Download Assessing Temperature - Trinity Valley Community College

TRINITY VALLEY COMMUNITY COLLEGE
ASSOCIATE DEGREE NURSING
RNSG 1216
PROCEDURE GUIDE AND CHECK OFF SHEET
ASSESSING TEMPERATURE
A change in body temperature can be a sign that there is an infection or an inflammatory process occurring in the
body. There are some medications and conditions that affect body temperature. The nurse must be aware of the
patient’s status in order to take the appropriate interventions. Note: This can be an independent or dependent
action.
Delegation: This procedure can be delegated to unlicensed assistive personnel with proper training. The nurse
retains the responsibility for knowing the patient’s temperature and taking the appropriate nursing interventions
based on that knowledge.
Procedure
The following equipment is needed for this
skill:
a. thermometer (oral, rectal, tympanic)
b. water soluble lubricating jelly if rectal
c. thermometer probe
covers
d. unsterile gloves.
1. Select the route of temperature to be
taken.
Oral Temperatures
Normal
Scientific Rationale
b. Lubrication prevents rectal trauma.
c. Prevents transmission of
microorganisms between patients.
There are 4 methods of taking a temperature. The route chosen
should be the safest and most convenient for the patient.
Newborn
N/A
Infant up to 1 y
99.4
Toddler 1-3
99.0-99.7
3-12 y
98.6
12-18 years
97.8-98.6
Adult
98.6 +/- 1
Older Adult
97.6 +/- 1
Glass Thermometers
2.
3.
Prepare the glass thermometer:
a) Inspect the thermometer for defects
and wipe the thermometer with
alcohol swab or place disposable
probe cover.
b) Shake the thermometer with a
flicking wrist motion until <96.0
degrees.
a. Place the thermometer under the
patient’s tongue for 2-4 minutes.
a. Glass thermometers must be clean and free of defects, the
thermometer must be wiped with an alcohol swab before
use or used with a probe cover. Each glass thermometer will be
used for only one patient.
b. Glass thermometers have mercury in them. If broken the
mercury requires special clean-up/removal procedures. The
thermometer must be held so that the numbers can be read from
left to right. The thermometer is slightly rotated in the hand until
the column of mercury can be read.
a. The thermometer is placed in the sublingual pocket because of
the rich supply of blood vessels found there. Leaving the
thermometer in place for 2 minutes ensures more reliable results.
Note: Glass thermometers are a safety risk in more than one
way. Never use a glass thermometer with a very young patient or
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Procedure
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one that is combative and could bite the thermometer.
b. Wait 20 to 30 minutes before
measuring an oral temperature if patient
has smoked or ingested hot or cold liquids
or food.
4. Remove the thermometer from the
patient’s mouth; remove probe cover so
that the contaminated area is covered
and discard.
5. Read the thermometer from left to right.
6. Wash hands.
7. Report any abnormal data to the
appropriate personnel.
8. Document the temperature in the
patient’s record.
Electronic Thermometer
9. Prepare the thermometer: Turn on the
machine by removing the probe.
10. Place the disposable probe cover on the
instrument.
11. Place the thermometer under the
patient’s
tongue.
12. Observe for the thermometer to signal
that the temperature has been taken.
13. Complete steps 7-9 above.
Tympanic Temperatures
Normal14. Complete steps 10-11.
Pull the auricle back, gently. Pull the
auricle down and back for a child. Pull the
auricle up and back for an adult.
15. Place the probe in the ear with the tip of
the probe aimed at the patient’s nose.
16. Listen for the auditory signal that the
reading is complete.
17. Complete steps 7-9 above.
Axillary Temperatures
Normal-
18. Prepare the thermometer.
19. Remove the probe and place probe cover.
20. Place the thermometer in the center of
the patient’s axilla.
21. Have the patient cross his/her arm across
the chest.
b. Smoking or oral intake of food or fluids can cause false oral
temperature readings.
The probe cover should peel back on itself and cover the area that
came into contact with body secretions.
Thermometers are made to read from left to right.
Prevents spread of microorganisms.
Any abnormal finding must have a corresponding nursing action.
All data must be documented in patient’s record.
Normal data remains the same as for oral route.
Check the electronic thermometer and make sure that it is set for
the oral, rectal or tympanic route. These thermometers can be
programmed to take temperatures using any of the routes.
Electronic thermometers are multi-patient use equipment. Probe
covers must be used to prevent cross contamination.
The sublingual pocket has a rich blood supply which is close to the
surface.
Some electronic thermometers give an auditory signal when
completed; some have a visual signal or both.
Same as for the oral route.
These maneuvers straighten the ear canal and allow the
instrument probe to be directed toward the tympanic membrane.
The probe must be directed toward the tympanic membrane. An
error in directions will result in incorrect readings.
The machine will sound when the temperature reading is
complete. Usually 2-3 seconds.
Axillary temperatures are generally 1 degree below oral readings.
Always document the actual temperature reading obtained and
the route used.
Make sure if using an electronic thermometer that it is set for
axillary temperatures.
Removing the probe turns on the electronic machines and the
probe cover acts as a barrier between patients.
For accurate readings the thermometer must be placed in an area
with the most surface contact.
The thermometer must remain in place for 8-10 minutes and
must remain in contact with the surface area (if electronic, it must
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Procedure
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remain until the buzz indicates completion).
22. Complete steps 7-9 above.
Rectal Temperatures
Normal-
23. Position the patient in the left Sims (sidelying) position and drape for privacy.
24. Don unsterile gloves.
25. Remove the probe and place probe cover
or place thermometer cover on glass
thermometer.
26. Lubricate the tip of the probe with water
soluble jelly.
27. Gently insert the thermometer probe
about 1.5 inches (3-3.5 cm) into the
rectum.
28. Hold the thermometer in place for 2-4
minutes if using a glass thermometer or
hold the probe in place until the signal.
29. Complete steps 7-9.
Rectal temperatures are generally 1 degree higher than oral.
Always document the actual temperature reading obtained and
the route used.
Note: There are some conditions in which a rectal temperature is
contraindicated, such as rectal or perineal surgery or injury, due to
the possibility of rectal trauma.
The left Sims position provides for easy access to the patient’s
anus. Draping the patient is a matter of respect for the dignity of
the patient and minimizes the patient’s discomfort during the
procedure.
Taking a rectal temperature has a greater risk of exposure to body
secretions.
Removing the probe turns on the electronic machines and the
probe cover acts as a barrier between patients.
Water soluble lubricating jelly assists with the insertion of the
probe and minimizes trauma to the rectum.
Allows the probe to come into contact with the rectal mucosa.
The probe should be angled toward the patient’s umbilicus.
2-4 minutes are required for an accurate reading with a glass
thermometer. The signal from an electronic thermometer is to
notify the operator that the reading has been taken.
N:ADN/ADN Syllabus/CBC Curriculum/Level I/1216/Performance Checklist for Basic Skills - Assessing Temperature
Reviewed 04/16
160B