Question

PN 105 Fundamentals of NursingI Concept Map - Fever of Unknown Origin Greg Crew was admitted to your unit with the diagnosis of "fever of unknown or e has been admitted with the same symptoms on at least three other occasions where there was ailure to establish a diagnosis. He has had a fever of 100.8 for over three (3) days; has been on a series of antibiotics with no positive outcome which would be resolution of the fever. He is admitted to your unit with the diagnosis of "fever of unknown origin" and weight loss of 6 pounds in 2 weeks. You note there is tenting over the sternum and his eye appear sunken. He is receiving D/SNS 100 m/L per hour via infusion pump; Tylenol 650 mg by mouth every 4 hours for fever over 100.4; blood, urine and sputum for culture and sensitivity; increase oral fluids to 2500 m/l per 24 hours; and bedrest with bathroom privileges. gin Please complete your concept map. Reviewed 3/19

Answer 1

Nursing diagnosis 1- Dehydration related to fever as evidenced by sunken eyes and tenting

Nursing diagnosis 2- Weakness related to fever

# Nursing Interventions and Rationales:

1. Assess vitals

Note presence of fever. Elevated heart rate and breathing may indicate fever or dehydration. Get baseline to determine if interventions are effective

2. Assess skin for signs of dehydration

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.

3.Obtain history from patient and caregiver to determine cause

The cause and time of onset of symptoms helps to determine the appropriate course of action.

4 Monitor intake and output

Determine fluid balance; monitor for and measure vomiting or diarrhea; note amount and color of urine (darker with dehydration)

5. Remove excess clothing or blankets, educate patient /caregivers

6. Encourage oral fluid intake; administer IV fluids asrequired

Offer snacks and liquids frequently and monitor patient’s response, especially with vomiting and diarrhea.

IV fluid replacement may be required if patient is resistant to or cannot tolerate oral intake.

7. Apply cool compresses to patient’s forehead, hands and feet or place in tepid bath

Do not apply ice packs to skin, but cool moist cloths and tepid baths help reduce fever through evaporative cooling; monitor for shivering which may indicate cooling too quickly

8. 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

9. Provide education and counseling for patients, parents and caregivers

Help families understand treatment methods and ways to treat patient at home

Provide demonstrations as necessary for accurate thermometer use and guidance regarding intake and output

# Positive outcome :-

Dehydration resolved by IV fluid therapy

#. Negative outcome :-

Fever haven't decreased as the cause of his fever is not getting clear .

# Evaluation :-

On evaluation after providing intervention , the patient's dehydration got resolved but fever was persistent .