Take temperature every 1 to 4 hours to obtain an accurate core temperature. Identify route and record measurements. Use the same method each time temperature is taken to track accurate trends of temperature and maintain accuracy of results.- Administer antipyretics as prescribed and record effectiveness. Antipyretics act on hypothalamus to regulate temperature.
Use nonpharmacologic measures to reduce excessive fever, such as removing sheets, blankets, and most clothing; placing ice bags on axillae and groin; and sponging with tepid water. Explain these measures to patient. Nonpharmacologic measures lower body temperature and promote comfort. Sponging reduces body temperature by increasing evaporation from skin. Tepid water is used because cold water increases shivering, thereby increasing metabolic rate and causing temperature to rise.- Use a hypothermia blanket if patient's temperature rises above 103°F (39.4°C). Monitor vital signs every 15 minutes for 1 hour and then as indicated. Temperatures that exceed 103°F cannot be controlled with antipyretics alone.
- Turn hypothermia blanket off if shivering occurs. Shivering increases metabolic rate, increasing temperature.
- Monitor heart rate and rhythm, blood pressure, respiratory rate, LOC and level of responsiveness, and capillary refill time every 1 to 4 hours to evaluate effectiveness of interventions and monitor for complications.
Determine patient's preferences for oral fluids and encourage patient to drink as much as possible, unless contraindicated. Monitor and record intake and output, and administer IV fluids, if indicated. Because insensible fluid loss increases by 10% for every 1.8°F (1°C) increase in temperature, patient must increase fluid intake to prevent dehydration.
Suggested NIC Interventions
Environmental Management; Fever Treatment; Fluid Management; Temperature Regulation: Vital Signs Monitoring |