S7 · Body temperature too high or too low
Actual ⚠ URGENT Safety and protection
Definition
Body temperature is outside the safe range because of illness, surroundings, or medicine.- Infection
- heat
- cold exposure
- burns
- medicines
- brain injury
- Very high or very low temperature
- shivering or sweating
- hot or cold skin
- confusion
📋 Scenario
A child has a temperature of 40 degrees and is flushed and restless.
Subjective (S): "I feel really hot."
Objective (O): Temperature 40 C; flushed; heart rate 150/min in a child; restless; poor drinking.
Assessment tools for this scenario: CP-SAFE Safety & Falls Score
Validated scales to consider: Morse Fall Scale
**CarePath diagnosis:** Body temperature too high or too low related to suspected infection, as evidenced by a temperature of 40 C, flushed skin, a heart rate of 150/min, and restlessness.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Check temperature. | Regular temperature checks show how high the fever is and whether treatment is working. |
| Add or remove layers. | Removing extra layers helps heat leave the body when temperature is high, while adding layers helps retain heat if it is too low. |
| Give fluids. | Fever and fast breathing increase fluid loss, so fluids prevent dehydration and help the child cool. |
| Give fever medicine as ordered. | Fever medicine acts on the brain's temperature control to lower the temperature and increase comfort. |
| Use cooling measures only as ordered. | Over-cooling can cause shivering, which raises body heat again, so cooling is used only as ordered and alongside fever medicine. |
| Report abnormal results. | A very abnormal result may mean serious illness, so the doctor must hear quickly to find the cause and treat it. |
**Expected outcomes**
- Within 2 hours: temperature below 38 C, child calmer and drinking fluids, no convulsions.
**Linking the data to the diagnosis**
The child says they feel really hot. The nurse found a temperature of 40 C, flushing, a heart rate of 150/ min, restlessness and poor drinking. The temperature is well above the safe range, so the problem has already occurred and this is an actual diagnosis, with infection as the likely cause. The plan aims within 2 hours for a temperature below 38 C, a calmer child who is drinking fluids, and no convulsions. Because a child with this temperature, fast heart rate and poor drinking can become seriously unwell, abnormal results are reported promptly.
CarePath diagnosis
Body temperature too high or too low related to suspected infection, as evidenced by a temperature of 40 C, flushed skin, a heart rate of 150/min, and restlessness.
Interventions and rationale
Listed in priority order — for urgent statements the first action is to get help.
| Intervention | Rationale |
|---|---|
| 1. Check temperature. | Regular temperature checks show how high the fever is and whether treatment is working. |
| 2. Add or remove layers. | Removing extra layers helps heat leave the body when temperature is high, while adding layers helps retain heat if it is too low. |
| 3. Give fluids. | Fever and fast breathing increase fluid loss, so fluids prevent dehydration and help the child cool. |
| 4. Give fever medicine as ordered. | Fever medicine acts on the brain's temperature control to lower the temperature and increase comfort. |
| 5. Use cooling measures only as ordered. | Over-cooling can cause shivering, which raises body heat again, so cooling is used only as ordered and alongside fever medicine. |
| 6. Report abnormal results. | A very abnormal result may mean serious illness, so the doctor must hear quickly to find the cause and treat it. |
Expected outcomes
- Within 2 hours: temperature below 38 C, child calmer and drinking fluids, no convulsions.
Linking the data to the diagnosis
The child says they feel really hot. The nurse found a temperature of 40 C, flushing, a heart rate of 150/ min, restlessness and poor drinking. The temperature is well above the safe range, so the problem has already occurred and this is an actual diagnosis, with infection as the likely cause. The plan aims within 2 hours for a temperature below 38 C, a calmer child who is drinking fluids, and no convulsions. Because a child with this temperature, fast heart rate and poor drinking can become seriously unwell, abnormal results are reported promptly.