Method of Measuring Body Temperature

Subject: Fundamentals of Nursing

Overview

Method of Measuring Body Temperature

S.N. Nursing Action Rationable
1 Identify patient. Ensures that right procedure is performed for right patient.
2 Determine the need to assess the client's temperature. Obtains any specific instruction and information.
3 Assess for factors that may alter temperature. Allows to accurately assessing  for presence and significance of temperature alteration.
4 Ascertain the method of taking temperature. Ensures right sites.
5 Explain the procedure to the patient and instruct him how to co-operate. Obtains patient's cooperation and reduces anxiety.
6 Close room door or draw curtain around bed. Provides privacy
7 Wash and dry hands. Prevents cross infection.
8 Prepare equipment. Arranging articles aids for smooth functioning.
9

Assist patient in assuming comfortable position. For rectal method provide privacy and position the patient in a sim's position. In young children, position laterally with knees flexed prone across lap.  In case of oral method, ensure that the patient had not taken any hot or cold food and fluids orally or smoked within 15-30 minutes prior to procedure. For axillary method, expose axilla and dry with cotton or towel.

Position ensures easy access to temperature measurement site.
10

If using mercury thermometer:

Wipe thermometer dry, using a clean cotton swab using rotary motion from bulb to stem.

Shake down the mercury by holding the thermometer between the thumb and the forefinger at the tip of it stem. Shake till the mercury is below 350C ( 95f).

Wiping from an area of least contamination to an area of greatest contamination prevents sored of organisms.

Reduces chances of error in reading temperature.
11

Take temperature

For Oral Method

Ask the patient to open his/her mouth and place the bulb of thermometer at the base of the tongue on the side of frenulum in the posterior  sublingual pocket. Instruct the patient to close the lips firmly around stem.

Leave the thermometer in the place for 2-3 minutes.

For Rectal Method

Don disposable gloves.

Apply lubricant on the bulb of the thermometer using a cotton ball.

With the non-dominant hand, expose the anus  raising upper buttocks.

Instruct the patient to breathe deeply and insert the  thermometer into the anus.

3.5-4cm in adults

2.5 cm in child

1.5 cm in infant

Do not force insertion.

Hold the thermometer in the place for 1-2 minutes. Wipe patient's anal area with soft tissue to remove lubricant or feces and discard tissue.

For Axillary Method

Place the bulb in the center of axilla.

Place the arm tightly across chest to hold the thermometer in the place.

Hold the thermometer in the place for 3-5 minutes.

Blood supply is more in this area and hence reflects bthe temperature of blood in the large blood vessels.Clenching teeth can cause the thermometer to break and cause injury.

Ensures accurate reading.

Protect from infection.

Lubricant facilitates easy insertion.

Ensures relax the anal spincture.

Ensures accurate reading.

 
12 Remove the thermometer. Wipe using a cotton ball stem to bulb in a rotatory manner if needed. Wiping from an area of least contamination to an area of greatest contamination prevents spread of organisms.
13 Read the temperature holding thermometer at eye level and rotate it till reading is visible and read it accurately. Holding at eye level ensures easy reading.
14 Clean the thermometer. Shake down the mercury level. Dry it and store it in the container.  Makes clean. 
15

15 If using a digital thermometer:

  • Take the thermometer out of its holder.
  • Put the tip into a new throw-away plastic cover. If you do not have a cover, clean the pointed end (probe) with soap and warm water or rubbing alcohol. Rinse it with cool water.
  • Put the end with the covered tip securely in armpit, oral cavity and rectum.
  • Keep the thermometer in place until the digital thermometer beeps.
  • Remove the thermometer when numbers show up in the "window".
  • Read the numbers in the window.
  
16  Help the patient assume a comfortable position. Promotes comfort.
17 Replace articles. Leaves the unit clean and articles ready for further use.
18 Wash hands Reduces chance of contamination.
19 Document temperature Communicates finding among staffs.

 
Things to remember

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