Risk factors may include
Extremes of age or weight; dehydration, exposure to cold or hot environments, illness or trauma affecting temperature regulation
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Child Will
Regain or maintain appropriate body temperature for age and size.
Provide proper environmental controls and safeguards.
Nursing intervention with rationale:
1. Note conditions promoting fevers—infection, inflammation, hot environment, and dehydration.
Rationale: Determines choice of interventions.
2. Measure and monitor child’s temperature, using properly functioning thermometer.
Rationale: Inaccurate measurement can result in inappropriate treatment.
3. Discuss variables in temperature measurements for age of child and where temperature is measured.
Rationale: Knowledge of normal ranges for age of child—newborn through adolescent—is critical to knowing when a fever requires treatment. Temperature may be measured orally, rectally, and at the axillary space, with rectal measurement being on average approximately 1 degree higher than oral, and axillary being 1 degree lower than oral. Note: Temperature of 100.4 F (38 C) or greater in newborns and infants needs immediate attention. For toddlers and older children, temperatures up to 104 F (40 C) may be tolerated unless accompanied by other signs, such as poor color, breathing problems, severe lethargy, headache, or stiff neck (Cincinnati Children’s Hospital Medical Center [CCHMC], 2006).
4. Be aware of heat loss related to age and body mass.
Rationale: Newborn is more vulnerable to heat loss than older child because of body surface area, higher metabolic rate, and sensitivity to environmental conditions.
5. Observe for seizure activity. Provide safety precautions, as indicated.
Rationale: Higher fevers may trigger febrile seizures in susceptible children.
6. Adjust bedclothes, linens, and environment. Apply cool cloth to head and bathe in lukewarm bath.
Rationale: Limiting linens and use of room fan can help lower body temperature. Note: Use of alcohol sponge bath is contraindicated as fumes are inhaled by infant.
7. Administer antipyretics, for example, acetaminophen (Tylenol), 10 to 15 mg/kg every 4 hours or ibuprofen (Motrin), 10 to 15 mg/kg every 6 hours, as indicated. Avoid use of aspirin.
Rationale: Some degree of fever may be useful for fighting infection; however, excessive levels may have adverse effects and require intervention. Aspirin is believed to be associated with the onset of Reye’s syndrome (London et al, 2007).