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Nursing Care Plan: Pyrexia (Fever)
Definition/Problem: Elevated body temperature above normal range (pyrexia) due to infection, inflammation, heat illness, or other causes. Can increase metabolic demand and risk for complications, particularly in vulnerable populations (infants, elderly, immunocompromised, Black patients with potential disparities in care).
Assessment
Vital signs: temperature (core if possible), pulse, respiratory rate, blood pressure, oxygen saturation. Obtain trends.
Onset, duration, pattern of fever (intermittent, remittent, continuous, relapsing).
Associated symptoms: chills, rigors, diaphoresis, malaise, headache, myalgias, dehydration, altered mental status, seizures (in pediatrics).
Skin assessment: color, perfusion, turgor, presence of rash or focal infection signs.
Intake/output: oral/IV fluids, urine output, evidence of dehydration.
Laboratory and diagnostic data: CBC (WBC), cultures (blood, urine, sputum), inflammatory markers (CRP, ESR), lactate, electrolytes, imaging results.
Medication history: antipyretics, antibiotics, immunosuppressants, recent vaccinations, recent antibiotic use.
Risk factors: recent surgery, invasive devices, chronic disease, immunosuppression, extremes of age, exposure history.
Psychosocial/cultural factors: beliefs about fever and treatments, access to care, trust in providers.
Nursing Diagnoses
Hyperthermia related to infection/inflammatory response or environmental exposure as evidenced by elevated temperature, diaphoresis, tachycardia, and complaints of feeling hot.
Risk for fluid volume deficit related to increased insensible water loss from diaphoresis and increased metabolic rate.
Imbalanced nutrition: less than body requirements related to anorexia, nausea, or increased metabolic demands.
Risk for ineffective thermoregulation related to immature/altered physiological control (infants, elderly).
Risk for impaired gas exchange related to increased metabolic demand or underlying pulmonary infection.
Risk for ineffective tissue perfusion related to tachycardia and dehydration.
Knowledge deficit regarding fever management and when to seek care.
Goals/Outcomes (short-term and long-term)
Temperature will decrease to within patient-specific acceptable range (e.g., <100.4°F or baseline) within 4–6 hours of interventions.
Patient will demonstrate decreased discomfort and report improved thermal comfort.
Maintain adequate hydration: urine output ≥30 mL/hr in adults (adjust for pediatrics).
No signs of complications (e.g., febrile seizures in children, hemodynamic instability, altered mental status).
Patient/caregiver will verbalize understanding of antipyretic dosing, nonpharmacologic measures, and follow-up plan.
Nursing Interventions with Rationale
Monitor temperature and vital signs every 1–2 hours (or per protocol) and document trends.
Rationale: Detect changes early, evaluate response to interventions, and identify deterioration.
Administer antipyretics as ordered (acetaminophen or ibuprofen) with correct dosing and timing; verify allergies.
Rationale: Antipyretics lower hypothalamic set point, reduce discomfort, and can limit metabolic stress.
Implement nonpharmacologic cooling measures:
Tepid sponge baths or lukewarm cloths to skin folds; remove excessive blankets/clothing; maintain comfortable room temperature; encourage light clothing.
Rationale: Promotes heat loss through conduction and evaporation without causing shivering, which can raise metabolic demand.
Encourage oral fluid intake and provide IV fluids if oral intake inadequate or patient shows dehydration signs.
Rationale: Fever increases insensible losses and metabolic needs; maintaining perfusion and electrolyte balance reduces risk of complications.
Monitor intake and output and daily weights as indicated.
Rationale: Track hydration status and response to fluid therapy.
Promote rest and energy conservation; cluster care to allow uninterrupted rest periods.
Rationale: Reduces metabolic demand and supports recovery.
Assess for source of infection and assist with specimen collection for culture before antibiotic initiation when possible.
Rationale: Identifying causative organism guides targeted therapy and improves outcomes.
Administer antibiotics or other ordered treatments promptly when indicated and monitor for effectiveness and adverse effects.
Rationale: Treat underlying cause of fever; timely therapy reduces morbidity.
Monitor for complications: changes in mental status, seizures (especially in children), hemodynamic instability, hypoxia, or organ dysfunction.
Rationale: Early detection allows rapid intervention to prevent deterioration.
Use measures to prevent shivering during cooling (e.g., warm blankets for shivering, slow temperature reduction).
Nursing Care Plan: Pyrexia (Fever)
Definition/Problem: Elevated body temperature above normal range (pyrexia) due to infection, inflammation, heat illness, or other causes. Can increase metabolic demand and risk for complications, particularly in vulnerable populations (infants, elderly, immunocompromised, Black patients with potential disparities in care).
Assessment
Vital signs: temperature (core if possible), pulse, respiratory rate, blood pressure, oxygen saturation. Obtain trends.
Onset, duration, pattern of fever (intermittent, remittent, continuous, relapsing).
Associated symptoms: chills, rigors, diaphoresis, malaise, headache, myalgias, dehydration, altered mental status, seizures (in pediatrics).
Skin assessment: color, perfusion, turgor, presence of rash or focal infection signs.
Intake/output: oral/IV fluids, urine output, evidence of dehydration.
Laboratory and diagnostic data: CBC (WBC), cultures (blood, urine, sputum), inflammatory markers (CRP, ESR), lactate, electrolytes, imaging results.
Medication history: antipyretics, antibiotics, immunosuppressants, recent vaccinations, recent antibiotic use.
Risk factors: recent surgery, invasive devices, chronic disease, immunosuppression, extremes of age, exposure history.
Psychosocial/cultural factors: beliefs about fever and treatments, access to care, trust in providers.
Nursing Diagnoses
Hyperthermia related to infection/inflammatory response or environmental exposure as evidenced by elevated temperature, diaphoresis, tachycardia, and complaints of feeling hot.
Risk for fluid volume deficit related to increased insensible water loss from diaphoresis and increased metabolic rate.
Imbalanced nutrition: less than body requirements related to anorexia, nausea, or increased metabolic demands.
Risk for ineffective thermoregulation related to immature/altered physiological control (infants, elderly).
Risk for impaired gas exchange related to increased metabolic demand or underlying pulmonary infection.
Risk for ineffective tissue perfusion related to tachycardia and dehydration.
Knowledge deficit regarding fever management and when to seek care.
Goals/Outcomes (short-term and long-term)
Temperature will decrease to within patient-specific acceptable range (e.g., <100.4°F or baseline) within 4–6 hours of interventions.
Patient will demonstrate decreased discomfort and report improved thermal comfort.
Maintain adequate hydration: urine output ≥30 mL/hr in adults (adjust for pediatrics).
No signs of complications (e.g., febrile seizures in children, hemodynamic instability, altered mental status).
Patient/caregiver will verbalize understanding of antipyretic dosing, nonpharmacologic measures, and follow-up plan.
Nursing Interventions with Rationale
Monitor temperature and vital signs every 1–2 hours (or per protocol) and document trends.
Rationale: Detect changes early, evaluate response to interventions, and identify deterioration.
Administer antipyretics as ordered (acetaminophen or ibuprofen) with correct dosing and timing; verify allergies.
Rationale: Antipyretics lower hypothalamic set point, reduce discomfort, and can limit metabolic stress.
Implement nonpharmacologic cooling measures:
Tepid sponge baths or lukewarm cloths to skin folds; remove excessive blankets/clothing; maintain comfortable room temperature; encourage light clothing.
Rationale: Promotes heat loss through conduction and evaporation without causing shivering, which can raise metabolic demand.
Encourage oral fluid intake and provide IV fluids if oral intake inadequate or patient shows dehydration signs.
Rationale: Fever increases insensible losses and metabolic needs; maintaining perfusion and electrolyte balance reduces risk of complications.
Monitor intake and output and daily weights as indicated.
Rationale: Track hydration status and response to fluid therapy.
Promote rest and energy conservation; cluster care to allow uninterrupted rest periods.
Rationale: Reduces metabolic demand and supports recovery.
Assess for source of infection and assist with specimen collection for culture before antibiotic initiation when possible.
Rationale: Identifying causative organism guides targeted therapy and improves outcomes.
Administer antibiotics or other ordered treatments promptly when indicated and monitor for effectiveness and adverse effects.
Rationale: Treat underlying cause of fever; timely therapy reduces morbidity.
Monitor for complications: changes in mental status, seizures (especially in children), hemodynamic instability, hypoxia, or organ dysfunction.
Rationale: Early detection allows rapid intervention to prevent deterioration.
Use measures to prevent shivering during cooling (e.g., warm blankets for shivering, slow temperature reduction).
