Hyperthermia (Fever) Nursing Diagnosis & Care Plan

This nursing care plan and management guide can assist in providing care for patients with fever or pyrexia. Get to know the nursing assessment, interventions, goals, and nursing diagnosis to promote safe nursing care for patients with fever.

What is Fever?
Nursing Diagnosis
Goals and outcomes
Nursing interventions and rationales
Recommended Resources
See also
References and Sources

What is Fever?

Fever, also known as pyrexia, is a condition characterized by an elevation in the body’s core temperature above its normal range, triggered by a shift in the ‘set-point’ temperature regulated by the hypothalamus. This increase is typically a response to various physiological processes, including infections, inflammation, malignancies, or autoimmune disorders. These processes involve the release of immune mediators that signal the hypothalamus to raise the body’s core temperature as a defense mechanism.

While the normal body temperature hovers around 37°C (98.6°F), it can fluctuate slightly throughout the day due to metabolic activities, hormone levels, and activity cycles. However, fever causes a more significant rise in temperature beyond these normal variations, typically categorized into low-grade, moderate-grade, and high-grade fever.

Category	Temperature
Low-grade fever	37.3 to 38.0 ºC (99.1 to 100.4 ºF)
Moderate-grade fever	38.1 to 39.0 ºC (100.6 to 102.2 ºF)
High-grade fever	39.1 to 41.0 ºC (102.4 to 105.8 ºF)
Hyperthermia	Greater than 41.0 ºC (105.8 ºF)

Fever and hyperthermia (also known as hyperpyrexia) are distinct conditions. In fever, the hypothalamus raises the body’s ‘set-point’ temperature in response to infections or inflammation, allowing controlled temperature increase. Hyperthermia, however, occurs when the body’s temperature rises uncontrollably beyond the hypothalamic set-point, often due to an inability to dissipate heat, and is not regulated by the hypothalamus, posing greater risks to organ function. Please see our Hyperthermia Nursing Care Plans here.

Nursing Diagnosis

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with fever based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Ineffective Thermoregulation related to elevated body temperature as evidenced by increased core temperature, flushed skin, and shivering secondary to infectious process (specify).
Fluid Volume Deficit related to excessive fluid loss through sweating and increased metabolic demand, as evidenced by dry mucous membranes, decreased urine output, and tachycardia.

Goals and outcomes

The following are the common goals and expected outcomes for patients with fever:

Patient’s temperature will decrease to within the normal range (36-37°C or 96.8-98.6°F).
Patient will report reduced discomfort, such as decreased chills, sweating, or body aches.
Patient will maintain adequate fluid intake to prevent dehydration, with stable urine output.
Patient will show no signs of complications such as seizures, dehydration, or confusion.

Nursing interventions and rationales

Nursing interventions for fever focus on managing the patient’s elevated body temperature while ensuring comfort and preventing complications. These interventions aim to reduce fever through both pharmacological and non-pharmacological methods, maintain hydration, and address environmental factors that may influence thermoregulation.

Nursing assessment for fever

Measure the patient’s temperature using consistent and appropriate methods (oral, rectal, tympanic, etc.) based on the patient’s condition.
Different sites provide varying temperature readings, and selecting the correct method ensures accuracy. For example, rectal measurements are typically higher than oral or axillary, and using a consistent site is crucial for reliable comparisons.

Ask the patient or review their medical history to understand their normal baseline body temperature.
Some patients may naturally have higher or lower baseline temperatures, and recognizing these variations is essential to avoid misinterpreting normal fluctuations as fever.

Do not rely on patient-reported feelings of warmth or palpation of the skin to diagnose fever. Always confirm with a thermometer.
Diagnosis of fever by palpation is unreliable, with up to 40% inaccuracy. Accurate measurement using a thermometer ensures proper diagnosis and management.

When fever is suspected, choose the most appropriate and accurate method for the patient’s condition, such as rectal for more precise measurements in critical cases.
Rectal temperature measurements tend to be more accurate, especially in situations where precise readings are necessary, such as for febrile infants or critically ill patients.

Record the temperature along with the site of measurement and the time, and monitor trends rather than relying on single readings.
Accurate documentation helps monitor changes in the patient’s condition over time and ensures that trends are interpreted correctly, taking into account site-specific variations in readings.

Regularly assess the skin for warmth, flushing, sweating, or night sweats, as well as for cold, dry skin that may indicate a serious condition despite elevated core temperature.
Fever often presents with warm, flushed skin due to increased vasodilation, but dry, cold skin or extremities can indicate peripheral vasoconstriction, which may signal a more severe underlying problem such as hyperpyrexia or compromised circulation.

Frequently monitor temperature, pulse, and respiratory rate, paying close attention to pulse-temperature dissociation in specific conditions like typhoid fever.
Fever typically causes an increase in heart rate by 4.4 beats per minute per 1°C increase in core temperature. Monitoring for abnormalities, such as pulse-temperature dissociation, can help identify specific underlying conditions, such as brucellosis or drug-induced fever.

Assess for involuntary muscle contractions (rigors), piloerection, and the patient’s tendency to curl up or minimize body surface exposure.
These symptoms indicate the body’s effort to conserve heat and raise the core temperature, reflecting the body’s physiological response to fever. Recognizing these signs allows for appropriate interventions, such as cooling measures, if the fever becomes excessive.

Monitor the pattern of fever (e.g., intermittent, remittent, or sustained) and note any specific timing, such as evening fevers.
Identifying specific fever patterns can provide clues to the underlying cause. For instance, evening fevers may indicate tuberculosis, and cyclic fevers may be linked to conditions like malaria.

Monitor for hyperpyrexia in patients with severe infections or CNS hemorrhage and assess for neurological symptoms, such as headache, altered mental status, or seizures.
Hyperpyrexia can result in significant complications, such as increased intracranial pressure and brain injury. Early identification of dangerously high fevers allows for rapid intervention to prevent adverse outcomes.

Assess for signs of infection, such as increased white blood cell count, hypotension, or altered mental status, particularly in hospitalized patients.
Sepsis is a common cause of fever in hospitalized patients and can quickly progress to life-threatening conditions if not promptly identified and treated. Early recognition and intervention can improve patient outcomes.

Regularly assess for signs of dehydration, sweating, or wet dressings, and monitor skin condition.
Sweating and moisture from incontinence or dressings can lead to heat loss through evaporation, further lowering body temperature in a patient with fever. Keeping the skin dry helps prevent additional heat loss.

Monitor for signs of the body’s inflammatory response, such as increased white blood cell count, muscle breakdown, and elevated acute phase reactants.
Fever triggers an immune and inflammatory response, which includes leukocytosis, increased protein breakdown, and collagen synthesis. Monitoring for these signs helps assess the severity of the fever and its underlying cause, ensuring that appropriate interventions are provided.

General interventions for management of fever

Encourage the patient to increase fluid intake, such as water or electrolyte-rich fluids, during fever episodes.
Fever, especially when accompanied by an inflammatory response, can lead to dehydration due to increased fluid loss through sweating and increased metabolic activity. Proper hydration supports immune function and helps regulate body temperature.

Provide education to the patient regarding how antipyretics work, why they are prescribed, and the importance of following the dosing schedule.
Educating the patient enhances their understanding of fever management and ensures they adhere to the treatment plan. It also helps prevent misuse of medications and ensures the patient knows when to seek further medical attention if symptoms persist.

Evaluate the patient’s surroundings for drafts, cold surfaces, or wet clothing/dressings that may increase heat loss.
Environmental factors like air drafts, wet clothing, or contact with cold surfaces can lead to excessive heat loss, especially in pediatric or vulnerable populations. Identifying and minimizing these factors is crucial for maintaining a stable body temperature. Cold objects near the patient can cause heat loss via radiation, especially in infants and neonates. Adjusting the patient’s positioning away from cold surfaces can reduce this risk.

Ensure the patient’s room is free from drafts and relocate them if they are near cold windows or walls. Close doors and windows to prevent air drafts.
Preventing heat loss through convection (air drafts) and radiation (proximity to cold surfaces) supports thermoregulation and helps avoid excessive cooling in febrile patients.

Cover cold surfaces, such as weighing scales or examination tables, with pre-warmed blankets or towels before placing the patient on them.
Preventing heat loss through conduction by covering cold surfaces ensures the patient retains body heat, which is particularly important for infants and at-risk populations.

Lower the room temperature and increase air circulation using fans to help cool the patient in a controlled manner.
Fever increases metabolic demand, and adjusting the environment helps lower body temperature and prevent overheating. Proper air circulation supports heat loss through convection.

Encourage the patient to rest and minimize physical exertion.
Rest reduces oxygen consumption and metabolic demand, which is elevated during fever. Resting helps conserve energy and supports recovery.

Pharmacological interventions

Administer COX inhibitors such as ibuprofen or acetaminophen to reduce fever, as indicated.
These medications inhibit the cyclooxygenase (COX) enzyme, preventing the conversion of arachidonic acid into prostaglandin E2 (PGE2), which is responsible for raising the hypothalamic set-point and inducing fever. By reducing PGE2 levels, these medications help lower body temperature.

Regularly monitor the patient’s body temperature following the administration of antipyretic medications.
Monitoring ensures that the medication is effectively reducing fever. It also helps assess the need for additional interventions and prevents overuse of antipyretics, which may lead to complications such as liver or kidney damage.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

References and Sources

References and sources used for this nursing diagnosis guide for hyperthermia.

Barnason, S., Williams, J., Proehl, J., Brim, C., Crowley, M., Leviner, S., … & Papa, A. (2012). Emergency nursing resource: non-invasive temperature measurement in the emergency department. Journal of Emergency Nursing, 38(6), 523-530.
Brody, G. M. (1994). Hyperthermia and hypothermia in the elderly. Clinics in geriatric medicine, 10(1), 213-229.
Fink, E. L., Kochanek, P. M., Clark, R. S., & Bell, M. J. (2012). Fever control and application of hypothermia using intravenous cold saline. Pediatric critical care medicine: a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 13(1), 80.
Hostler, D., Northington, W. E., & Callaway, C. W. (2009). High-dose diazepam facilitates core cooling during cold saline infusion in healthy volunteers. Applied Physiology, Nutrition, and Metabolism, 34(4), 582–586. doi:10.1139/h09-011
Isaak, R. S., & Stiegler, M. P. (2016). Review of crisis resource management (CRM) principles in the setting of intraoperative malignant hyperthermia. Journal of anesthesia, 30(2), 298-306.
Isaak, R. S. (2016). Malignant hyperthermia: case report. Reactions, 1599, 130-30.
O’Connor, J. P. (2017). Simple and effective method to lower body core temperatures of hyperthermic patients. The American journal of emergency medicine, 35(6), 881-884.
Reifel Saltzberg, J. M. (2013). Fever and Signs of Shock. Emergency Medicine Clinics of North America, 31(4), 907–926. doi:10.1016/j.emc.2013.07.009
Schneiderbanger, D., Johannsen, S., Roewer, N., & Schuster, F. (2014). Management of malignant hyperthermia: diagnosis and treatment. Therapeutics and clinical risk management, 10, 355.
Sessler, D. I., Lee, K. A., & McGuire, J. (1991). Isoflurane anesthesia and circadian temperature cycles in humans. Anesthesiology, 75(6), 985-989.
Tayefeh, F., Plattner, O., Sessler, D. I., Ikeda, T., & Marder, D. (1998). Circadian changes in the sweating to-vasoconstriction interthreshold range. Pflügers Archiv: European Journal of Physiology, 435(3), Emergency Nurses Association

Fever (Pyrexia) Nursing Care Plan and Management

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