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Nursing Care Plan for Dehydration & Fever

Biodigital Picmonic
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Pathophysiology

A fever is a 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 diseases. 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 the 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. 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 Outcome

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

Fever & Dehydration Nursing Care Plan

Subjective Data:

Fever

  • The 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

  • Assess vitals
  Note the presence of fever. Elevated heart rate and breathing may indicate fever or dehydration. Get baseline to determine if interventions are effective  
  • Assess skin for signs of dehydration
  The 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.  
  • Obtain history from parent or caregiver to determine the cause
  The cause and time of onset of symptoms help to determine the appropriate course of action.  
  • Monitor intake and output
  Determine fluid balance; monitor for and measure vomiting or diarrhea; note amount and color of urine (darker with dehydration)  
  • 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.  
  • 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 the 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 the patient is resistant to or cannot tolerate oral intake.  
  • Apply cool compresses to patient’s forehead, hands and feet or place in a tepid bath
  Do not apply ice packs to the skin, but cool moist cloths and tepid baths  help reduce fever through evaporative cooling; monitor for shivering which may indicate cooling too quickly  
  • 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

 

  • Provide education and counseling for patients, parents, and caregivers
  Help families understand treatment methods and ways to treat patients at home Provide demonstrations as necessary for accurate thermometer use and guidance regarding intake and output.  

References

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  • Question 1 of 5

The nurse is caring for a 2-day-old with only one wet diaper since birth. Which additional assessments will the nurse perform to assess for dehydration? Select all that apply.

  • Question 2 of 5

A 3-year-old child presents to the emergency department with lethargy. The nurse obtains vital signs. Which of the following is NOT considered a fever?

  • Question 3 of 5

A child with an infection develops a fever. The nurse caring for the child knows that which part of the brain allows the higher temperature in response to the infection?

  • Question 4 of 5

The nurse is assessing a 7-year-old client for dehydration. Which of the following indicate that the child is dehydrated? Select all that apply.

  • Question 5 of 5

The nurse caring for a child admitted with gastroenteritis knows which of the following are signs of severe dehydration? Select all that apply.

Module 0 – Nursing Care Plans Course Introduction
Module Obstetrics (OB) & Pediatrics (Peds) Care Plans

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