Home » Nursing Procedure » Nursing Procedure Taking Temperatures

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What is Body temperature? Body temperature is the difference between heat produced and heat lost. The hypothalamus acts as the body’s thermostat to maintain a constant body temperature. The balance is maintained between the body’s heat producing functions (metabolism, shivering, muscle contraction, exercise, and thyroid activity) and the heat-losing functions (radiation, convection, conduction, and evaporation).  When one temperature becomes greater than the other, temperature changes are seen greater heat-producing functions result in temperature elevations (fever/hyperthermia), and greater heat losing functions result in temperature decreases (hypothermia).

Sites of measurement of Body temperature:


  • Core temperature true body temperature. Rectal, bladder, and tympanic temperatures are in general the most reliable sites for maesuring body temperature.
  • Sublingual convenient site to measuring body temperature. Tachypnea and consumption of hot or cold substances affect result. Best for intermittent measurement.
  • Axillary temperatures average 1.5° to 1.9°C lower than tympanic. The accuracy of axillary temperatures is affected by inability to maintain probe position.
  • Tympanic measured with specifically designed thermometer. In theory, correlates well with core temperature. In practice, correlates poorly because of difficulty performing the technique and technical malfunctions, with a high degree of user dissatisfaction.
  • Skin poor correlation with core temperature.

ROUTE

ADVANTAGES

DISADVANTAGES

Oral (Normal: 98.6_F; 37_C)

Rectal (Normal: 99.5_F; 37.5_C)

Tympanic

(Normal: 99.5_F; 37.5_C)

Axillary

(Normal: 97.6_F; 36.5_C)

Forehead

(Normal: 94_F; 34.4_C)

Temporal arterial

(Normal: Close to rectal temperature, 1_F or 0.5_C higher than an oral temperature, and 2_F or 1_C higher than an axillary temperature)

  • Easy, fast, accurate
  • More reflective of core Temperature
  • Fast
  • More reflective of core temperature
  • Safe, good for children
  • Safe, good for children and newborns
  • Safe and easy
  • Cannot be used for clients who are unconscious, confused, prone to seizures, recovering from oral surgery, or under age 6.
  • Need to wait 15–20 minutes after eating.
  • Cannot be used for clients who have rectal bleeding, hemorrhoids, or diarrhea or who are recovering from rectal surgery.
  • Contraindicated for cardiac clients because it may stimulate the vagus nerve and decrease heart rate.
  • Not recommended for newborns because of risk of perforating anus.
  • Reports of accuracy are conflicting.
  • Measures skin surface, which can be variable.
  • Measures skin surface temperature.
  • Least accurate method.

Equipment Needed:

  1. Thermometer:  Glass, oral, or rectal, at client’s bedside. Or Electronic thermometer with disposable protective
  2. Sheath Tympanic membrane thermometer with probe
  3. Cover Disposable, single-use chemical strip thermometer
  4. Lubricant for rectal and glass thermometer
  5. Two pairs of nonsterile gloves
  6. Tissues

Purpose of Nursing Procedure Taking Temperatures: The thermometer measures body temperature. Measurements may be oral, rectal, temporal artery, tympanic, axillary, or skin. A rectal measurement is most reflective of core temperature, whereas skin or surface measurements are the least reflective. Thermometers measure temperature in either degrees Fahrenheit (F) or centigrade/Celsius (C).

Types of thermometers include:

  • Glass mercury thermometer: Used for oral, rectal, or axillary temperature measurements.
  • Electronic digital thermometer: Used for oral, rectal, or axillary temperature measurements.
  • Tympanic thermometer: Uses infrared sensors to sense temperature measurements of the tympanic membrane.
  • Temporal artery thermometer: Measures arterial temperature through infrared scanning of the temporal artery.
  • Disposable paper strips with temperature sensitive dots: Used for oral or skin/surface temperature measurements.

Client education needed when measuring Body temperature:

  • Explain to client why an accurate body temperature is needed.
  • Describe the equipment to the client and explain what to expect during the procedure.
  • Answer any questions regarding the procedure and fears the client may have.

General Guidelines for Nursing Procedure Taking Temperatures:

  1. Review medical record for baseline data and factors that influence vital signs.
  2. Explain to the client that vital signs will be assessed.
  3. Encourage client to remain still and refrain from drinking, eating, and smoking.
  4. Assess client’s toileting needs and proceed as appropriate.
  5. Gather equipment.
  6. Provide for privacy.
  7. Wash hands and apply gloves.
  8. Adjust Position the client in a sitting or lying position with the head of the bed elevated 45° to 60° for measurement of all vital signs except those designated otherwise.
  9. Remove gloves and wash hands.

Oral Temperature: Glass Thermometer

  1. Select correct color tip of thermometer from client’s bedside container
  2. Remove thermometer from storage container and cleanse under cool water.
  3. Use a tissue to dry thermometer from bulb’s end toward fingertips.
  4. Read thermometer by locating mercury level. It should read 35.5°C (96°F).
  5. If thermometer is not below normal body temperature reading, grasp thermometer with thumb and forefinger and shake vigorously by snapping the wrist in a downward motion to move mercury to a level below normal.
  6. Place thermometer in client’s mouth under the tongue and along the gum line to the posterior sublingual pocket. Instruct client to hold lips closed.
  7. Leave in place as specified by agency policy, usually 3–5 minutes.
  8. Remove thermometer and wipe with a tissue away from fingers toward the bulb’s end.
  9. Read at eye level and rotate slowly until mercury level is visualized.
  10. Shake thermometer down, and cleanse glass thermometer with soapy water, rinse under cold water, and return to storage container.
  11. Remove and dispose of gloves in receptacle.
  12. Wash hands.
  13. Record reading and indicate site as “OT.”
  14. Wash hands.

Oral Temperature Electronic Thermometer

  1. Repeat Procedure 1–8 of General Guidelines
  2. Place disposable protective sheath over probe
  3. Grasp top of the probe’s stem. Avoid placing pressure on the ejection button.
  4. Place tip of thermometer under the client’s tongue and along the gumline to the posterior sublingual pocket lateral to center of lower jaw.
  5. Instruct client to keep mouth closed around thermometer.
  6. Thermometer will signal (beep) when a constant temperature registers.
  7. Read measurement on digital display of electronic thermometer. Push ejection button to discard disposable sheath into receptacle and return probe to storage well.
  8. Inform client of temperature reading.
  9. Remove gloves and wash hands.
  10. Record reading and indicate site “OT.”
  11. Return electronic thermometer unit to charging base.
  12. Wash hands.

Rectal Temperature

  1. Repeat Procedure 1–8 of General Guidelines.
  2. Place client in the Sims’ position with upper knee flexed. Adjust sheet to expose only anal area.
  3. Place tissues in easy reach. Apply gloves.
  4. Prepare the thermometer.
  5. Lubricate tip of rectal thermometer or probe (usually a rectal thermometer has a red cap).
  6. With dominant hand, grasp thermometer. With other hand, separate buttocks to expose anus.
  7. After Instruct client to take a deep breath. Insert thermometer or probe gently into anus: infant, 1.2 cm (0.5 inches); adult, 3.5 cm (1.5 inches). If resistance is felt, do not force insertion.
  8. Hold thermometer in place for about 2 minutes.
  9. Wipe secretions off glass thermometer with a tissue. Dispose of tissue in a receptacle.
  10. Read measurement and inform client of temperature reading.
  11. While holding glass thermometer in one hand, use other hand to wipe anal area with tissue to remove lubricant or feces. Dispose of soiled tissue. Cover client.
  12. Cleanse thermometer.
  13. Remove and dispose of gloves in receptacle. Wash hands.
  14. Record reading and indicate site Rectal Temperature RT

Axillary Temperature

  1. Repeat Procedure 1–8 of General Guidelines.
  2. Remove client’s arm and shoulder from one sleeve of gown. Avoid exposing chest.
  3. Make sure axillaries skin is dry; if necessary, pat dry.
  4. Prepare thermometer.
  5. Place thermometer or probe into center of axilla. Fold client’s upper arm straight down and place arm across client’s chest.
  6. Leave glass thermometer in place as specified by agency policy (usually 6–8 minutes). Leave an electronic thermometer in place until signal is heard.
  7. Remove and read thermometer.
  8. Inform client of temperature reading.
  9. Cleanse glass thermometer. Shake thermometer down, and cleanse glass thermometer with soapy water, rinse under cold water, and return to storage container.
  10. Assist client with replacing gown.
  11. Record reading and indicate site Axillary Temperature
  12. Wash hands.

Disposable (Chemical Strip) Thermometer

  1. Repeat Procedure 1–8 of General Guidelines.
  2. Apply tape to appropriate skin area, usually forehead.
  3. Observe tape for color changes.
  4. Record reading and indicate method.
  5. Wash hands.

Tympanic Temperature: Infrared Thermometer

  1. Repeat Procedure 1–8 of General Guidelines.
  2. Position client in Sims’ position.
  3. Remove probe from container and attach probe cover to tympanic thermometer unit.
  4. Turn client’s head to one side. For an adult, pull pinna upward and back; for a child, pull down and back. Gently insert probe with firm pressure into ear canal.
  5. Remove probe after the reading is displayed on digital unit (usually 2 seconds).
  6. Remove probe cover and replace in storage container.
  7. Return tympanic thermometer to storage unit.
  8. Record reading and indicate site
  9. Wash hands.

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