Nursing Care Plan Example for Hyperthermia, Fever, High Temperature

Fever

 

Scenario:

An 86 year old male comes into the ER. Pt is lethargic but alert enough to tell his health history and reason for coming to the ER. Pt states he has became very weak the past week and is unable to walk to his mailbox because he is so tired. The pt’s daughter is with him. According to the daughter, the patient lives alone and his wife passed away 6 months ago. Vital signs: HR 100 regular, BP 135/78, Temperature 102.4 (orally), and O2 Saturation 95% on room air. Pt also informs you he hasn’t been able to keep any food or water down due to nausea. On assessment, you note that the patient looks dehydrated. Pt’s skin turgor is greater than 5 seconds. Lab results: WBC 19.3, UA (urinalysis) Leukocyte esterase large and bacteria 5-10, WBC too many to count, Influenza screen negative.

Nursing Diagnosis:

Hyperthermia related to infection as evidence by temperature 102.4 orally, loss of appetite, weakness, and dehydration.

 

Subjective Data:

Pt states he has became very weak the past week and is unable to walk to his mailbox because he is so tired. According to the daughter, the patient lives alone and his wife passed away 6 months ago. Pt also informs you he hasn’t been able to keep any food or water down due to nausea.

 

Objective Data:

Pt is lethargic but alert enough to tell his health history and reason for coming to the ER.  The pt’s daughter is with him.  Vital signs: HR 100 regular, BP 135/78, Temperature 102.4 (orally), and O2 Saturation 95% on room air.On assessment, you note that the patient looks dehydrated. Pt’s skin turgor is greater than 5 seconds. Lab results: WBC 19.3, UA (urinalysis) Leukocyte esterase large and bacteria 5-10, WBC too many to count, Influenza screen negative.

 

Nursing Outcomes ( short term goals ):

-Pt’s temperature will between 97.8-98.6 within 24 hours of hospitalization. -Pt’s skin turgor will be less than 5 seconds within 24 hours of hospitalization.-Pt will report increase in energy within 72 hours of hospitalization.

 

Nursing Interventions:

-The nurse will assess every four hours the patient’s oral temperature and report any temperatures greater than 100.4 to the doctor.-The nurse will administer ordered antipyretics to the patient for a temperature greater than 100.4 per md order.-The nurse will encourage and offer oral fluid intake every two hours to the patient.-The nurse will have the patient rate his energy level on a scale 1-10 with 10 being the highest in energy within 72 hours of hospitalization.

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