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 / Scientific Rationale /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. / b. Lubrication prevents rectal trauma.
c. Prevents transmission of
microorganisms between patients.
1. Select the route of temperature to be taken. / There are 4 methods of taking a temperature. The route chosen should be the safest and most convenient for the patient.
Oral Temperatures
Normal
/Newborn N/A
Infant up to 1 y 99.4Toddler 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. 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. 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.
3. a. Place the thermometer under the patient’s tongue for 2-4 minutes.
b. Wait 20 to 30 minutes before measuring an oral temperature if patient has smoked or ingested hot or cold liquids or food. / 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 one that is combative and could bite the thermometer.
b. Smoking or oral intake of food or fluids can cause false oral temperature readings.
4. Remove the thermometer from the patient’s mouth; remove probe cover so that the contaminated area is covered and discard. / The probe cover should peel back on itself and cover the area that came into contact with body secretions.
5. Read the thermometer from left to right. / Thermometers are made to read from left to right.
6. Wash hands. / Prevents spread of microorganisms.
7. Report any abnormal data to the appropriate personnel. / Any abnormal finding must have a corresponding nursing action.
8. Document the temperature in the
patient’s record. / All data must be documented in patient’s record.
Electronic Thermometer
/ Normal data remains the same as for oral route.9. Prepare the thermometer: Turn on the machine by removing the probe. / 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.
10. Place the disposable probe cover on the
instrument. / Electronic thermometers are multi-patient use equipment. Probe covers must be used to prevent cross contamination.
11. Place the thermometer under the patient’s
tongue. / The sublingual pocket has a rich blood supply which is close to the surface.
12. Observe for the thermometer to signal
that the temperature has been taken. / Some electronic thermometers give an auditory signal when completed; some have a visual signal or both.
13. Complete steps 7-9 above.
Tympanic Temperatures
Normal- /Same as for the oral route.
14. 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. / These maneuvers straighten the ear canal and allow the instrument probe to be directed toward the tympanic membrane.
15. Place the probe in the ear with the tip of the probe aimed at the patient’s nose. / The probe must be directed toward the tympanic membrane. An error in directions will result in incorrect readings.
16. Listen for the auditory signal that the reading is complete. / The machine will sound when the temperature reading is complete. Usually 2-3 seconds.
17. Complete steps 7-9 above.
Axillary Temperatures
Normal-
/Axillary temperatures are generally 1 degree below oral readings. Always document the actual temperature reading obtained and the route used.
18. Prepare the thermometer. / Make sure if using an electronic thermometer that it is set for axillary temperatures.19. Remove the probe and place probe cover. / Removing the probe turns on the electronic machines and the probe cover acts as a barrier between patients.
20. Place the thermometer in the center of the patient’s axilla. / For accurate readings the thermometer must be placed in an area with the most surface contact.
21. Have the patient cross his/her arm across the chest. / The thermometer must remain in place for 8-10 minutes and must remain in contact with the surface area (if electronic, it must remain until the buzz indicates completion).
22. Complete steps 7-9 above.
Rectal Temperatures
Normal- / 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.
23. Position the patient in the left Sims (side-lying) position and drape for privacy. / 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.
24. Don unsterile gloves. / Taking a rectal temperature has a greater risk of exposure to body secretions.
25. Remove the probe and place probe cover or place thermometer cover on glass thermometer. / Removing the probe turns on the electronic machines and the probe cover acts as a barrier between patients.
26. Lubricate the tip of the probe with water soluble jelly. / Water soluble lubricating jelly assists with the insertion of the probe and minimizes trauma to the rectum.
27. Gently insert the thermometer probe
about 1.5 inches (3-3.5 cm) into the rectum. / Allows the probe to come into contact with the rectal mucosa. The probe should be angled toward the patient’s umbilicus.
28. Hold the thermometer in place for 2-4 minutes if using a glass thermometer or hold the probe in place until the signal. / 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.
29. Complete steps 7-9.
N:ADN/ADN Syllabus/CBC Curriculum/Level I/1216/Performance Checklist for Basic Skills - Assessing Temperature Reviewed 04/16