15 Fever nursing care plan:Key Assessments, Diagnoses, and Interventions

Posted on by Soumya Ranjan Parida
Nursing Care Plan for Fever: 15 Comprehensive Care Plans | Nursing Notes

Nursing Care Plan for Fever

Comprehensive care plans for effective fever management

Introduction to Fever Nursing Care Plans

A fever nursing care plan is a critical component in the management of patients experiencing elevated body temperature. Fever (pyrexia) is not a disease itself but a symptom of an underlying condition. As a nurse, properly addressing fever requires a systematic approach that considers the patient’s overall condition, age, and specific needs.

This resource provides 15 comprehensive nursing care plans that address the various aspects of fever management. Each care plan follows the nursing process framework—assessment, diagnosis, planning, intervention, and evaluation—to ensure holistic care delivery.

Key Point: An effective fever nursing care plan focuses not just on temperature reduction but on addressing the underlying cause, preventing complications, ensuring comfort, and educating patients and caregivers about proper fever management.

Understanding Fever: Nursing Perspective

From a nursing perspective, understanding the physiological basis of fever is essential for implementing appropriate interventions. Fever is typically defined as a core body temperature above 38.0°C (100.4°F), although normal temperature can vary slightly between individuals.

Pathophysiology of Fever

Fever results from the body’s response to pyrogens (fever-producing substances), which can be exogenous (from outside the body, like bacterial toxins) or endogenous (produced within the body, like cytokines). These pyrogens trigger the hypothalamus to raise the body’s thermoregulatory set point, leading to heat conservation and heat production mechanisms being activated.

Phases of Fever

Phase Description Nursing Implications
Onset (Chill Phase) Set point rises; patient feels cold despite rising temperature Provide warmth, monitor vital signs, ensure hydration
Plateau (Fever Phase) Body temperature equals new set point; patient no longer feels cold Implement cooling measures as ordered, continue monitoring
Defervescence (Resolution Phase) Set point returns to normal; body releases excess heat Manage diaphoresis, change wet linens, continue hydration

Classification of Fever

Classification Temperature Range
Low-grade fever 38.0°C to 38.5°C (100.4°F to 101.3°F)
Moderate-grade fever 38.6°C to 39.5°C (101.5°F to 103.1°F)
High-grade fever ≥ 39.6°C (≥ 103.3°F)
Hyperpyrexia ≥ 41.0°C (≥ 105.8°F) – Medical emergency
Study Tip

Remember that fever is often beneficial as it enhances immune function by increasing neutrophil production, T-lymphocyte activation, and interferon production. The decision to treat fever should consider the patient’s overall condition, not just the temperature reading.

Comprehensive Assessment for Fever

A thorough assessment is the foundation of an effective fever nursing care plan. Consider these key assessment components:

Essential Assessment Parameters

Vital Signs

  • Temperature: Document value, site of measurement, and pattern
  • Heart Rate: Note tachycardia (increases by about 10 bpm for each 1°F rise)
  • Respiratory Rate: Assess for tachypnea
  • Blood Pressure: Monitor for hypotension (may indicate sepsis)
  • Oxygen Saturation: Evaluate for hypoxemia

Physical Assessment

  • Skin: Color, temperature, moisture, presence of rash
  • Neurological: Level of consciousness, irritability, seizure activity
  • Respiratory system: Breath sounds, cough, sputum
  • Gastrointestinal: Appetite, nausea, vomiting, diarrhea
  • Musculoskeletal: Joint pain, muscle aches, weakness
  • Integumentary: Presence of wounds, cellulitis, pressure injuries
  • Urinary system: Urinary output, characteristics, dysuria

Laboratory and Diagnostic Considerations

  • Complete blood count (CBC) with differential
  • Blood cultures if sepsis is suspected
  • Urinalysis and culture
  • Chest X-ray if respiratory symptoms are present
  • Inflammatory markers (CRP, ESR, procalcitonin)

Important: Always consider age-specific variations when assessing fever. Neonates, elderly patients, and immunocompromised individuals may not mount a typical febrile response despite significant infection. Additionally, patients on antipyretic therapy, steroids, or those with certain conditions may have blunted fever response.

15 Nursing Diagnoses for Fever

The following nursing diagnoses address the various aspects of patient care related to fever. Each diagnosis is accompanied by a comprehensive fever nursing care plan that includes assessment findings, expected outcomes, nursing interventions with rationales, and evaluation criteria.

1. Hyperthermia

NANDA Definition

Body temperature elevated above normal range due to failure of thermoregulation.

Assessment Findings

  • Body temperature above 38.0°C (100.4°F)
  • Warm/hot skin to touch
  • Flushed skin
  • Increased respiratory rate
  • Tachycardia
  • Shivering or chills
  • Diaphoresis (during fever resolution)
  • Headache
  • Altered mental status (with high temperature)

Expected Outcomes

  • Patient will maintain body temperature within normal range (36.5°C-37.5°C)
  • Patient will demonstrate absence of complications related to hyperthermia
  • Patient will verbalize comfort related to temperature control
  • Patient will maintain adequate hydration status

Nursing Interventions with Rationales

Intervention Rationale
Monitor body temperature q2-4h or as indicated, using consistent measurement site and method Provides accurate assessment of temperature trends and response to interventions. Different measurement methods can yield different results.
Administer antipyretics as prescribed (e.g., acetaminophen, NSAIDs) Reduces fever by acting on the hypothalamus to lower the thermoregulatory set point.
Apply cooling measures if temperature exceeds 39.5°C (103°F): lightweight clothing, reduced room temperature, cool compresses to axilla and groin Facilitates heat loss through conduction, convection, and evaporation. Targeting major blood vessels in the axilla and groin improves efficiency.
Avoid extreme cooling measures like ice baths or alcohol rubs Can cause shivering (which increases heat production), vasoconstriction, discomfort, and in the case of alcohol, potential absorption through skin.
Encourage oral fluid intake of 2-3 liters per day unless contraindicated Replaces fluid losses from increased metabolic rate, diaphoresis, and insensible losses, preventing dehydration.
Monitor neurological status with high fevers (>40°C/104°F) High fevers can lead to altered mental status, seizures, and other neurological complications.
Document and report patterns of fever Different fever patterns may suggest specific underlying pathologies (e.g., intermittent, remittent, sustained).

Evaluation

  • Patient’s temperature has returned to normal range
  • Patient reports increased comfort
  • No signs of dehydration are present
  • No complications related to hyperthermia have developed

2. Risk for Imbalanced Body Temperature

NANDA Definition

Vulnerable to failure to maintain body temperature within normal parameters, which may compromise health.

Risk Factors

  • Extremes of age (very young, elderly)
  • Dehydration
  • Exposure to extreme environmental temperatures
  • Illness or trauma affecting temperature regulation
  • Medications affecting thermoregulation
  • Sedation
  • Altered metabolic rate
  • Inappropriate clothing for environmental temperature

Expected Outcomes

  • Patient will maintain stable body temperature within normal range
  • Patient/caregiver will identify factors that affect body temperature regulation
  • Patient/caregiver will demonstrate measures to prevent temperature fluctuations

Nursing Interventions with Rationales

Intervention Rationale
Identify patients at high risk for temperature instability and monitor more frequently Early identification of at-risk patients allows for preventive interventions and closer monitoring.
Monitor ambient room temperature and adjust as needed Environmental temperature significantly impacts body temperature regulation, especially in vulnerable patients.
Assess medication regimen for drugs that affect thermoregulation Many medications (e.g., anticholinergics, antipsychotics, anesthetics) can impair temperature regulation.
Ensure appropriate clothing and bedding based on patient’s condition and environmental temperature Proper clothing facilitates appropriate heat conservation or dissipation as needed.
Maintain adequate hydration status Fluid balance is essential for thermoregulation processes including sweating and circulation.
Educate patient/family about signs of temperature imbalance and when to seek medical attention Promotes early recognition and intervention for temperature problems after discharge.

Evaluation

  • Patient maintains body temperature within normal range
  • Patient/caregiver verbalizes understanding of risk factors affecting temperature regulation
  • Patient/caregiver demonstrates preventive measures appropriately

3. Acute Pain

NANDA Definition

Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end, and with a duration of less than 3 months.

Assessment Findings

  • Verbal reports of pain (headache, myalgia, arthralgia)
  • Guarding or protective behavior
  • Facial expressions of pain
  • Self-focusing behaviors
  • Restlessness
  • Changes in vital signs (may be present with acute pain)
  • Grimacing

Expected Outcomes

  • Patient will report decreased pain as evidenced by pain scale rating (reduction of at least 2 points or to an acceptable level for the patient)
  • Patient will demonstrate improved function and ability to participate in activities
  • Patient will verbalize effective pain management strategies

Nursing Interventions with Rationales

Intervention Rationale
Assess pain using an appropriate scale (numeric, visual analog, FACES) including location, intensity, quality, timing, aggravating factors, and relieving factors Systematic assessment provides baseline data and helps determine the most appropriate interventions.
Administer prescribed analgesics, particularly acetaminophen or NSAIDs as ordered These medications address both fever and pain through different mechanisms. Acetaminophen acts on the hypothalamus, while NSAIDs reduce inflammation and pain.
Apply non-pharmacological measures: positioning, gentle massage, cool compresses to forehead for headache Complementary approaches enhance medication effectiveness and provide additional comfort without added side effects.
Provide quiet, relaxing environment by reducing noise and bright lights Environmental stimuli can exacerbate pain perception, particularly with fever-related headaches and generalized discomfort.
Reassess pain 30 minutes after intervention Determines effectiveness of interventions and guides further treatment decisions.
Document pain assessment, interventions, and patient response Facilitates continuity of care and evaluation of treatment effectiveness.

Evaluation

  • Patient reports decreased pain intensity on pain scale
  • Patient demonstrates improved ability to rest, move, and participate in care
  • Patient identifies effective pain management techniques

4. Risk for Deficient Fluid Volume

NANDA Definition

Vulnerable to experiencing decreased intravascular, interstitial, and/or intracellular fluid volumes, which may compromise health.

Risk Factors

  • Elevated body temperature
  • Increased metabolic rate
  • Excessive diaphoresis
  • Reduced oral intake due to nausea or malaise
  • Vomiting or diarrhea (may accompany certain febrile illnesses)
  • Hyperventilation during febrile episodes
  • Extremes of age

Expected Outcomes

  • Patient will maintain adequate hydration as evidenced by balanced intake and output
  • Patient will demonstrate moist mucous membranes, good skin turgor, and stable vital signs
  • Patient/caregiver will verbalize signs of dehydration and strategies to maintain fluid balance
  • Urine output will remain >0.5 mL/kg/hour

Nursing Interventions with Rationales

Intervention Rationale
Monitor intake and output accurately; maintain I&O record Provides objective data to assess fluid balance status and guide replacement therapy.
Assess for signs of dehydration: dry mucous membranes, poor skin turgor, sunken eyes, decreased urine output, concentrated urine Early detection of dehydration allows for prompt intervention before severe dehydration occurs.
Offer fluids frequently (every 1-2 hours while awake) in small amounts Small, frequent offerings enhance tolerance and absorption, particularly if the patient has nausea.
Provide preferred fluids when possible, including oral rehydration solutions, clear broths, diluted juices, and ice pops Enhances acceptance and intake; some options (especially oral rehydration solutions) provide electrolytes as well as fluids.
Administer IV fluids as prescribed if oral intake is inadequate Ensures hydration when oral route is insufficient or contraindicated.
Monitor serum electrolytes and correct imbalances as ordered Fever and associated fluid losses can lead to significant electrolyte disturbances, particularly sodium and potassium.
Educate patient/family on importance of hydration during fever Improves compliance with fluid intake recommendations and continuity of care after discharge.

Evaluation

  • Patient maintains balanced intake and output
  • Patient shows moist mucous membranes and appropriate skin turgor
  • Vital signs remain within acceptable parameters
  • Patient/caregiver verbalizes understanding of hydration needs and strategies

5. Impaired Comfort

NANDA Definition

Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental, and social dimensions.

Assessment Findings

  • Reports of discomfort
  • Restlessness
  • Irritability
  • Inability to relax
  • Disturbed sleep
  • Increased perspiration
  • Feeling too hot or experiencing chills
  • Complaints of generalized malaise

Expected Outcomes

  • Patient will report improved comfort level
  • Patient will demonstrate ability to rest comfortably
  • Patient will identify effective comfort measures

Nursing Interventions with Rationales

Intervention Rationale
Assess patient’s specific discomfort and preferences for comfort measures Individualized assessment allows for targeted interventions that meet patient’s specific needs.
Change bed linens and gown when damp from perspiration Damp clothing and linens cause discomfort and can promote chilling.
Adjust room temperature based on patient’s preference Perception of environmental comfort varies among individuals, especially during febrile states.
Provide additional blankets during chills and remove during fever spikes Addresses the changing thermal comfort needs during different phases of fever.
Offer cool, moist cloths to forehead, back of neck, or wrists Provides local cooling and comfort without causing systemic chilling.
Minimize environmental stimuli by dimming lights and reducing noise Sensory stimuli can increase perception of discomfort, particularly during febrile states when sensitivity is heightened.
Offer frequent oral care Fever often causes dry mouth, and oral care enhances comfort and prevents complications like oral mucositis.
Apply lip balm to prevent or treat dry, cracked lips Dehydration associated with fever often leads to dry lips, causing discomfort.

Evaluation

  • Patient reports improved comfort level
  • Patient appears relaxed and able to rest
  • Patient identifies and utilizes effective comfort measures

6. Decreased Activity Tolerance

NANDA Definition

Insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Assessment Findings

  • Verbal report of fatigue or weakness
  • Abnormal heart rate or blood pressure response to activity
  • Exertional discomfort or dyspnea
  • Decreased ability to perform usual activities
  • Generalized weakness
  • Lethargy

Expected Outcomes

  • Patient will demonstrate improved activity tolerance as fever resolves
  • Patient will participate in activities of daily living without excessive fatigue
  • Patient will balance activity with adequate rest periods
  • Patient will maintain stable vital signs during activities

Nursing Interventions with Rationales

Intervention Rationale
Assess activity tolerance using 0-10 scale or standardized tool Provides objective measurement of fatigue and energy levels to guide interventions and evaluate progress.
Monitor vital signs before, during, and after activities Identifies physiological responses that may indicate intolerance to activity.
Plan care activities to allow for rest periods Conserves energy and prevents excessive fatigue.
Assist with ADLs as needed, encouraging self-care when appropriate Balances need for assistance with benefits of maintaining independence and physical activity.
Implement energy conservation techniques (sitting instead of standing for activities, keeping frequently used items within reach) Reduces energy expenditure while allowing completion of necessary activities.
Encourage adequate nutritional intake to support energy needs Provides metabolic substrates necessary for energy production and recovery.
Educate about gradually increasing activity as fever resolves and strength improves Prevents deconditioning while respecting physiological limitations during recovery.

Evaluation

  • Patient demonstrates increased activity tolerance as evidenced by participation in ADLs with less fatigue
  • Patient maintains stable vital signs during activity
  • Patient appropriately balances activity with rest

7. Risk for Impaired Skin Integrity

NANDA Definition

Vulnerable to alteration in epidermis and/or dermis, which may compromise health.

Risk Factors

  • Excessive diaphoresis
  • Increased body temperature
  • Altered metabolic state
  • Decreased activity/mobility during illness
  • Altered nutrition during febrile state
  • Dehydration
  • External factors: bedding materials, medical devices, environmental humidity

Expected Outcomes

  • Patient will maintain intact skin integrity
  • Patient will demonstrate practices that protect skin integrity
  • Patient/caregiver will identify risk factors for skin breakdown

Nursing Interventions with Rationales

Intervention Rationale
Perform comprehensive skin assessment at least once per shift Early identification of skin changes allows for prompt intervention before breakdown occurs.
Implement appropriate risk assessment tool (e.g., Braden Scale) and reassess regularly Standardized tools provide objective measurement of risk and guide preventive measures.
Keep skin clean and dry, especially in areas of perspiration Moisture from diaphoresis increases risk of skin maceration and breakdown.
Change bed linens and patient gowns when damp Reduces skin exposure to moisture and potential irritants.
Apply moisture barrier to areas at risk for moisture-associated skin damage Protects skin from irritation and maceration caused by persistent moisture.
Reposition patient at least every 2 hours or more frequently if needed Reduces pressure on any one area, maintaining blood flow and tissue integrity.
Use pressure-redistributing devices as needed Minimizes pressure on bony prominences and vulnerable areas.
Maintain adequate hydration and nutrition Supports skin integrity at the cellular level.

Evaluation

  • Patient’s skin remains intact without evidence of breakdown
  • Patient/caregiver demonstrates skin protection measures
  • Risk assessment scores remain stable or improve

8. Imbalanced Nutrition: Less Than Body Requirements

NANDA Definition

Intake of nutrients insufficient to meet metabolic needs.

Assessment Findings

  • Decreased appetite
  • Reported food intake less than recommended daily requirements
  • Altered taste sensation
  • Weight loss (if febrile state is prolonged)
  • Weakness and fatigue
  • Nausea or vomiting
  • Increased metabolic demands due to fever

Expected Outcomes

  • Patient will maintain adequate nutritional intake to meet metabolic needs
  • Patient will maintain stable weight (or demonstrate weight gain if previously deficient)
  • Patient will identify foods/fluids they can tolerate during febrile state

Nursing Interventions with Rationales

Intervention Rationale
Assess nutritional status including weight, intake patterns, and laboratory values Establishes baseline and identifies specific nutritional needs.
Monitor and document daily food intake Provides objective data about nutritional adequacy and trends over time.
Offer small, frequent meals rather than large meals More easily tolerated when appetite is decreased; prevents overwhelming the patient.
Provide foods according to patient preferences when possible Enhances likelihood of intake; respects patient autonomy and cultural preferences.
Offer cool, soft foods when appetite is poor Often better tolerated during febrile states than hot, strong-smelling foods.
Administer antiemetics as prescribed before meals if nausea is present Reduces barrier to intake by minimizing nausea and vomiting.
Consider nutritional supplements between meals Provides concentrated nutrients when volume of food intake is limited.
Consult with dietitian for individualized nutritional plan Provides specialized expertise for complex nutritional needs.
Provide oral care before meals Enhances taste sensation and improves appetite.

Evaluation

  • Patient consumes at least 75% of daily nutritional requirements
  • Patient maintains stable weight
  • Patient identifies and consumes foods that are tolerated during fever
  • Laboratory values reflecting nutritional status remain or return within normal limits

9. Disturbed Sleep Pattern

NANDA Definition

Time-limited disruptions of sleep quantity and quality due to external factors.

Assessment Findings

  • Verbalized difficulty falling asleep or staying asleep
  • Observed restlessness during sleep periods
  • Increased irritability or anxiety
  • Reports of feeling tired after sleep period
  • Dark circles under eyes
  • Frequent position changes during rest periods
  • Physical discomfort from fever and associated symptoms

Expected Outcomes

  • Patient will report improved quality and quantity of sleep
  • Patient will demonstrate behaviors indicating adequate rest (decreased irritability, improved energy)
  • Patient will identify factors that promote sleep

Nursing Interventions with Rationales

Intervention Rationale
Assess sleep patterns and factors affecting sleep Identifies specific issues impacting sleep and guides targeted interventions.
Administer antipyretics as prescribed, timing doses to optimize temperature control during sleep hours Temperature fluctuations significantly disrupt sleep; reducing fever enhances comfort and improves sleep quality.
Schedule nursing care to allow for uninterrupted sleep periods Consolidating care activities minimizes disruptions during rest periods.
Provide a comfortable environment: appropriate room temperature, reduced lighting and noise Environmental factors significantly impact sleep quality, especially during illness.
Offer comfort measures before sleep (back rub, position change, fresh linens) Enhances physical comfort, promoting easier sleep initiation.
Limit caffeine intake, especially in afternoon and evening Caffeine is a stimulant that can interfere with sleep onset and quality.
Encourage relaxation techniques such as deep breathing or guided imagery Reduces anxiety and physical tension that may interfere with sleep.
Administer sleep medication as prescribed if non-pharmacological measures are insufficient Pharmacological intervention may be necessary to break the cycle of sleep disturbance during acute illness.

Evaluation

  • Patient reports improved sleep quality and duration
  • Patient demonstrates reduced signs of sleep deprivation
  • Patient identifies and utilizes effective sleep-promoting strategies

10. Ineffective Thermoregulation

NANDA Definition

Temperature fluctuation between hypothermia and hyperthermia.

Assessment Findings

  • Fluctuating body temperature
  • Alternating periods of chills and fever
  • Flushed or pale skin
  • Warm to touch alternating with cold skin
  • Moderate to severe diaphoresis
  • Tachycardia
  • Changes in mental status

Expected Outcomes

  • Patient will demonstrate stabilizing body temperature within normal range
  • Patient will experience fewer episodes of temperature fluctuation
  • Patient/caregiver will verbalize understanding of disease process causing temperature fluctuation

Nursing Interventions with Rationales

Intervention Rationale
Monitor temperature frequently (q2-4h) or continuously if severe fluctuations are present Allows for early detection of temperature changes and timely intervention.
Document pattern of temperature fluctuations including associated symptoms Certain patterns may suggest specific etiologies (e.g., intermittent spikes in abscess, quotidian pattern in malaria).
Implement warming measures during chills: blankets, warm liquids, increased room temperature Provides comfort during the chill phase when patient feels cold despite rising temperature.
Apply cooling measures during fever spikes: light clothing, decreased room temperature, cool compresses Facilitates heat dissipation during fever phase, reducing discomfort and potential complications.
Administer antipyretics as prescribed on a scheduled basis rather than as needed Scheduled administration maintains more consistent temperature control than PRN dosing.
Change wet clothing and linens promptly Wet linens can cause rapid heat loss and chilling after diaphoresis.
Monitor for complications of temperature instability (dehydration, altered mental status) Severe or prolonged temperature fluctuations can lead to significant physiological stress and complications.
Administer prescribed antimicrobial therapy on schedule Treating underlying infection is essential for resolving the cause of thermoregulatory dysfunction.

Evaluation

  • Patient demonstrates more stable body temperature with fewer fluctuations
  • Patient reports increased comfort related to temperature stability
  • Temperature pattern shows improvement in response to interventions

11. Risk for Electrolyte Imbalance

NANDA Definition

Vulnerable to changes in serum electrolyte levels that may compromise health.

Risk Factors

  • Excessive diaphoresis from fever
  • Decreased oral intake
  • Vomiting or diarrhea (common with some febrile illnesses)
  • Increased metabolic rate
  • Fluid volume deficit
  • Altered kidney function (may occur with severe infection or sepsis)
  • Medication effects (diuretics, certain antibiotics)

Expected Outcomes

  • Patient will maintain electrolyte levels within normal limits
  • Patient will not exhibit signs and symptoms of electrolyte imbalance
  • Patient/caregiver will verbalize understanding of factors affecting electrolyte balance

Nursing Interventions with Rationales

Intervention Rationale
Monitor serum electrolyte levels as ordered and report abnormal values Laboratory monitoring provides objective data about electrolyte status and trends.
Assess for clinical manifestations of electrolyte imbalances: muscle weakness, altered mental status, cardiac arrhythmias, neuromuscular irritability Clinical signs may appear before laboratory abnormalities are severe; early recognition allows prompt intervention.
Monitor intake and output, including insensible losses from fever and diaphoresis Fluid balance significantly impacts electrolyte concentrations; fever increases insensible losses.
Administer replacement electrolytes as prescribed Replaces specific electrolyte deficits based on laboratory values and clinical assessment.
Offer oral rehydration solutions containing balanced electrolytes when appropriate Provides both fluid and electrolyte replacement in physiologically balanced proportions.
Encourage foods high in potassium, magnesium, and other depleted electrolytes as appropriate Dietary sources of electrolytes can help maintain balance, particularly during recovery phase.
Maintain continuous cardiac monitoring for patients with significant electrolyte abnormalities Electrolyte imbalances, particularly potassium, calcium, and magnesium, can cause serious cardiac arrhythmias.
Monitor renal function through laboratory values and urine output Kidney function affects electrolyte regulation and excretion.

Evaluation

  • Patient maintains electrolyte levels within normal limits
  • Patient demonstrates absence of signs/symptoms of electrolyte imbalance
  • Patient demonstrates adequate hydration status

12. Anxiety

NANDA Definition

Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response; a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat.

Assessment Findings

  • Expressed concerns about health status or disease progression
  • Restlessness
  • Increased questioning
  • Difficulty concentrating
  • Increased heart rate
  • Heightened alertness
  • Sleep disturbance
  • Worry about impact of illness on responsibilities

Expected Outcomes

  • Patient will report decreased anxiety levels
  • Patient will demonstrate effective coping strategies
  • Patient will verbalize understanding of condition and treatment plan
  • Patient will exhibit fewer physical manifestations of anxiety

Nursing Interventions with Rationales

Intervention Rationale
Assess level of anxiety using standardized scale or subjective report Establishes baseline and helps evaluate effectiveness of interventions.
Provide clear, concise information about fever, its cause, and treatment plan Knowledge reduces fear of the unknown and gives patients a sense of control.
Use calm, reassuring approach during interactions Nurse’s demeanor can significantly impact patient’s anxiety level.
Encourage verbalization of fears and concerns Expression of emotions can reduce their intensity and allows for addressing specific concerns.
Teach simple relaxation techniques: deep breathing, guided imagery, progressive muscle relaxation These techniques activate the parasympathetic nervous system, counteracting the stress response.
Limit exposure to stressful situations and stimuli Reduces additional sources of anxiety when coping resources are already strained.
Include family/support persons in discussions and care as appropriate Support system involvement provides emotional reassurance and enhances understanding of care.
Administer anti-anxiety medications if prescribed Pharmacological intervention may be necessary for severe anxiety that interferes with rest or recovery.

Evaluation

  • Patient reports decreased anxiety levels
  • Patient demonstrates use of effective coping strategies
  • Patient displays relaxed posture and facial expression
  • Patient verbalizes accurate understanding of condition and care

13. Deficient Knowledge

NANDA Definition

Absence or deficiency of cognitive information related to a specific topic.

Assessment Findings

  • Verbalized lack of information about fever management
  • Inaccurate follow-through of instructions
  • Inappropriate or exaggerated behaviors (e.g., excessive concern over minor temperature elevation)
  • Questions indicating misconceptions about fever
  • Expressed interest in learning about fever management
  • Request for information

Expected Outcomes

  • Patient/caregiver will verbalize understanding of fever management
  • Patient/caregiver will demonstrate appropriate techniques for temperature monitoring
  • Patient/caregiver will identify situations requiring medical attention
  • Patient/caregiver will correctly administer prescribed medications

Nursing Interventions with Rationales

Intervention Rationale
Assess current knowledge level and learning needs regarding fever management Identifies specific knowledge gaps and misconceptions to address; establishes baseline for teaching plan.
Provide information about normal body temperature range and what constitutes fever Establishes basic understanding of temperature parameters and variations.
Teach proper technique for temperature measurement using appropriate device Ensures accurate monitoring at home; different methods (oral, temporal, axillary) require specific techniques.
Educate about appropriate use of antipyretics: dosage, frequency, maximum daily dose Promotes safe medication administration and prevents overdosing or underdosing.
Discuss non-pharmacological measures for fever management (adequate hydration, light clothing) Provides complementary approaches that can enhance comfort and support temperature regulation.
Clarify common misconceptions about fever (e.g., that all fevers require treatment, that fever itself is dangerous) Addresses potentially harmful beliefs that may lead to inappropriate management strategies.
Identify warning signs that require medical attention: very high fever (>103°F/39.4°C), altered mental status, severe headache with stiff neck, difficulty breathing Enables appropriate decision-making about when home management is insufficient.
Provide written materials to reinforce verbal teaching Written materials serve as reference after discharge when specific details may be forgotten.
Use teach-back method to verify understanding Confirms comprehension and identifies areas needing clarification.

Evaluation

  • Patient/caregiver accurately describes fever management strategies
  • Patient/caregiver demonstrates correct technique for temperature measurement
  • Patient/caregiver verbalizes appropriate situations requiring medical attention
  • Patient/caregiver demonstrates correct medication administration

14. Risk for Infection Transmission

NANDA Definition

Vulnerable to invasion and multiplication of disease-causing organisms, which may compromise health.

Risk Factors

  • Presence of infectious agent
  • Insufficient knowledge about avoiding transmission
  • Close proximity of susceptible individuals
  • Inadequate hygiene practices
  • Environmental conditions conducive to organism growth
  • Inadequate vaccination status

Expected Outcomes

  • Patient will demonstrate behaviors that reduce risk of transmitting infection to others
  • Patient/caregiver will verbalize understanding of infection transmission methods
  • Patient will identify and implement appropriate isolation precautions when needed

Nursing Interventions with Rationales

Intervention Rationale
Implement appropriate isolation precautions based on suspected or confirmed pathogen Different pathogens require specific isolation measures (e.g., droplet, contact, airborne) to prevent transmission.
Teach and reinforce proper hand hygiene techniques Hand hygiene is the single most effective measure for preventing infection transmission.
Educate about respiratory hygiene: covering coughs/sneezes, proper disposal of tissues Reduces airborne and droplet transmission of respiratory pathogens.
Instruct on proper handling and disposal of contaminated materials Prevents environmental contamination and indirect transmission through fomites.
Teach about maintaining distance from vulnerable individuals during infectious period Reduces exposure risk for immunocompromised, very young, elderly, and other high-risk individuals.
Provide education about the duration of contagiousness for specific infections Enables appropriate decision-making about isolation duration and return to work/school.
Encourage completion of full course of antimicrobial therapy if prescribed Incomplete treatment may result in persistent infection and continued transmission risk.

Evaluation

  • Patient demonstrates proper hygiene practices and infection control measures
  • Patient verbalizes understanding of transmission-reduction strategies
  • Secondary cases among contacts are minimized or prevented

15. Fatigue

NANDA Definition

An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work.

Assessment Findings

  • Verbalized overwhelming lack of energy
  • Inability to maintain usual routines
  • Decreased performance
  • Increased rest requirements
  • Lethargy or listlessness
  • Increased physical complaints
  • Emotional lability or irritability

Expected Outcomes

  • Patient will report improved energy levels
  • Patient will perform activities of daily living with less fatigue
  • Patient will identify energy conservation techniques
  • Patient will establish realistic activity goals considering current health status

Nursing Interventions with Rationales

Intervention Rationale
Assess fatigue level using standardized scale (e.g., 0-10 scale, Fatigue Severity Scale) Provides objective measurement for baseline and ongoing evaluation of interventions.
Identify and address underlying factors contributing to fatigue (fever, dehydration, poor nutrition, sleep disturbance) Targeting root causes is more effective than symptomatic treatment alone.
Plan care activities to allow for rest periods Scheduled rest prevents excessive fatigue and allows for energy recovery.
Help prioritize activities based on energy levels and importance Prioritization ensures energy is used for most important tasks when resources are limited.
Teach energy conservation techniques: sitting instead of standing, organizing tasks to minimize steps, using assistive devices These strategies reduce energy expenditure while still allowing completion of necessary activities.
Encourage adequate nutritional intake with emphasis on hydration and easily digestible, nutrient-dense foods Nutrition provides metabolic substrates essential for energy production and recovery.
Promote adequate sleep hygiene (consistent sleep schedule, comfortable environment, relaxation techniques) Quality sleep is essential for energy restoration and healing.
Advise on gradual return to normal activities as fever resolves Prevents relapse and allows physiological systems to recover progressively.

Evaluation

  • Patient reports increased energy levels on fatigue scale
  • Patient performs ADLs with less fatigue
  • Patient demonstrates use of energy conservation techniques
  • Patient establishes and follows realistic activity schedule

Special Considerations

Age-Specific Considerations

Infants and Young Children

  • Higher risk for febrile seizures
  • Dehydrate more quickly due to higher body water percentage
  • May not complain specifically of discomfort but show behavior changes
  • Temperature should be measured rectally (most accurate) or temporal artery in infants
  • Careful dosing of antipyretics based on weight, not age

Older Adults

  • May have blunted febrile response (baseline temperature often lower)
  • More susceptible to complications of fever (dehydration, confusion)
  • Often present with subtle signs (confusion, falls) rather than significant temperature elevation
  • Multiple comorbidities may complicate assessment and treatment
  • Medication interactions with antipyretics more common

Immunocompromised Patients

  • Fever may be the only sign of serious infection
  • Lower threshold for medical evaluation (often any temperature >100.4°F/38°C)
  • Higher risk for rapid deterioration
  • May require more aggressive workup, even for seemingly mild fever
  • Careful monitoring for subtle changes in condition

Nursing Tip: Remember that the pattern of fever can provide diagnostic clues. Continuous fever (minimal fluctuation), remittent fever (fluctuates but remains above normal), intermittent fever (returns to normal between spikes), and relapsing fever (fever-free periods of days) all suggest different underlying pathologies.

Proper Documentation

Accurate documentation is essential for quality fever nursing care plans and continuity of care. When documenting fever and related care, include:

Documentation Guidelines

Temperature Documentation

  • Exact temperature reading with decimal point
  • Method/route of measurement (oral, rectal, temporal, axillary)
  • Time of measurement
  • Pattern observations (e.g., cyclic patterns, response to antipyretics)

Associated Symptoms

  • Presence of chills, diaphoresis
  • Associated complaints (headache, myalgia)
  • Mental status changes
  • Other relevant symptoms related to underlying cause

Interventions

  • Medications administered (name, dose, route, time, effect)
  • Non-pharmacological interventions implemented
  • Patient response to interventions
  • Education provided

Assessment Data

  • Vital signs trends
  • Hydration status
  • Skin assessment
  • Neurological status
  • Relevant laboratory or diagnostic results
Sample Documentation Entry

7/15/2023 1400 – Temperature 39.2°C (102.6°F) oral. Patient reports headache (6/10) and generalized muscle aches. Skin warm and flushed. Alert and oriented x3. Oral mucous membranes slightly dry. Given acetaminophen 650 mg PO per order. Cool compress applied to forehead. Encouraged oral fluids; patient consumed 300 mL water. Education provided about fever management and importance of hydration. Will reassess in 30 minutes. – N. Johnson, RN

References

  • Herdman, T.H., & Kamitsuru, S. (Eds.). (2018). NANDA International nursing diagnoses: Definitions and classification, 2018-2020. Thieme.
  • Butcher, H.K., Bulechek, G.M., Dochterman, J.M., & Wagner, C. (2018). Nursing interventions classification (NIC) (7th ed.). Elsevier.
  • Moorhead, S., Swanson, E., Johnson, M., & Maas, M.L. (2018). Nursing outcomes classification (NOC): Measurement of health outcomes (6th ed.). Elsevier.
  • Potter, P.A., Perry, A.G., Stockert, P., & Hall, A. (2021). Fundamentals of nursing (10th ed.). Elsevier.
  • Ignatavicius, D.D., Workman, M.L., & Rebar, C.R. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care (10th ed.). Elsevier.
  • World Health Organization. (2021). Fever management guidelines. Retrieved from https://www.who.int/publications
  • Centers for Disease Control and Prevention. (2022). Guidelines for isolation precautions in healthcare settings. Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

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