Appropriate Nursing Intervention for Fever in Emergency Setting
The correct answer is D: measure the patient's fluid intake and output. This patient presenting with high-grade fever, tachycardia, and tachypnea requires close monitoring for dehydration, which is a common and dangerous complication of fever that directly impacts morbidity and mortality.
Rationale for Fluid Monitoring
Fever commonly causes dehydration through increased insensible losses, and dehydration is a primary physiologic driver of the tachycardia and tachypnea observed in this patient. 1 The American Heart Association explicitly identifies dehydration as a key underlying condition causing compensatory tachycardia in febrile patients. 1
Critical Evidence Supporting Fluid Monitoring
Decreased urine output is an alarming clinical sign in febrile patients that indicates developing hemodynamic compromise. 1 This makes monitoring fluid intake and output essential for early detection of deterioration.
In nursing home residents with fever, impaired oral intake was highly associated with elevated serum sodium or BUN/creatinine ratios (82% correlation), indicating early dehydration. 2 Staff documentation and intervention at the first indication of impaired intake can prevent dehydration. 3
Among febrile patients who died, 100% had laboratory evidence of dehydration (elevated serum sodium and/or BUN/creatinine ratios), and 80% had both abnormalities. 2 This demonstrates that dehydration during fever directly contributes to mortality.
Fever increases oxygen consumption and metabolic demands, making adequate hydration critical for maintaining cardiac output and tissue perfusion. 4
Why Other Options Are Inappropriate
Option A (Provide Dry Clothing)
While keeping the patient comfortable is reasonable, providing dry clothing does not address the underlying physiologic derangements causing the vital sign abnormalities. The tachycardia and tachypnea are compensatory responses to fever and potential dehydration, not primarily due to wet clothing. 1
Option B (Keep Limbs Close to Body)
This intervention would actually be counterproductive. Keeping limbs close to the body reduces heat dissipation and could worsen hyperthermia. There is no evidence supporting this as beneficial in febrile patients.
Option C (Cover Scalp with Cap)
Covering the scalp would impair heat loss through the head and potentially worsen fever. This contradicts basic fever management principles where promoting heat dissipation (not retention) is appropriate when treating hyperthermia.
Clinical Context and Priorities
The triad of fever, tachycardia, and tachypnea represents alarming clinical signs that warrant immediate assessment for serious complications including sepsis, dehydration, and organ dysfunction. 1 In this context:
Tachycardia in febrile patients is most commonly a physiologic response to fever and dehydration rather than a primary arrhythmia. 1 The appropriate nursing intervention addresses the underlying cause (dehydration) rather than treating the tachycardia itself.
Monitoring fluid balance allows early detection of inadequate hydration and guides fluid resuscitation, which is the cornerstone of initial treatment for fever-related hemodynamic stress. 5, 4
Aggressive fluid resuscitation is the initial treatment for patients presenting with fever and hemodynamic changes, making accurate intake/output monitoring essential for guiding therapy. 5
Common Pitfalls to Avoid
Do not assume tachycardia in a febrile patient represents a primary cardiac arrhythmia requiring antiarrhythmic treatment. When heart rate is <150 bpm without ventricular dysfunction, tachycardia is likely secondary to the underlying condition (fever, dehydration). 1
Do not overlook early signs of dehydration. Staff vigilance in detecting impaired oral intake and monitoring urine output is critical, as routine vital signs alone have limited value in detecting early dehydration. 3, 2
Do not delay fluid assessment and resuscitation. Early intervention when impaired intake is first noted can prevent progression to severe dehydration and its associated mortality. 3, 2