Nursing diagnosis: Hyperthermia related to increased metabolic rate, illness; dehydration; direct effect of circulating endotoxins on the hypothalamus, altering temperature regulation
Possibly evidenced by
Increase in body temperature higher than normal range
Flushed skin, warm to touch
Increased respiratory rate, tachycardia
Desired Outcomes/Evaluation Criteria—Client Will
Demonstrate temperature within normal range and be free of chills.
Experience no associated complications.
Nursing intervention with rationale:
1. Monitor client temperature—degree and pattern. Note shaking chills or profuse diaphoresis.
Rationale: Temperature of 102 F to106 F (38.9 C–41.1 C) suggests acute infectious disease process. Fever pattern may aid in diagnosis: sustained or continuous fever curves lasting more than 24 hours suggest pneumococcal pneumonia, scarlet or typhoid fever; remittent fever varying only a few degrees in either direction reflects pulmonary infections; and intermittent curves or fever that returns to normal once in 24-hour period suggests septic episode, septic endocarditis, or tuberculosis (TB). Chills often precede temperature spikes. Note: Use of antipyretics alters fever patterns and may be restricted until diagnosis is made or if fever remains higher than 102 F (38.9 C).
2. Monitor environmental temperature. Limit or add bed linens, as indicated.
Rationale: Room temperature and linens should be altered to maintain near-normal body temperature.
3. Provide tepid sponge baths. Avoid use of alcohol.
Rationale: Tepid sponge baths may help reduce fever. Note: Use of ice water or alcohol may cause chills, actually elevating temperature. Alcohol can also cause skin dehydration.
4. Administer antipyretics, such as acetylsalicylic acid (ASA) (aspirin) or acetaminophen (Tylenol).
Rationale: Antipyretics reduce fever by its central action on the hypothalamus; fever should be controlled in clients who are neutropenic or asplenic. However, fever may be beneficial in limiting growth of organisms and enhancing autodestruction of infected cells.
5. Provide cooling blanket, or hypothermia therapy, as indicated.
Rationale: Used to reduce fever, especially when higher than 104 F to 105 F (39.5 C–40 C), and when seizures or brain damage are likely to occur.