Fever

Fever

Clinical Findings

Neuro: Headache, dizziness, lightheadedness, confusion. Resp: Hyperpnea, tachypnea, abnormal lung sounds. CV:Tachycardia or bradycardia, signs of congestive heart failure. Skin:Warm to hot or cool, flushed or pale, dry or diaphoretic. MS: Body aches or cramps, stiff neck, stiff joints, weakness, fatigue, chills, shivering. GI/GU: Nausea and vomiting, constipation, diarrhea, UTI. Metabolic:Temperature >100.4_F (38 C).

Nursing Interventions

■ Place Pt in position of comfort and offer reassurance. ■ Offer Pt cool compress to forehead or nape of neck and encourage fluids as ordered. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Assess for associated symptoms: Fluid-volume status (dehydration, decreased urine output), surgical site complications (redness, tenderness, swelling, and warmth), lung sounds (crackles, rhonchi, diminished or absent), deep vein thrombosis (pain, redness, and warmth), GI/GU (diarrhea, constipation, UTI, odoriferous discharge). ■ Review medical record for medication, recent labs (WBC, blood and sputum cultures, and urinalysis), treatments, and temperature trends, for possible causes of fever. ■ Encourage Pt to cough and deep breathe (if incentive spirometer ordered, encourage Pt to use regularly). ■ Administer p.r.n. antipyretic medication per order. ■ Notify physician of change in Pt status, including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including antipyretic medication, alternative cooling measures, ordering labs (WBC, blood and sputum cultures, or urinalysis) or chest x-ray. ■ Document assessments, any interventions, and outcome. ■ Note: If fever is reasonably anticipated in relation to Pt’s clinical status (e.g., admitted to hospital for pneumonia), it is not immediately necessary to notify physician, unless there exists a need to order (or clarify an order for) antipyretic medication.