TEMPERATURE

MEASURING
Temperature, pulse, blood pressure (BP), and respiration are the most

frequent data obtained by health care practitioners.

When to measure the temperature

 On a client's admission to a health care facility
 In a hospital or care facility on a routine schedule ace
physician's order or institution's standards of practice
 When assessing the client during home health visits
 Before and after a surgical or invasive diagnostic
procedure
 Before and after the administration of medications or
therapies that affect cardiovascular, respiratory
functions
 When the client's general physical condition changes
(econsciousness, increased severity of pain)
 When the client reports specific symptoms of physic
(e.g., feeling "funny" or "different")
 Body temperature is depended to the external
environment. The core temperature, or temperature of
the deep body tissues, is under control of the
hypothalamus and is maintained within a narrow range.
Skin or body surface temperature rises and falls as the
tempera­ture of the surrounding environment changes
and can fluctu­ate dramatically.
The body tissues and cells function best within a rela­
tively narrow temperature range, from 36° C to 38° C
(96.8° F to 100.4° F), but no single temperature is
normal for all peo­ple. An acceptable temperature range
for adults depends on age, gender, range of physical
activity, and state of health.
 Many factors affect body temperature. Physiological and
behavioral control mechanisms act to maintain a constant
core temperature. For example, the mechanism of peripheral
vasodilation increases blood flow to the skin, which in­creases
the amount of heat radiated to the environment. Clients who
lack sweat gland function are unable to tol­erate warm
temperatures because they cannot cool them­selves
adequately. Fever occurs when heat loss mechanisms are
unable to keep pace with excess heat production, result­ing in
an abnormal rise in body temperature. When an indi­vidual has
a febrile condition, pyrexia, the nurse initiates temperature-
control measures such as controlling environ­mental
temperatures, removing external coverings, and ad­ministering
ordered antipyretics to achieve better tempera­ture control.
 Average usual temperature varies depending
on the measurement site used. Research
findings from numerous studies are
contradictory; however, it is generally
accepted that rectal temperatures are
usually 0.5° C (0.9° F) higher than oral
temperatures, and axillary and tympanic
tempera­tures are usually 0.5° C (0.9° F)
lower than oral tempera­tures.
Each site has advantages and disadvantages.
The nurse determines the safest and most
accurate site for the client.
 Core and Surface Temperature
Measurement Sites
CORE SITE SURFACE SITE

Rectum Scin
Tympanic Oral
Esophagus Axilla
Pulmonary

Urinary bladder
 Two types of thermometers are commonly available to
measure body temperature: electronic and chemical dot
sin­gle use or reusable. Each type has advantages and
limita­tions. The mercury-in-glass thermometer, a
standard device for temperature measurement for nearly
years, has been eliminated from most hospitals because
of the environmental hazards of mercury-contains.
However, mercury-in-glass thermometer may be found
in client's homes. The electronic thermometer consists of
a battery-powered display unit, a thin wire cord, and
temperature-processing probe covered by a disposable
sheath. Separate probes are available for oral and rectal
temperature measuring. The oral probe has a blue tip,
and the rectal a red tip.
Advantages and Limitations of Select
Temperature Measurement
Sites
Oral
Advantages
Easily accessible—requires no position change.
Comfortable for client
Provides accurate surface temperature reading.
Reflects rapid change in core temperature.
Shown to be reliable route to measure temperature in intubated clients.
Limitations
Causes delay in measurement if client recently ingested hot/cold fluids
or foods, smoked, or receive oxygen by mask/cannula.
Should not be used with clients who have had oral surgery, trauma,
history of epilepsy, or shaking chills.
Should not be used with infants, small children, uncon­scious, or
uncooperative clients
 Tympanic Membrane Sensor

Advantages
Easily accessible site.
Can be obtained without disturb­ing of client.
Can be used for clients with tachypnea without affecting breathing.
Provides accurate core reading because eardrum is close to hypothal­amus;
sensitive to core temperature changes
Very rapid measurement (2 to 5 seconds).
Unaffected by oral intake of food or fluids or smoking
Can be used in newborns
Limitations
More variability of measurement than with other core temperature devices
Requires disposable sensor cover with only one size available
Otitis media and cerumen impaction can distort readings
Should not be used with clients who have had surgery of the ear or tympanic
membrane
Does not accurately measure core temperature changes during and af­ter
exercise
Cannot obtain continuous measurement
Affected by ambient temperature devices such as incubators, radiant warmers,
and facial fans
 Rectal
Advantages
Argued to be more reliable when oral temperature
cannot be obtained
Limitations
May lag behind core temperature during rapid
temperature changes
Should not be used for clients with diarrhea, clients who
have had rec­tal surgery, rectal disorders, bleeding
tendencies
Requires positioning and may be source of client
embarrassment and anxiety
Requires lubrication
Should not be used for routine vital signs in newborns
 Axilla
Advantages
Safe and inexpensive
Can be used with newborns and unconscious clients
Limitations
Long measurement time
Requires continuous positioning by nurse
Measurement lags behind core temperature during rapid
temperature
changes
Not recommended to detect fever in infants and young children
Requires exposure of thorax, which can result in temperature
loss,
especially in newborns
 Skin
Advantages
Inexpensive
Provides continuous reading
Safe and noninvasive
Can be used for neonates
Limitations
Measurement lags behind other sites during temperature changes,
especially during hyperthermia
Sweat can impair adhesion
Another form of electronic thermometer is used exclu­sively for tympanic
temperature. An otoscope-like specu­lum with an infrared sensor tip
detects heat radiated from the tympanic membrane of the ear. Within 2
to 5 seconds after placement in the auditory canal and depressing the
scan button, a value appears on the display unit. A sound signals when
the peak temperature reading has been measured.
Chemical dot single-use or reusable
thermometers are disposable thin strips of
plastic with a temperature sensor at one end.
The sensor consists of a matrix of chemically im­
pregnated dots that are formulated to change
color at differ­ent temperatures. each
representing temperature increments of 0.1° C
over a range of 35.5° C to 40.4° C. The
Fahrenheit version has 45 dots with increments
of 0.2° F and a range of 96.0° F to 104.8° F.
Chemical dots on the thermometer change color
to reflect temperature reading, usually within 60
seconds. Most are designed for single use.
 Electronic thermometer
Advantages
Disposable, easy to store
Used for clients in isolation
Useful for screening tempera­tures, especially for infants and during invasive
procedures ( during surgery)
Limitations
Can be difficult to read
Has been shown to underesti­mate and overestimate temper­ature can be reused
for a single client the chemical dots return to the original color within a few
seconds. The chemical thermometers are most commonly used for oral tempera­
tures. They can also be used at axillary or rectal sites, cov­ered by a plastic
sheath at the latter, with a placement time of 3 minutes.
Not appropriate for monitoring temperature therapies
Plastic sheath unbreakable;
Ideal for children
Very rapid measurement
Limitations
Probe or sensor covers are expensive
 The skill of temperature measurement can be delegated
to as­sistive personnel. Before delegating this skill the
nurse may:
 Inform assistive personnel if any precautions are needed
in positioning the client during measurement
 Instruct assistive personnel of appropriate route and de­
vice to measure temperature
 Provide assistive personnel the frequency of temperature
measurement for select client
 Determine that assistive personnel are aware of the
client's previous temperature measures
 Instruct assistive personnel in the need to report abnor­
malities that should be reconfirmed by the nurse
1. Determine need to measure client's body
temperature:
a. Note client's risks for temperature alterations:
expected or diagnosed infection, open wounds or burns,
white blood cell count below 5000 or above 12,000,
immunosuppressive drug therapy, injury to
hypothalamus, exposure to temperature extremes, blood
product infusion, hypothermia or hyperthermia therapy,
or postoperative status.
b. Assess for signs and symptoms that may accomany
temperature alteration:
Fever: (depending on stage) pale or flushed skin; skin
warm or hot to touch; skin dry or di­aphoretic; dry
mucous membranes; tachycardia; muscle or joint pain;
nausea, vomiting, or diarrhea; feeling hot or cold;
restlessness.
2. Assess for factors that normally influence
temperature:

a. Age
No single temperature is normal for all people. A
temperature within an acceptable range in an adult may
reflect a fever in an older adult. Undeveloped
temperature control mechanisms in in­fants and children
can cause temperature to rise and fall rapidly
b. Exercise
c. Hormones
d. Stress
e. Environmental temperature
f. Medications
g. Daily fluctuations
Physical signs and symptoms may alert nurse to alteration in body
temperature.

Hyperthermia: Decreased skin turgor, tachycardia; hypoten­sion;

decreased venous filling; concentrated urine.
Heatstroke: Hot, dry skin; tachycardia; hypotension; exces­sive thirst;
muscle cramps; visual disturbances; confusion or delirium.
Hypothermia: Pale skin; skin cool or cold to touch; brady­cardia and
dysrhythmias; uncontrollable shivering; re­duced level of
consciousness; shallow respirations.
Older adults have a narrower range of temperature than do
younger adults.
Muscle activity raises heat production.
Women have wider temperature fluctuations than men be­cause of
menstrual cycle hormonal changes; body temperature change can
vary during menopause.
Stress elevates temperature.
Infants and older adults are more sensitive to environmental
temperature changes.
 Drugs may impair or promote sweating, vasoconstriction,
vasodilation change temperature.
Body temperature normally changes 0.5 to 1° C during a
24- hour period. Temperature is lowest during early
morning. Most clients have maximum temperature
elevation around 6 pm; temperature falls gradually
during night.
Determines if client's status contraindicates selection of
a' specific method or site.
 Body temperature is within acceptable range for
client's age-group.
 Body temperature returns to baseline range follow­ing
therapies for abnormal temperature.
 IMPLEMENTATION

1. Perform hand hygiene.

2. Assist client to comfortable position that provides easy
access to temperature measurement site.
3. Obtain temperature reading.
a. Oral temperature measurement with electronic
thermometer
(1) Apply disposable gloves (optional).
2. Remove thermometer pack from charging unit. Attach oral
thermometer probe stem (blue tip) to thermometer unit.
3. Remove thermometer pack from charging unit. Attach rectal
thermometer probe stem
(red tip) to thermometer unit. Grasp top of probe stem, being
careful not to apply pres­
sure on the ejection button.
(3) Slide disposable plastic probe cover over ther­mometer probe
stem until cover locks in place.
(4) Squeeze liberal portion of lubricant on tis­sue. Dip
thermometer's blunt end into lubri­
cant, covering 2.5 to 3.5 cm (1 to 1V2 inches) for adult.
(5) With nondominant hand, separate client's but­tocks to expose
anus. Ask client to breathe
slowly and relax.
(6) Gently insert thermometer into anus in di­rection of umbilicus
3.5 cm (l'/2 inches) for adult. Do not force thermometer.
(7) If resistance is felt during insertion, with draw immediately.
Never force thermometer.
Once positioned, hold thermometer probe in place until audible
signal indicates comple­tion and client's temperature appears
on dig­ital display; remove thermometer probe from anus (see
illustration
Push ejection button on thermometer stem to discard plastic probe
cover into an appropri­ate receptacle.
Return thermometer stem to storage position of recording unit.
Wipe client's anal area with soft tissue to remove lubricant or feces,
and discard tissue. Assist client in assuming a comfortable
position.
Remove and dispose of gloves in appropri­ate receptacle. Perform
hand hygiene.
Return thermometer to charger.
c. Axillary temperature measurement with electronic thermometer
(1) Draw curtain around bed and/or close room door. Assist client to
supine or sitting posi­tion. Move clothing or gown away from
shoulder and arm.
button releases plastic cover from probe stem.
Probe cover prevents transmission of microorganisms b<
tween clients. Lubrication minimizes trauma to rectal
mucosa during ii
sertion. Tissue avoids contamination of remaining
cant in container.
Fully exposes anus for thermometer insertion. Relaxes i
sphincter for easier thermometer insertion.
Ensures adequate exposure against blood vessels in i
wall.
Prevents trauma to mucosa.
Probe must stay in place until signal occurs to ensure
accu­rate reading
STEP 3b(9) Probe removed smoothly from anus.
Reduces transmission of microorganisms.
 Returning thermometer stem automatically
causes digital reading to disappear. Provides for
comfort and hygiene.
 Reduces transmission of microorganisms.
Maintains battery charge of thermometer unit.
 Maintains client's privacy, minimizes
embarrassment, and promotes comfort. Exposes
axilla for correct thermometer probe placement.