Page 941 - Saunders Comprehensive Review For NCLEX-RN

CHAPTER 32

Metabolic and Endocrine Problems

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Priority Concepts
Glucose Regulation; Thermoregulation

I. Fever
A. Description
1. Fever is an abnormal body temperature elevation.
2. A child’s temperature can vary depending on activity,
emotional stress, disease processes, medications, type
of clothing the child is wearing, and temperature of
the environment.
3. A fever in an infant less than 1 month old is
considered an emergency, and the pediatric specialist
should be contacted immediately if this occurs.
4. Assessment findings associated with the fever provide
important indications of the seriousness of the fever.
B. Assessment
1. Temperature elevation: Normal temperature range for
a child is 36.4° C to 37.0° C (97.5° F to 98.6° F); 38.0° C
(100.4° F) is considered to be fever.
2. Flushed skin, warm to touch
3. Diaphoresis
4. Chills
5. Restlessness or lethargy
C. Interventions
1. Monitor vital signs; take the temperature via the
electronic route or per agency procedures.
2. Remove excess clothing and blankets, reduce the room
temperature, and increase the air circulation; use
other cooling measures such as the application of a
cool compress to the forehead if appropriate.
3. Administer a sponge bath with tepid water for 20 to 30
minutes and gently squeeze water from a facecloth
over the back and chest. Recheck the temperature 30
minutes after the bath. Do not use alcohol because it
can cause peripheral vasoconstriction.
4. Administer antipyretics such as ibuprofen as
prescribed.

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