Sample Nursing Care Plan for Fever (Hyperthermia)

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 InterventionsRationales
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 monitoringThis ensures the readings are accurate and not different solely based on different locations or temperature devices
Monitor for adverse symptoms of hyperthermiaSymptoms 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 InterventionsRationales
If the elevated temperature is due to infection, administer antipyreticsAntipyretics such as Tylenol should be administered regularly (without exceeding 4 g within 24 hours)
Utilize temperature management devices such as cooling blankets or padsThese devices continuously circulate cold water that comes into contact with the patient’s skin, thus decreasing their temperature
Remove excess clothing and beddingThe patient should have minimal, light-weight clothing and bedding
Provide a tepid water bathLukewarm water will evaporate on the patient’s skin, thus decreasing their temperature
If tolerated, provide cold PO fluids or administer cooled IV fluidsThese strategies can help cool the patient internally
Slowly decrease the temperature to avoid shiveringThe 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 InterventionsRationales
Monitor for dehydrationDehydration 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 neededFluid 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 labsElectrolyte imbalances can occur with hyperthermia and/or dehydration. Kidney function should also be monitored due to the risk of rhabdomyolysis
Administer PO fluids if toleratedPO 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.

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