MEASURING BODY TEMPERATURE EQUIPMENTEQUIPMENTS:Thermometer

Glass or electronic and disposable protective sheath; Disposable (chemical) Tympanic

Tissues Two pairs of non-sterile gloves Lubricant (rectal, glass thermometer)

ACTION RATIONALE 1. Review medical record for baseline data and factors that influence vital signs.

1. Establishes parameters for client’s normal measurements, provides direction in device selection, and determines site to use for measurement.

2. Explain to the client that vital signs will be assessed. Encourage client to remain still and refrain from drinking, eating, or smoking.

2. Encourages participation, allays anxiety, and ensures accurate measurements. Cold or hot liquids and smoking alter circulation and body temperature.

3. Assess client’s toileting needs and proceed as appropriate.

3. Prevents interruptions during measurements, communicates caring, and promotes client comfort.

4. Gather equipment as indicated above. 4. Facilitates organized assessment and measurement.

5. Provide for privacy. 5. Decreases embarrassment.6. Wash hands and don gloves. 6. Hands are washed before and after every

contact with a client. Gloves are worn to avoid contact with all bodily secretions and to reduce transmission of microorganisms.

7. 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.

7. Promotes comfort and site access for all measurements.Activity and movement can elevate heart and respiratory rates.

8. Oral Temperature: Glass Thermometera. Select correct color tip of thermometer from client’s bedside container.

b. Remove thermometer from storage container and cleanse under cool water.

c. Wipe thermometer dry with a tissue from bulb’s end toward fingertips.

d. Read thermometer by locating mercury level.It should read 35.5°C (96°F).

e. If thermometer is not below a 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.

f. Place thermometer in mouth under the tongue and along the gum line to the posterior sublingual pocket. Instruct client to hold lips closed.

a. Identifies correct device; a blue color tip usually denotes an oral thermometer.

b. Cleansing removes disinfectant that can cause irritation to oral mucosa. Cool water prevents expansion of the mercury.

c. Wipe from area of least contamination to most contaminated area.

d. Thermometer must be below normal body temperature to ensure an accurate reading.

e. Shaking briskly lowers level of mercury in the column. Because glass thermometers break easily, make sure that nothing in the environment comes in contact with the thermometer when shaking it.

f. Ensures contact with large blood vessels under the tongue. Prevents environmental air from coming in contact with the bulb.

g. Leave in place as specified by agency policy, usually 3–5 minutes.

h. Remove thermometer and wipe with a tissue away from fingers toward the bulb’s end.

i. Read at eye level and rotate slowly until mercury level is visualized.

j. Shake thermometer down, and cleanse glass thermometer with soapy water, rinse under cold water, and return to storage container.

k. Remove and dispose of gloves in receptacle.Wash hands.

l. Record reading and indicate site as “OT.”

g. Thermometer must stay in place long enough to ensure an accurate reading.

h. Mucus on thermometer may interfere with disinfectant solution’s effectiveness. Wipe from area of least contamination to most contaminated area.

i. Ensure an accurate reading.

j. Mechanical cleansing removes secretions that promote growth of microorganisms. Hot water may cause coagulation of secretions and cause expansion of mercury in thermometer.

k. Reduces transmission of microorganisms.

l. Accurate documentation by site allows for comparison of data.

9. Oral Temperature: Electronic Thermometera. Place disposable protective sheath over probe.

b. Grasp top of the probe’s stem. Avoid placing pressure on the ejection button.

c. Place tip of thermometer under the client’s tongue and along the gum line to the posterior sublingual pocket lateral to center of lower jaw.

d. Instruct client to keep the mouth closed around thermometer.

e. Thermometer will signal (beep) when a constant temperature registers.

f. Read measurement on digital display of electronic thermometer. Push ejection button to discard disposable sheath into receptacle and return probe to storage well.

g. Inform client of temperature reading.

h. Remove gloves and wash hands.

i. Record reading and indicate site “OT.”

j. Return electronic thermometer unit to charging base.

a. Prevents transmission of microorganisms.

b. Pressure on the ejection button releases the sheath from the probe.

c. Sublingual pocket contains superficial blood vessels.

d. Maintains thermometer in proper place and decreases amount of time for an accurate reading.

e. Signal indicates temperature reading.

f. Reduces transmission of microorganisms.Ensures that the electronic system is ready for next use.

g. Promotes client’s participation in care.

h. Reduces transmission of microorganisms.

i. Accurate documentation by site allows for comparison of data.

j. Ensures charging base is plugged into electrical outlet and ready for next use.

10. Rectal Temperaturea. Place client in the Sims’ position with upper knee flexed. Adjust sheet to expose only anal area.

b. Place tissues in easy reach. Don gloves.

a. Proper positioning ensures visualization of anus. Flexing knee relaxes muscles for ease of insertion.

b. Tissue is needed to wipe anus after device is removed.

c. Prepare the thermometer (refer to steps 8b and 8c).

d. Lubricate tip of rectal thermometer or probe(a rectal thermometer usually has a red cap).

e. With dominant hand, grasp thermometer.With non-dominant hand, separate buttocks to expose anus.

f. Instruct client to take a deep breath. Insert thermometer or probe gently into anus: infant, 1.2 cm (0.5 in.); adult, 3.5 cm (1.5 in.). If resistance is felt, do not force insertion.

g. Length of time (refer to step 8g).

h. Wipe secretions off glass thermometer with a tissue. Dispose of tissue in a receptacle.

i. Read measurement and inform client of temperature reading.

j. While holding glass thermometer in one hand, wipe anal area with tissue to remove lubricant or feces with other hand and dispose of soiled tissue. Cover client.

k. Cleanse thermometer (refer to step 8j).

l. Remove and dispose of gloves in receptacle.Wash hands.

m. Record reading and indicate site as “RT.”

d. Promotes ease of insertion of thermometer or probe.

e. Aids in visualization of anus.

f. Relaxes anal sphincter. Gentle insertion decreases discomfort to client and prevents trauma to mucous membranes.

h. Removes secretions and fecal material for visualization of mercury level. Prevents transmission of microorganisms.

i. Encourages client participation.

j. Prevents contamination of clean objects with soiled thermometer, decreases skin irritation, and promotes client comfort. Prevents embarrassment.

l. Decreases transmission of microorganisms.

m. Accurate documentation by site allows for comparison of data.

11. Axillary Temperaturea. Remove client’s arm and shoulder from one sleeve of gown. Avoid exposing chest.

b. Make sure axillary skin is dry; if necessary, pat dry.

c. Prepare thermometer (refer to steps 8b and 8c).

d. Place thermometer or probe into center ofaxilla. Fold client’s upper arm straight down and place arm across client’s chest.

e. Leave glass thermometer in place as specified by agency policy (usually 6–8 minutes). Leave an electronic thermometer in place until signal is heard.

f. Remove and read thermometer.

g. Inform client of temperature reading.

a. Exposes axillary area.

b. Removes moisture and prevents a false low reading.

d. Puts device in contact with axillary blood supply.Maintains the device in proper position.

e. Device must stay in place long enough to ensure an accurate reading. Signal indicates temperature reading.

g. Encourages client participation.

h. Cleanse glass thermometer (refer to steps 8h and 8j) and return to storage container.

i. Assist client with replacing gown.

j. Record reading and indicate site as “AT.”

h. Prevents transmission of microorganisms and breakage of glass thermometer.

i. Promotes comfort.

j. Promotes accurate documentation for data comparison.

12. Disposable (Chemical Strip) Thermometera. Apply tape to appropriate skin area, usually forehead.

b. Observe tape for color changes.

c. Record reading and indicate method.

a. Tape must be in direct contact with the client’s skin.

b. Color reflects temperature reading (refer to the manufacturer’s instructions).

c. Promotes accurate documentation for data comparison.

13.Tympanic Temperature: Infrared Thermometera. Position client in Sims’ position.

b. Remove probe from container and attach probe cover to tympanic thermometer unit.

c. 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.

d. Remove probe after the reading is displayed on digital unit (usually 2 seconds).

e. Remove probe cover and replace in storage container.

f. Return tympanic thermometer to storage unit.

g. Record reading and indicate site as “ET.”

a. Promotes access to ear.

b. Prevents contamination.

c. Provides access to ear canal. Gentle insertion prevents trauma to external canal. Firm pressure is needed to ensure probe contact against tympanic membrane.

d. Reading is displayed within seconds.

e. Protects damage to the reusable probe.

f. Recharges batteries of unit.

g. Promotes accurate documentation for data comparison.