Here we will formulate a sample nursing care plan for fever (hyperthermia) with food poisoning based on a hypothetical case scenario.
It will include three fever nursing care plan examples with NANDA nursing diagnoses, nursing assessment, goal/expected outcome, and nursing interventions with rationales.
Fever (hyperthermia) with food poisoning Case Scenario
A 31-year old male presents to the ED with complaints of fever, chills, vomiting, and diarrhea. The patient reports that he has been sick with food poisoning for 2 days and started experiencing symptoms after eating seafood at a restaurant. He has been experiencing stomach pain, nausea, and vomiting and hasn’t been able to keep any foods or liquids down. The patient said when he took his temperature this morning it was 39.5 C. He took Tylenol but vomited soon after. When his fever did not decrease he decided to come to the hospital.
Upon assessment, the patient is diaphoretic, flushed, and shivering. His temperature is 40 C, heart rate is 117 BPM, blood pressure is 97/72 mmHg, respirations are 26 breaths/minute and oxygen saturation is 97% on room air. The patient’s pulse is bounding and weak, and his capillary refill is greater than 3 seconds. Skin tenting is noted on the back of the patient’s hand.
The patient’s blood work reveals elevated WBCs of 21.1 K/mcL and slightly low sodium of 134 mmol/L. A stool culture is sent and later reveals Salmonella.
The patient is admitted for Fever with food poisoning.
#1 Sample Nursing Care Plan for Fever (Hyperthermia) – Hyperthermia
Hyperthermia Nursing Assessment
Subjective Data:
- The patient complains of chills
Objective Data:
- The patient’s temperature is 40 C
- The patient’s heart rate is elevated
- He is diaphoretic, flushed, and shivering
Hyperthermia Nursing Diagnosis
Hyperthermia related to gastrointestinal infection as evidenced by a temperature of 40 C, heart rate of 117 BPM, and diaphoresis
Goal/Desired Outcome
Short-term goal: By the end of the shift the patient’s temperature will decrease to a normal level
Long-term goal: The patient will take the prescribed course of antibiotics and will remain free from complications of hyperthermia
Hyperthermia Nursing Interventions with Rationales
| Nursing Interventions | Rationales |
| Identify the cause of fever or hyperthermia: infection, heat stroke, medication reactions, post-anesthetic malignant hyperthermia, etc. | Diagnostic procedures such as imaging, lab work, and past medical history can help identify the cause of the fever and dictate the treatment options |
| Monitor temperature | The temperature should be monitored continuously or as frequently as required. An indwelling temperature monitor may be required |
| Use the same site and the same device for temperature monitoring | This ensures the readings are accurate and not different solely based on different locations or temperature devices |
| Monitor for adverse symptoms of hyperthermia | Symptoms include muscle cramps, orthostatic dizziness, weakness, vomiting, headache, confusion, or seizures |
#2 Sample Nursing Care Plan for Fever(Hyperthermia) – Ineffective thermoregulation
Ineffective Thermoregulation Nursing Assessment
Subjective Data:
- The patient is unable to take oral antipyretics due to vomiting
Objective Data:
- The patient’s temperature is 40 C
- The patient’s heart rate is elevated
- He is diaphoretic, flushed, and shivering
Nursing Diagnosis
Ineffective thermoregulation related to fever secondary to infection as evidenced by temperature of 40 C, elevated heart rate, diaphoresis, and shivering
Goal/Desired Outcome
Short-term goal: The patient will utilize temperature reduction strategies and his temperature will normalize by the end of the shift
Long-term goal: The patient will remain free from complications of fever and infection
Ineffective Thermoregulation Nursing Interventions with Rationales
| Nursing Interventions | Rationales |
| If the elevated temperature is due to infection, administer antipyretics | Antipyretics such as Tylenol should be administered regularly (without exceeding 4 g within 24 hours) |
| Utilize temperature management devices such as cooling blankets or pads | These devices continuously circulate cold water that comes into contact with the patient’s skin, thus decreasing their temperature |
| Remove excess clothing and bedding | The patient should have minimal, light-weight clothing and bedding |
| Provide a tepid water bath | Lukewarm water will evaporate on the patient’s skin, thus decreasing their temperature |
| If tolerated, provide cold PO fluids or administer cooled IV fluids | These strategies can help cool the patient internally |
| Slowly decrease the temperature to avoid shivering | The patient should not be cooled so aggressively that the patient shivers, as shivering increases heat production and oxygen consumption |
#3 Sample Nursing Care Plan for Fever (Hyperthermia) – Risk for deficient fluid volume
Risk for fluid volume deficit Nursing Assessment
Subjective Data:
- The patient has been unable to keep food or fluids down
Objective Data:
- The patient is tachycardic and slightly hypotensive
- The patient is diaphoretic
- Capillary refill is greater than 3 seconds and skin tenting is noted
Nursing Diagnosis
Risk for deficient fluid volume related to elevated temperature secondary to infection as evidenced by tachycardia, hypotension, skin tenting, and capillary refill greater than 3 seconds
Goal/Desired Outcome
Short-term goal: By the end of the shift the patient’s blood pressure, heart rate, and capillary refill will return to normal levels
Long-term goal: The patient will maintain an adequate fluid volume and suffer no long-term organ dysfunction
Risk for fluid volume deficit Nursing Interventions with Rationales
| Nursing Interventions | Rationales |
| Monitor for dehydration | Dehydration can occur with hyperthermia due to loss of fluid volume via diaphoresis. Dehydration can also occur with vomiting and diarrhea. Signs of dehydration include thirst, oliguria, skin tenting, and increased capillary refill time |
| Administer IV fluids if needed | Fluid administration is critical if sepsis is suspected due to systemic vasodilation and hypovolemia. Fluids may also be required after vomiting and diarrhea, and cooled fluids, in particular, can help decrease the patient’s temperature |
| Monitor labs | Electrolyte imbalances can occur with hyperthermia and/or dehydration. Kidney function should also be monitored due to the risk of rhabdomyolysis |
| Administer PO fluids if tolerated | PO fluids are equally as important as IV fluids in restoring the fluid volume balance |
Conclusion
To conclude, we created scenario-based 3 sample nursing care plans for fever (hyperthermia) with food poisoning. These nursing care plans include nursing assessment, NANDA nursing diagnosis, goal/expected outcome, and nursing interventions with rationales.
Reference
Ackley, B., Ladwig, G., Makic, M., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing Diagnoses Handbook: An Evidence-based Guide to Planning Care (12th ed.). Elsevier.
Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.
Swearingen, P. (2016). ALL-IN-ONE CARE PLANNING RESOURCE (4th ed.). Elsevier/Mosby.
