Nursing Care Plan for Fever & Dehydration

Pathophysiology

A fever is the rise in body temperature above what is considered a normal range. Most physicians consider a fever to be a temperature over 100° when taken orally, 99° when taken under the arm and over 100.4° when taken rectally. The purpose of a fever is to help the body fight off infection. Fevers can be mild and benign, but they can also alert to more serious disease. Not all fevers need treatment. It is recommended that, unless the child is visibly uncomfortable or in pain, fevers under 102° should not be treated.

Dehydration is an excessive loss of fluid from the body and is another common issue among children. Most children get enough water from eating and drinking, but fluid loss in a child can be dangerous, leading to brain damage or even death.

Etiology

The body’s temperature is controlled by the hypothalamus in the brain. When the body temperature rises, it is because the hypothalamus is resetting the temperature in response to some illness or infection. A higher temperature makes it more difficult for germs that cause infection to live. This is a normal defense system of the body and is not a disease in itself, but usually a symptom of some illness or infection. Alternatively, infants who are over bundled or in a very warm environment may develop a fever because the hypothalamus is not yet able to fully regulate temperature.

Dehydration occurs more often in infants and toddlers as they lose fluid much faster than older children and adults, and may occur from having an illness that causes vomiting or diarrhea or from fever. As the body temperature rises, the tissues use more water. If the child does not take in enough fluid when running a fever or with vomiting and diarrhea, they can dehydrate more quickly. Children who have other diseases such as diabetes may experience excessive urination that results in dehydration. In older children, sweating after play may contribute to fluid loss, but is not usually the only factor.

Desired Outome

Patient will maintain optimal fluid balance; patient will exhibit vital signs within normal range; patient will be free from infection

Fever & Dehydration Nursing Care Plan

Subjective Data:

Fever

  • Fussiness of infant or toddler or irritability
  • Lethargy
  • Changes in sleep habits
  • Decreased appetite
  • Headache
  • Body aches

Dehydration

  • Report of dry diapers or no urine output for 4-6 hours
  • Report of vomiting more than 24 hours
  • Lethargy
  • Irritability, fussiness (maybe inconsolable)
  • Abdominal pain

Objective Data:

Fever

  • Feel hot to touch
  • Elevated temperature
  • Tachypnea

Dehydration

  • Fever
  • Sunken eyes
  • Dry mouth or no tears when crying
  • Vomiting
  • Sunken soft spot on head (infants)
  • Tachycardia
  • Tachypnea
  • Decreased urine output

Nursing Interventions and Rationales:

  1. Assess vitals
    • Note presence of fever. Elevated heart rate and breathing may indicate fever or dehydration. Get baseline to determine if interventions are effective
  2. Assess skin for signs of dehydration
    • Skin may be dry, hot or flushed; note capillary refill and observe for dry mouth, cracked lips or crying without tears. Assess skin turgor for tenting.
  3. Obtain history from parent or caregiver to determine cause
    • The cause and time of onset of symptoms helps to determine the appropriate course of action.
  4. Monitor intake and output
    • Determine fluid balance; monitor for and measure vomiting or diarrhea; note amount and color of urine (darker with dehydration)
  5. Remove excess clothing or blankets, educate parents/caregivers
    • Infants are especially sensitive to over-bundling as they are unable to regulate temperature.

      Often when infants are ill, parents will bundle them up, but don’t realize they are making things worse.
  6. Encourage oral fluid intake; administer IV fluids if necessary
    • Oral fluid intake may be in the form of breastfeeding or bottle feeding in infants. Offer snacks and liquids frequently and monitor patient’s response, especially with vomiting and diarrhea.

      Children may be more responsive to frozen juice bars, ice pops or flavored gelatin. IV fluid replacement may be required if patient is resistant to or cannot tolerate oral intake.
  7. Apply cool compresses to patient’s forehead, hands and feet or place in tepid bath
    • Do not apply ice packs to skin, but cool moist cloths and tepid baths help reduce fever through evaporative cooling; monitor for shivering which may indicate cooling too quickly
  8. Administer medications as required
    • Anti-nausea medications may be given to children experiencing vomiting

      Antipyretic medications (acetaminophen) are often given to reduce fever

      Antibiotics may be given if fever is related to infection
  9. Provide education and counseling for patients, parents and caregivers
    • Help families understand treatment methods and ways to treat patient at home

      Provide demonstrations as necessary for accurate thermometer use and guidance regarding intake and output.

References

Date Published - Nov 15, 2018
Date Modified - Nov 15, 2018