infection, which is the underlying cause of the patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.

Offer a tepid bath.   To facilitate the body in cooling down and to provide comfort.

Elevate the head of the bed.  Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.

Fever Nursing Care Plan 2

Nursing Diagnosis: Hyperthermia related to surgical wound infection as evidenced by temperature of 38.0 degrees Celsius, pus draining from the wound, shivering chills, and profuse sweating.

Desired Outcome: Within 4 hours of interventions, the patient will have a stabilized temperature within the normal range and no signs of surgical wound infection.

Fever Nursing Interventions

Perform a proper surgical wound cleaning and dressing change on a daily basis.  To perform appropriate wound care and aid in the healing process against the infection that has triggered the fever.

Inform the surgical doctor regarding the signs of surgical wound infection and inquire about the need to use antipyretic and antibiotic drugs.  Use the antibiotic to treat bacterial infection, which is the underlying cause of the patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.

Administer IV fluids as prescribed. Encourage oral fluid intake if recommended post-operatively.  Hyperthermia can lead to dehydration.

Fever Nursing Care Plan 3

Nursing Diagnosis: Alteration in comfort related to hyperthermia.

Desired Outcome: Within 4 hours of interventions, the patient will have a stabilized temperature within the normal range and will verbalize feeling more comfortable.

Fever Nursing Interventions

Remove excessive clothing, blankets and linens. Adjust the room temperature.   To regulate the temperature of the environment and make it more comfortable for the patient.

Administer the prescribed antibiotic/ antiviral or antiparasitic and anti-pyretic medications.  Use the antibiotic/antiviral/antiparasitic drug to treat the infection, which is the underlying cause of the patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.

Offer a tepid sponge bath.   To facilitate the body in cooling down and to provide comfort.

Elevate the head of the bed.  Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.

Offer a evaporative cooling blanket to the patient.   Coolong blankets facilitate the body in cooling down and to provide comfort.

Fever Nursing Care Plan 4

Nursing Diagnosis: Fluid Volume Deficit related to dehydration due to fever as evidenced by temperature of 39.0 degrees Celsius, skin turgidity, dark yellow urine output, profuse sweating, and blood pressure of 89/58.

Desired Outcome: Within 48 hours of interventions, the patient will have a normal body temperature within the normal range and will verbalize feeling more comfortable.

Fever Nursing Interventions

Commence a fluid balance chart, monitoring the input and output of the patient.  To monitor patient’s urine output and fluid volume accurately and effectiveness of actions to reverse dehydration.

Start intravenous therapy as prescribed. Encourage oral fluid intake.  To replenish the fluids lost from profuse sweating, and to promote better blood circulation around the body.

Educate the patient (or guardian) on how to fill out a fluid balance chart at bedside.  To help the patient or the guardian take ownership of the patient’s care, encouraging them to drink more fluids as needed, or report any changes to the nursing team. 

Monitor patient’s serum electrolytes and recommend electrolyte replacement therapy (oral or IV) to the physician as needed.  Sodium is one of the important electrolytes that are lost when a person is sweating. Hyponatremia or low serum sodium level may cause brain swelling.

Assess the patient’s vital signs at least every 4 hours.  To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment

Fever Nursing Care Plan 5

Nursing Diagnosis: Hyperthermia related to possible catheter-associated UTI as evidenced by temperature of 38.7 degrees Celsius, cloudy urine, pain in lower back, positive urine dipstick, and profuse sweating.

Fever Nursing Interventions

Collect a urine sample and send to the lab for urinalysis and culture.  To confirm the medical diagnosis of urinary tract infection and determine the underlying bacteria that caused it.

Change the urinary catheter.  To remove the contaminated catheter and replace with a new one that is fit for purpose.

Perform regular catheter care properly.  Regular catheter care is required to ensure that there are no recurrence of infection. This involves proper documentation to show that it is done frequently.

Frequently Asked Questions

FAQ 1: What temperature constitutes a fever?

One of the most common questions nurses receive from patients is, “What temperature is considered a fever?” The answer is not as straightforward as one might think. Generally speaking, a body temperature above 100.4°F (38°C) is considered a fever. However, this can vary depending on a variety of factors.

For example, some people may have a slightly higher or lower normal body temperature than the average of 98.6°F (37°C). Additionally, the time of day can affect body temperature, with temperatures typically being lower in the morning and higher in the evening. Other factors that can influence body temperature include age, gender, and physical activity level.

It’s important to note that a fever is not always a cause for concern. In fact, fevers are a natural response to infection or illness and can help the body fight off harmful invaders. However, if a fever is accompanied by other symptoms such as severe headache, difficulty breathing, or a rash, it’s important to seek medical attention right away.

FAQ 2: How should fever be managed in patients?

Managing fever in patients is an important aspect of nursing care. Fever is a common symptom of many illnesses and can be a sign of an underlying infection or inflammation. Here are some guidelines for managing fever in patients:

• Assess the patient’s vital signs, including temperature, heart rate, and respiratory rate, and document them in the patient’s chart.
• Determine the cause of the fever, if possible, by performing a thorough physical examination and ordering diagnostic tests as needed.
• Administer antipyretic medications, such as acetaminophen or ibuprofen, as ordered by the healthcare provider. These medications can help reduce fever and relieve discomfort.
• Ensure the patient is well-hydrated by encouraging them to drink fluids, such as water, juice, or electrolyte solutions.
• Monitor the patient’s response to treatment and reassess their vital signs regularly.
• Provide comfort measures, such as cool compresses or tepid sponge baths, to help reduce fever and promote patient comfort.

It is important to remember that fever is a natural response to infection or inflammation and is a sign that the body’s immune system is working to fight off the underlying condition. In some cases, fever may be beneficial and should not be aggressively treated unless it is causing significant discomfort or other complications.

FAQ 3: When should a healthcare provider be contacted regarding fever?

Fever is a common symptom that can be caused by various health conditions. While most people can manage a fever at home, there are certain situations when it is important to seek medical attention. Here are some guidelines on when to contact a healthcare provider:

• If the fever lasts for more than three days, it is recommended to contact a healthcare provider. This is especially important if the fever is accompanied by other symptoms such as cough, sore throat, or difficulty breathing.
• If the fever is very high (above 103°F or 39.4°C), it is important to seek medical attention immediately. High fever can be a sign of a serious infection or other health condition.
• If the fever is accompanied by other symptoms such as severe headache, neck stiffness, rash, or confusion, it is important to seek medical attention. These symptoms can be a sign of a serious health condition that requires prompt treatment.

It is important to note that these guidelines are not exhaustive and that each individual case may require different medical attention.

References:

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.