**1. Nursing Assessment:**
*What the Patient Feels (Subjective Data):*
- The patient says they have a fever, feel very tired, and their body aches. They also say they’ve been waking up at night because of chills and sweating.
- They mention having a headache, a sore throat, and not feeling like eating much.
*What the Nurse Observes (Objective Data):*
- The patient’s temperature is 38.5°C (101.3°F). Their pulse is 102 beats per minute, and they are breathing a little faster than normal at 20 breaths per minute.
- Their skin feels warm and looks flushed. They sometimes sweat a lot.
- Their throat is a little red. A lab test showed their white blood cell count is high, which can mean an infection. More test results are on the way.
**2. Nursing Diagnoses:**
- The patient has a fever because of an infection.
- They might get dehydrated because they aren’t drinking enough.
- They feel uncomfortable because of the fever and aches.
- They aren’t sleeping well because of the chills and sweating.
**3. Nursing Interventions:**
*Checking and Observing:*
- Take their temperature, pulse, and breathing rate every 4 hours.
- Watch for signs of dehydration, like not peeing much or having a dry mouth.
*Helping Them Feel Better:*
- Give medicine like acetaminophen to lower their fever.
- Make sure they drink plenty of fluids, like water or electrolyte drinks.
- Use a cool washcloth on their forehead or give them a lukewarm bath. Don’t let them get too cold and start shivering.
- Keep their room quiet and comfy so they can rest.
*Teaching and Teamwork:*
- Explain how to take care of a fever, like staying hydrated, taking medicine, and looking out for serious symptoms.
- Work with the doctor and healthcare team to find and treat the cause of the fever.
**4. Goals and Outcomes:**
- The patient’s temperature will go down to normal (below 37.5°C or 99.5°F) in 48 hours.
- They will stay hydrated and feel more comfortable.
- The cause of the fever will be identified and treated.
**5. Evaluation:**
- The patient’s temperature, pulse, and breathing will be normal, and the fever won’t come back.
- They will feel more energetic and start eating better.
- They will understand how to care for themselves and stay hydrated.
**6. Follow-Up Plan:**
- Keep an eye on their symptoms to make sure the fever doesn’t come back or get worse.
- Schedule a follow-up visit to check how they are doing.
- Give them information and resources to help them continue their care.
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