FEVER_1_1

FEVER_1_1

1. ASSESSMENT

   • Diagnosis
     • Subjective Data
       • chills
         • cover pt with one sheet and administer meds as prescribed
       • seizures
         • Seizure precaution
     • Labs
       • x-ray: negative
       • CT (Head): negative
       • Electrolyte
         • NA = 143
         • K = 3.6
         • Mg =2.3
       • WBC = 15.5
     • Nursing Diagnosis
       • Hyperthemia as evidenced by increased body temperature
         • GOAL: Maintains body temperature within normal range 36.5 and 37.7 C (97.8 and 100 F) at the end or 12 hr shift
       • Risk for deficient fluid volume related to increased in metabolic rate, decreased oral intake and diaphoresis
         • GOAL: Maintains adequate fluid volume in presence of fever at the end of 12hr shift
     • Objective
       • VS: T=103.2, P=127, R=24,BP = 127/66 O2 = 98
         • Assess VS q 2hrs
       • diaphoresis
         • monitor I&O and weight
       • shivers

2. INTERVENTIONS

   • Hyperthermia
     • Monitor temperature q 2hrs
     • Monitor VS( BP,R, P) to determine response to increased temperature
     • Cover the patient with only a sheet to aid in lowering body temperature
     • Monitor for eletrolyte abnormalities, acid-base imbalances, cardiac dysrhythmias and decreased level of conciousness
     • Provide a cool environment
     • Teach the patient that shivering with infection- induced fever has detrimental effects and that activities that can cause shivering should be avoided. eg taking tepid bath, lowering room temperature
   • Risk for deficient Fluid volume
     • Monitor fluid status including intake and output and insensisble fluid loss (diaphoresis) to determine risk for or presence of fluid volume deficit
     • Instruct to increace oral fluid intake to promote fluid balance
     • Monitor weight because fluid loss is reflected in decreasing body weight
     • Observed for indications of dehydration (e.g., poor skin tugor, delayed capillary refill, weak or thready pulse, severe thirst, dry mucuos membranes, decreased urine output, hypotention) to ensure early treatment of fluid deficit
   • Medications
     • Acetaminophen (TYLENOL) 650 mg po q 6 h
       • SE: Nause, Vomiting, hepatoxicity, rash
       • MOA:inihibits the synthesis of prostaglandins that may operate as mediators off pain and fever, primarily in the CNS
     • Levoflaxacin (levaquin) IV 750 @ 175/hr
       • SE: Nausea, vomiting, diarrhea, headache, dizziness, photosensitivty.
       • MOA: Bateriacidal; inhibits bacterial DNA synthesis via inhibition of DNA gyrase
     • Lorazepam (Ativan) 2 mg po prn
       • SE: dizziness, drowsiness, confusion, headache, orthostatic hypotension, tachycardiac, apnea, hypotension, blurred vision, dry mouth, constipation
       • MOA: Potentiates the actions of GABA, expecially in the limbic system and the reticular formation

3. EVALUATION

   • Therapeutic response
     • Body temperature return to normal
     • Electrolyte and acid base balance in normal range
     • VS in normal range
     • The patient is free of fever and chills

4. PATHOPHYSIOLOGY: According to Mayo Clinic a fever is a temporary increase in your body temperature, often due to an illness. Having a fever is a sign that something out of the ordinary is going on in your body. For an adult, a fever may be uncomfortable, but usually isn't a cause for concern unless it reaches 103 F (39.4 C) or higher. For infants and toddlers, a slightly elevated temperature may indicate a serious infection. Signs and symptoms may include: Sweating Shivering Headache Muscle aches Loss of appetite Dehydration General weakness High fevers between 103 F (39.4 C) and 106 F (41.1 C) may cause: Hallucinations Confusion Irritability Convulsions Dehydration