FEVER

FEVER

1. ASSESSMENT

   • Diagnosis
     • Subjective Data
       • chills
       • seizures
     • 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
       • 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
     • Objective
       • VS: T=103.2, P=127, R=24,BP = 127/66 O2 = 98
       • diaphoresis
       • 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
   • 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
     • Encourage 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