Name: Yasmin Habib

Fever
Diagnosis:
1. Potential for fluid and electrolyte imbalance related to increased body temperature. 2. Discomfort related to pyrexia Expected Outcome: At the end of 4 hours, patients body temperature is within normal ranges.

Goal:
Put will have balanced intake and output in 24 - 48 hours.

Intervention:

1. Check vital signs 2. Administer antipyretics and antibiotics if ordered 3. Provide comfort, do TSB, change clothings and linens to keep the patient dry 4. Do septic screen if ordered 5. Monitor for signs of infection, document and refer to the physician any unusualities noted

1- Decrease Body Heat Production: Advise patient to take a complete rest to minimize unnecessary energy expenditure which may increases body temperature. Anticipate patient's needs and keep things within reach to avoid activity on his part. Inform patient of his condition and treatment to reduce apprehension and anxiety.

2- Promote Body Heat Lost: Dress the patient with lightweight clothing. Keep the patient cool by providing a fan or nurse him in air-conditioner room. Sponge the patient with tepid water. Take a cool bath if necessary. Increase fluid intake if the patient has no restriction. Fluid can be in the form of water, iced drinks, ice-blocks, jelly, juices, or whatever he will drink. Severe anti-fever medicine (paracetamol eg. Panadol) if the temperature reaches at least 39oC for adults.

3- Monitor and Maintain Body Functions: Take temperature readings every 4 to 6 hourly. Pulse, respirations and blood pressure should also be monitored in high fever as these vial signs may indicate complications. An increase temperature is usually accompany with increase respiration and heart rates.

Patient behavioral changes such as confusion, restless, or disorientation should be noted in high fever. Check the state of hydration since fever tends to be very debilitating and dehydrating. More about dehydration is in the topic Day-to-Day Care, Observation: Fluid Balance. Fluid intake should be increased to replace fluids lost through insensible water loss and sweating. The inclusion of soups is recommended because of their sodium content. Provide measures to stimulate appetite and offer well-balanced meals to meet increased metabolic needs. More on how to encourage eating can be found in the topic Day-to-Day Care, General: Meals.

4- Promote Comfort: Provide oral hygiene to keep the mouth and lips moist. If patient is lying on bed, frequent changing of position and linen help to reduce discomfort. Frequent changing of clothes is also necessary because of increased sweating. Severe paracetamol such as Panadol if the patient has headache. Use a lightweight blanket if he feels cold or is shivering.

Evaluation:
Put has achieved balanced intake = output. or Pt has not achieved balanced I&O (Continues to have intake < output)