fever

Nursing Care Plans for Fever Hyperthermia

5 Nursing Care Plans for Fever -Hyperthermia

Fever, also known as hyperthermia or pyrexia, is a medical condition when there is an uncontrolled rise in the body temperature, measured as 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.

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 fever 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).

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

Below are 5 nursing care plans that a nurse can consider in the care of a patient who has hyperthermia.

Nursing Care Plan 1

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

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

InterventionsRationales
Assess the patient’s vital signs at least every 4 hours.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. Paracetamol) administered.
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 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 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.

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 nursing interventions, the patient will have a stabilized temperature within the normal range and no signs of surgical wound infection.

In addition to the nursing interventions mentioned previously, here are some possible actions related to this particular nursing diagnosis:

InterventionsRationales
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.
Start intravenous therapy as prescribed. Encourage oral fluid intake if recommended post-operatively.Hyperthermia can lead to dehydration.

Nursing Care Plan 3

Nursing Diagnosis: Alteration in comfort related to hyperthermia.

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

InterventionsRationales
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 cooling blanket to the patient.To facilitate the body in cooling down and to provide comfort.

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 nursing interventions, the patient will have a stabilized temperature within the normal range and will verbalize feeling more comfortable.

In addition to the nursing interventions mentioned previously, here are some possible actions related to this particular nursing diagnosis:

InterventionsRationales
Commence a fluid balance chart, monitoring the input and output of the patient.To monitor patient’s 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.

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.

In addition to the nursing interventions mentioned previously, here are some possible actions related to this particular nursing diagnosis:

InterventionsRationales
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.

With proper use of the nursing process, a patient can benefit from various nursing interventions to eliminate fever and promote client comfort and well being.

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. (2017). 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. (2018). 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.

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