Pyrexia care plan
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Pyrexia (Fever) Nursing Care Plan
What is Pyrexia?
Pyrexia is a core body temperature above the normal range (>37.5°C/99.5°F orally, or >38.0°C/100.4°F rectally). It results from the hypothalamus resetting its thermoregulatory set-point upward in response to pyrogens (endogenous: IL-1, IL-6, TNF; exogenous: bacterial LPS). Fever is a symptom, not a disease, and the underlying cause must always be identified.
Temperature classification:
- Low-grade: 37.5 - 38.5°C
- Moderate: 38.6 - 39.5°C
- High-grade: 39.6 - 40.5°C
- Hyperpyrexia: >40.5°C (medical emergency)
In surgical patients, pyrexia may indicate ischaemia, intestinal perforation, or abscess formation, while hypothermia in that setting suggests septicaemic shock. (Bailey and Love's Short Practice of Surgery, 28th Ed.)
Step 1: Nursing Assessment
Subjective Data
- Patient/carer reports feeling hot, shivery, or unwell
- History of recent infection, surgery, travel, immunosuppression, or new medications
- Associated symptoms: headache, myalgia, rigors, rash, dysuria, cough, vomiting
Objective Data
| Parameter | Finding in Pyrexia |
|---|---|
| Temperature | >37.5°C (method-appropriate threshold) |
| Pulse | Tachycardia (HR rises ~10 bpm per 1°C rise) |
| Respiratory rate | Increased (compensatory) |
| Blood pressure | May be low if sepsis developing |
| Skin | Flushed, hot, diaphoretic; may have rigors |
| Mucous membranes | Dry if dehydrated |
| Mental status | Confusion in elderly or severe pyrexia |
| Urine output | Decreased if dehydrated |
Relevant Investigations
- FBC (WBC differential), CRP, ESR, procalcitonin
- Blood cultures x2 (if T >38.3°C and source unknown)
- Urine MC&S, chest X-ray, wound swabs as directed by source
- LFTs, U&E, lactate (if sepsis suspected)
Step 2: Nursing Diagnoses
- Hyperthermia related to infectious/inflammatory process as evidenced by elevated body temperature, flushed skin, tachycardia
- Deficient Fluid Volume related to increased insensible fluid losses (diaphoresis, tachypnoea) and reduced oral intake
- Acute Pain / Discomfort related to headache, myalgia, rigors associated with pyrexia
- Risk for Febrile Seizure (particularly in paediatric patients) related to rapid rise in temperature
- Activity Intolerance related to weakness, malaise, and increased metabolic demand
- Deficient Knowledge related to self-care measures and when to seek medical review
Step 3: Goals and Expected Outcomes
| Timeframe | Goal |
|---|---|
| Short-term (1-4 hrs) | Temperature reduces to <37.5°C or patient-defined normal; patient reports improved comfort |
| Short-term | Adequate hydration maintained: moist mucous membranes, urine output >0.5 mL/kg/hr |
| Medium-term | Source of pyrexia identified; appropriate treatment initiated |
| Long-term | Patient/carer able to accurately monitor temperature and understands when to seek help |
| Long-term | No complications (seizure, dehydration, delirium) occur |
Step 4: Nursing Interventions and Rationale
Monitoring
| Intervention | Rationale |
|---|---|
| Monitor temperature every 1-4 hours (more frequently if >39.5°C or deteriorating) | Tracks trend, evaluates response to interventions, detects hyperpyrexia early |
| Monitor vital signs (HR, BP, RR, SpO2) with each temperature check | Tachycardia and hypotension signal possible sepsis progression |
| Record fluid intake and output strictly | Detects early dehydration caused by sweating and insensible losses |
| Monitor mental status (GCS/AVPU) | Pyrexia can cause confusion, especially in elderly; deteriorating consciousness may indicate sepsis |
| Observe for rigors, rash, petechiae, localising signs | Guides differential diagnosis and urgency of escalation |
| Weigh patient daily if prolonged fever | Detects fluid deficit; 1 kg weight loss ≈ 1 L fluid loss |
Non-Pharmacological Interventions
| Intervention | Rationale |
|---|---|
| Remove excess clothing/bedding; maintain a cool, well-ventilated environment | Promotes heat loss by radiation and convection without causing shivering |
| Apply a tepid sponge or tepid wet flannel to forehead, axillae, and groin | Facilitates evaporative cooling at high-blood-flow surface areas |
| Encourage oral fluid intake (water, diluted juice, oral rehydration solutions) | Replaces fluid lost through sweating; supports immune function and thermoregulation |
| Fan therapy (room fan or electric fan) used with tepid sponging | Enhances evaporation from moist skin; can reduce temperature by 0.5-1°C |
| Encourage light, cool, breathable clothing | Reduces heat retention while preventing shivering-induced heat production |
| Ensure adequate rest; reduce unnecessary physical activity | Fever increases basal metabolic rate by ~10-13% per 1°C; rest conserves energy |
| Offer light, nutritious meals; high-calorie supplementation if prolonged fever | Increased metabolic demand requires nutritional support to prevent catabolism |
| Oral hygiene every 2-4 hours | Fever causes dry mouth and increased risk of oral infection; maintains comfort |
| Reposition every 2 hours if bedbound | Reduces risk of pressure injuries; diaphoretic skin is particularly vulnerable |
Pharmacological Interventions
| Intervention | Rationale |
|---|---|
| Administer antipyretics (paracetamol/acetaminophen or ibuprofen) as prescribed | Inhibit COX enzymes - block conversion of arachidonic acid to prostaglandin E2 (PGE2), lowering the hypothalamic set-point. Paracetamol 1 g PO/IV every 4-6 hours (max 4 g/24 hrs in adults) |
| Monitor temperature 30-60 min post-antipyretic administration | Confirms drug efficacy; guides whether additional cooling measures or dose escalation is needed |
| Do NOT use aspirin in children under 16 | Risk of Reye's syndrome |
| Administer IV fluids as prescribed if oral intake inadequate or patient is vomiting | Maintains circulating volume and prevents end-organ hypoperfusion |
| Administer antibiotics/antivirals/antifungals as prescribed once cultures taken | Addresses underlying infectious cause; do not delay antibiotics if sepsis is suspected (target: within 1 hour of suspicion) |
| For hyperpyrexia (>40.5°C): prepare for IV antipyretics, ice-water immersion, or cooling blanket as directed by clinician | Hyperpyrexia causes protein denaturation, rhabdomyolysis, DIC, and neurological damage |
| Administer dantrolene if malignant hyperthermia suspected | Malignant hyperthermia is a life-threatening emergency - dantrolene inhibits sarcoplasmic reticulum calcium release |
Patient and Family Education
| Intervention | Rationale |
|---|---|
| Teach correct thermometer use and documentation | Ensures accurate home monitoring |
| Explain when to seek immediate medical help: T >39.5°C not responding to antipyretics, new rash, neck stiffness, altered consciousness, signs of breathing difficulty | Enables timely escalation of dangerous conditions (meningitis, sepsis) |
| Advise on adequate fluid intake during fever episodes | Prevents dehydration at home |
| Explain the role of fever in immune response; avoid unnecessary anxiety about low-grade fever | Promotes adherence to treatment; prevents overuse of antipyretics |
| Teach signs of dehydration (dark urine, sunken eyes, dry mouth, dizziness) | Empowers self-monitoring |
Step 5: Evaluation
Reassess the patient at defined intervals and document:
- Temperature trending down toward normal range
- Patient reports improved comfort and reduced rigors/myalgia
- Adequate hydration: urine output >0.5 mL/kg/hr, moist mucous membranes
- No new complications (seizure, delirium, hypotension)
- Vital signs improving (HR, RR returning toward normal)
- Underlying cause identified and treatment initiated
- Patient/family verbalize understanding of home monitoring and warning signs
Special Considerations
| Population | Key Considerations |
|---|---|
| Neonates (<3 months) | Any fever (T >38°C) is a medical emergency - immature immune response; sepsis workup mandatory |
| Elderly | May not mount significant fever even with serious infection; confusion may be the presenting feature; hypothermia can paradoxically indicate sepsis |
| Immunocompromised | Fever threshold for urgent intervention is lower (T >38°C); empirical broad-spectrum antibiotics often started early |
| Post-operative patients | "5 Ws" mnemonic: Wind (pneumonia, day 1-2), Water (UTI, day 3-5), Wound (infection, day 5-7), Walking (DVT/PE, day 5+), Wonder drugs (drug fever, any time) |
| Paediatric patients | High risk of febrile convulsions (6 months - 6 years); aggressive early cooling; avoid aspirin |
| Pregnant patients | Pyrexia can cause fetal tachycardia, neural tube defects (first trimester), and preterm labour; treat promptly; ibuprofen avoided in third trimester |
Escalation: When to Call the Doctor
- Temperature >40°C not responding to antipyretics within 1 hour
- Associated: neck stiffness, photophobia, non-blanching petechial rash
- Systolic BP <90 mmHg, HR >130 bpm, RR >25 (suspected sepsis - follow sepsis 6 protocol)
- New onset confusion or reduced GCS
- Temperature in a neonate (<3 months)
- Rigors persisting despite antipyretics and cooling
Sources: Bailey and Love's Short Practice of Surgery 28th Ed.; Nurseslabs Fever Care Plan (Updated Nov 2024); NursTogether Hyperthermia Care Plans
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