Rectal measurement

Equipment:
Gloves
Disposable bag
Lubricant
Appropriate chart
Appropriate thermometer (that is, low-reading thermometer if client suspected of being hypothermic)
Modesty sheet/towel to protect client’s dignity

Procedure	Rationale
Screen the bed/close door	Promotes comfort and dignity; minimizes embarrassment
Assist client into lateral position with upper leg flexed; keep majority of client covered; expose anal area only	For patient comfort and dignity
Apply lubricant to a tissue and dip end of thermometer into lubricant	Minimizes trauma to rectal mucosa during insertion. Using tissue avoids contamination of tube/container
Ask client to relax and take deep breaths With non-dominant hand separate client’s buttocks to expose anus	Relaxes anal sphincter for ease of insertion
Insert the thermometer no more than 5 cm into the rectum and hold the thermometer in place. Allow the thermometer time to register (minimum two minutes). Note the reading	To prevent trauma To allow adequate time for the thermometer to register
Wipe client’s anal area with a soft tissue; remove gloves and dispose in clinical waste bag	To promote comfort and prevent crossinfection
Assist the client into a comfortable position and record on measurement chart	To promote client comfort and adhere to legislation surrounding record keeping
Report any significant change or abnormality	To ensure prompt attention
Clean thermometer, adhering to local policy	To minimize the risk of cross-infection