Procedures of Assessing Body Temperature ~ Nursing

Procedures of Assessing Body Temperature

Equipment:
■ Thermometer (generally, blue tip indicates oral and red tip indicates rectal) and cover.
■ Tissues.
■ Add as needed:
1 Rectal: Procedure gloves and water-soluble lubricant.
2 Axillary:Towel.
3 Be Safe! Do not use a glass-and-mercury thermometer.

Assessment:
■ Assess for signs and symptoms of temperature alterations (e.g., diaphoresis).
■ Assess for contraindications to the chosen site:
1 Oral: Do not use oral route for patients who cannot hold the thermometer properly, children, or those who use mouth breathing. If the patient has smoked, eaten, had a drink, or chewed gum, wait 20 to 30 minutes before taking oral temperature.
2 Tympanic: Assess for impacted earwax or hearing aid.
3 Rectal: Check the patient record for diarrhea or impacted stool.
4 Axillary: Check the record for presence of fever or hypothermia.
5 Skin: Assess for conditions that require an accurate, reliable reading (e.g., fever, hypothermia).

Key Points:
■ If the thermometer is not disposable, clean it before and after using.
■ Select the appropriate site and thermometer, considering comfort, safety, and accuracy.
■ Turn on, or otherwise ready the thermometer.
■ Insert the thermometer in its sheath, or use a thermometer designated only for the patient.

■ Insert. Leave an electronic thermometer in place until it beeps; for other thermometers use the recommended times.
1 Glass thermometer: Read at eye level after 5 to 8 minutes.
2 Rectal site: Read at eye level after 3 to 5 minutes.

■ Be Safe! Do not use an oral thermometer to take a rectal temperature. Hold a rectal thermometer securely in place, and never leave it unattended.
1 Axillary site: Dry the axilla before inserting the thermometer.
2 Tympanic site: Refer to figures below for placement.

■ Cleanse and store in recharging base (store glass thermometers safely to prevent breakage).

Documentation:
■ You will usually record temperature on a graphic or flowsheet.
■ If you need to write a nursing note (e.g., because of a fever), notify the primary provider of the abnormal findings, and document according to agency policy:
1 Temperature, indicating the route of measurement.
2 Supporting findings, such as “Skin is hot and dry,” and whether the temperature reading is consistent with the patient’s condition.
3 Note previous recordings, if any.

■ When evaluating, compare to normal range for developmental stage, site used, and patient’s baseline data. Look for trends to identify potential concerns.