Nursing Care Plan (NCP) for Dehydration & Fever

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Outline

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.

Writing a Nursing Care Plan (NCP) for Dehydration & Fever

A Nursing Care Plan (NCP) for Dehydration & Fever starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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Transcript

Hey guys, we’re going to talk about fever and dehydration and how to put this into a nursing care plan. 

 

First, we have to collect our information and this is all about just gathering that data. So, we have two things going on here, right? We have a fever and the patient’s dehydrated. Our subjective data are the things that are coming from the patient. Maybe the patient is saying they’re really lethargic, really tired, weak. Maybe they’ve had trouble sleeping, or body aches, all things that would show you that a patient’s not feeling well. Decreased appetite would also be that, or if the patient’s complaining of a headache, of course, if they’ve said that they’ve gotten an elevated temperature. Next, is the dehydration piece. So let’s say it’s a baby. They’ve had dry diapers, right? They’re not having output or an adult saying no output. They’re not getting it. Maybe they’ve said that they’ve been vomiting for 24 hours. That’s a sure-fire way to say that a patient would be dehydrated. 

 

Now, down to our objective data, and again, still two things here, we have a fever happening and we have dehydration. So, our objective data is going to be the things that we see and we observe. So for fever, they feel hot to touch. Maybe we’ve gotten a temp and it’s elevated. Maybe we’ve assessed that and they have a fever and let’s say they’re tachypnic because they are hot, and they’re trying to get rid of some of that extra heat that they have on them. So tachypnea and dehydration. We assess some dry mucous membranes, dry mouth, no tears like on a baby, so they’re so dehydrated that they don’t even make tears, never a good sign. Maybe we witnessed the vomiting happening. So again, that would show us that they are dehydrated and maybe they’re tachycardic and tachypnic from that. Then, obviously our decreased urinary output is going to also show us that they’re dehydrated. 

 

Alright, so let’s analyze the information and this is going to get us to diagnose and prioritize. So, what is the problem? These are the “what” questions? Well, there’s an infection of some sort, whether it be bacterial or viral and the patient’s dehydrated. So, let’s say for this hypothetical patient, we have a temp of 102 and we have dry diapers. We’ll say it’s a baby. Okay, so that is our problem. So, that’s showing a fever and showing dehydration. What needs to be improved? Well, the fever needs to be brought down and we need to hydrate the patient. That’s what needs to be improved. Yeah, the fever and hydration. So, we can improve that hopefully with some IV fluids and some antipyretics to help with that fever, or antibiotics if we determine that it’s a bacterial infection. What is the priority? Our priority is going to be to reduce that fever and make sure we’re not spreading it, and to hydrate. So fix the fluid balance. 

 

Alright, so now we’re going to ask the “how” questions, and this is going to help us plan, implement, and evaluate. So, how did we know it was a problem? Well, this is where you’re going to link your data that you have collected on your patients. For our hypothetical patient that we’re using here, we knew it was a problem because we felt the hot skin and we got a temp of 102, and then, we saw that there was no output. So, that’s how we know it was a problem. How are we going to address it? Well, we’re going to address it by, let’s say, I would do some cool compresses to help cool down the patient, or give some meds to help lower that fever right, and then hydrate. So, however that may be, probably for this patient would be IV. Then, how am I going to know it gets better? Well, the fever will be reduced and the wet diapers will start again and we’ll have some output. Our patient will report some wet diapers or the parent will. 

 

Alright, so now translate. This is where we’re super concise with these high level nursing concepts. So here, I think infection control, we have a fluid balance issue and then we have some patient education that’s needed. Alright, so let’s go on to transcribe. With transcribing, we’re looking at what the problem is. We’re looking at the data, how we’re going to intervene to fix, and then our, why, why is this intervention needed and what we expect to see happen? So, here are concepts, there are priorities, infection control, fluid balance, and patient education. First, let’s look at our data. We have a fever showing us that there’s an infection problem and that’s one of the things, perhaps they’ve had a swab done for strep or something like that, showing us that there’s an infection. 

 

Our interventions, well, we’re going to give an antibiotic to reduce that fever and by reducing that fever, we can hopefully get the fever down and make the patient not contagious anymore to limit that spread of infection with antibiotics. So, if we found out that it was a bacterial infection, we could give some antibiotics as an intervention and of course with meds, it’s as ordered, right, because we’re not ordering medication. Now, for the rationale. So the “why”, well, we want to lower that fever because by lowering the fever, that’s going to help the baby to drink and help the hydration status, which is going to help our fluid balance. When we get down here and also an antibiotic, why would we give out, well to help reduce the bacteria and If there was an infection, to help with infection control. So, our expected outcomes are going to be the fever being reduced and that’s by both meds to the antibiotic. Then on the antibiotics, if we can attack the bacterial infection, it will help reduce that fever and we’ll also help with hydration status, which brings us right into our fluid balance.

 

Alright, so our data, dry mucous membranes, no output, maybe some vomiting. Our interventions, we are going to IV and PO hydrate however we see fit. Remember, we need an order for IV, but we have to get some fluid back in the patient to bring balance. So why, well, it’s going to correct the dehydration. Our expected outcome is that we are going to have the patient have some urinary output within normal limits. With our patient education, we want to educate on medication frequency, so when they can take it, how often they can take it and if they do get prescribed an antibiotic, then we want to give instructions on that as well. We want to educate on frequency in our intervention and educate on how long to take. With our rationale, the “why”, well, we need the patient to know the correct dosing. We need them to know to take that antibiotic until it’s completed right, so that’ll be our why. Finally,  our expected outcome is that the patient will understand, verbalize or demonstrate an understanding. 

 

Alright guys, so let’s wrap it up and look at these key points. So, we are collecting information,  that’s our data we are going to analyze so that we can diagnose and prioritize. We are going to ask how, which is gonna allow for plan, implementation, and evaluation. We are going to translate, so these are our concise terms and then transcribed, so whatever form you find helpful for you. Then you can put all your care plans together. 

 

Alright guys, good,so under NURSING.com, you can look at all the care plans we have available to help you through this. We love you. Go out there and be your best selves and as always, happy nursing!

 

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