Nursing care plan for fever

Nursing care plan for fever

Nursing diagnosis-1: Body temperature elevated above the normal range Related to :

• Infections
• exposure to a hot environment
• vigorous activities
• medication
• dehydration
• increased metabolic rate

As evidenced by:

• thermometer reading above the normal range
• hot flushed skin
• increased heart rate
• increased respiratory rate
• seizure

Expected outcomes:

• Body temperature below 39°C.

Assessment	Rationales
Determine the cause of the fever.	Identification of causes can be helpful in management.
Assess the vital signs.	An increase in temperature and abnormal other vital signs can be determined.
Measure fluid intake and urine output.	Fluid resuscitation may be helpful in case of dehydration.
Assess serum electrolytes, especially sodium.	To avoid hyponatremia in profuse sweating in hyperthermia.

Interventions	Rationales
Control the environmental temperature, and move the client to a cool area.	Controlling the environment is helpful in reducing the core temperature of the body.
Remove excess clothing and covers from the patient’s body.	Removing clothes facilitates the evaporation process.
Provide cold sponging.	To decrease temperature through the conduction process.
Providing non-invasive cooling mattresses and cold packs applied to measure blood vessels.	Helps in lowering the core temperature.
Adjust cooling measures based on the patient’s physical response	Suddenly cooling body temperature may cause shivering and may require more energy.
Administer antipyretics.	To reduce temperature.
Administer ice-cold lavages and enemas.	To reduce temperature.

Nursing diagnosis-2: Imbalanced nutrition less than body requirements related to anorexia

Interventions	Rationales
Discuss with the dietician regarding diet. Also discuss with the patient regarding his/her likings or dislikings.	It increases the interest of the patient in food.
Teach and assist the client to rest before meals.	Fatigue decreases the desire to eat.
Offer frequent small feedings.	It becomes easy to eat and also meets the nutritional requirements effectively.
Teach the client measures to reduce nausea a. avoid the smell of food preparation. b. Loosen clothing while eating. c. Fresh air should be there in the eating place. d. Avoid lying down flat for at least 2 hours after eating.	Venous congestion of the GI tract may lead to nausea.
Avoid high-fat foods and fluids.	High-fat foods may create disturbances in absorption.
Unless contraindicated, advise the patient to take fluid at least 3000ml per 24 hr.	To avoid the risk of dehydration.

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