Body temperature elevated above normal range
• Flushed, warm skin
• Increased heart and respiratory rate
• Increased metabolic rate
• Decreased perspiration
• Exposure to hot environment
• Inappropriate clothing
• Vigorous activity
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Fluid and electrolytes
• Pharmacological function
• Respiratory function
• Physical regulation
• Tissue integrity
The patient will
• Remain afebrile.
• Maintain balance of intake and output within normal limits.
• Maintain urine speciﬁc gravity between 1.005 and 1.015.
• Exhibit moist mucous membranes.
• Exhibit good skin turgor.
• Remain alert and responsive.
SUGGESTED NOC OUTCOMES
Hydration; Infection Severity; Thermoregulation; Vital Signs
INTERVENTIONS AND RATIONALES
Determine: Monitor heart rate and rhythm, blood pressure, respira-
tory rate, LOC and level of responsiveness, and capillary reﬁll time
every 1–4 hr to evaluate effectiveness of interventions and monitor
Determine patient’s preferences for oral ﬂuids, and encourage
patient to drink as much as possible, unless contraindicated. Moni-
tor and record intake and output, and administer intravenous ﬂuids,
if indicated. Because insensible ﬂuid loss increases by 10% for every
1.8 F (1 C) increase in temperature, patient must increase ﬂuid
intake to prevent dehydration.
Perform: Take temperature every 1–4 hr to obtain an accurate core
temperature. Identify route and record measurements.
Administer antipyretics as prescribed and record effectiveness.
Antipyretics act on hypothalamus to regulate temperature.
Use nonpharmacologic measures to reduce excessive fever, such as
removing sheets, blankets, and most clothing; placing ice bags on
axillae and groin; and sponging with tepid water. Explain these
measures to patient. Nonpharmacologic measures lower body tem-
perature and promote comfort. Sponging reduces body temperature
by increasing evaporation from skin. Tepid water is used because
cold water increases shivering, thereby increasing metabolic rate and
causing temperature to rise.
Use a hypothermia blanket if patient’s temperature rises above
103 F (39.4 C), if ordered. Monitor vital signs every 15 min for
1 hr and then as indicated. Prolonged hyperthermia may lead to
complications such as seizures. Turn off blanket if shivering occurs.
Shivering increases metabolic rate, increasing temperature.
Manage: Report lack of responses to interventions to physician to
SUGGESTED NIC INTERVENTIONS
Environmental Management; Fever Treatment; Fluid Management;
Kayser-Jones, J. (2006, June). Preventable causes of dehydration: Nursing
home residents are especially vulnerable. American Journal of Nursing,