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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 160 Procedure Scientific Rationale 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 160A Procedure Scientific Rationale 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