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8 Measuring Body Temperature

Assessment

  • Assessed client for factors that normally influence temperature and temperature reading.
  • Determined site and device for most appropriate temperature measurement.
  • Determined client’s baseline temperature from client’s record.

Nursing diagnosis

  • Identified the purpose and risks associated with measuring body temperature. 

Planning

  • Identified expected outcomes.
  • Explained procedure to client.

Evaluation

  • Established client’s temperature as a baseline if temperature within normal range and no other temperature readings are documented. Compared client’s temperature with client’s baseline and normal temperature range.
  • Took temperature 30 minutes after antipyretics and every four hours for client with fever.
  • Identified expected outcomes.
  • Reported and recorded temperature correctly.

Measuring Body Temperature – Implementation

  1. Performed hand hygiene.
  2. Positioned client comfortably.
  3. Obtained temperature reading.
  4. Oral Temperature Measurement Using Electronic Thermometer:
    1. Applied clean gloves. (optional)
    2. Removed thermometer pack from charging unit.
    3. Grasped top of probe stem and slid disposable plastic probe cover over stem until cover locks in place being careful not to apply pressure on the ejection button.
    4. Placed thermometer probe under tongue in posterior sublingual pocket lateral to center of lower jaw.
    5. Asked client to hold thermometer probe with lips closed.
    6. Left thermometer probe in place until audible signal indicated completion and client’s temperature appeared on digital display; removed thermometer probe from under client’s tongue.
    7. Pushed ejection button on thermometer to discard plastic probe cover.
    8. Removed and discarded gloves, if worn. Performed hand hygiene.
    9. Returned thermometer to charger.
  5. Tympanic Membrane Temperature Measurement Using Electronic Thermometer:
    1. Assisted client in assuming comfortable position with head turned toward side, away from nurse. If client lying on side, used upper ear.
    2. Removed thermometer handheld unit from charging base, being careful not to apply pressure to the ejection button.
    3. Slid disposable speculum cover over tip until locked in place without touching cover.
    4. Held unit in same hand as ear being assessed. Inserted speculum into ear canal – pulling pinna backward, up and out for an adult.
    5. Moved thermometer in a figure-eight pattern and fitted speculum tip snugly in canal and pointed toward nose.
    6. Depressed button on unit. Left thermometer in place until audible signal and client temperature appeared on digital display.
    7. Carefully removed speculum from auditory meatus. Push ejection button to discard cover. (Waited two – three minutes before repeating)
    8. Returned unit to base.
    9. Assisted client in comfort measures.
    10. Performed hand hygiene.
  6. Axillary Temperature Measurement Using Electronic Thermometer:
    1. Provided privacy. Assisted client to supine or sitting position. Moved clothing or gown away from shoulder and arm.
    2. Prepared thermometer as per oral temperature measurement.
    3. Raised client arm away from torso. Inspected for lesions and excessive perspiration; dry axilla if necessary.
    4. Held probe in place until audible signal and client temperature appeared on digital display, removed probe from axilla.
    5. Pushed ejection button to discard probe cover.
    6. Returned unit to base.
    7. Assisted client with comfort and privacy.
    8. Performed hand hygiene.
  7. Rectal Temperature Measurement with Electronic Thermometer: Theory testing only.
    1. Provided privacy. Assisted client to side-lying Sim’s position. Moved aside bed linen to expose only anal area.
    2. Applied clean gloves.
    3. Slid disposable plastic probe cover over thermometer probe stem until covered locks in place being careful not to apply pressure on the ejection button.
    4. Squeezed lubricant onto tissue. Dipped end of thermometer into lubricant, covering 2.5-3.5 cm adult.
    5. With non-dominant hand, separated client’s buttocks to expose anus. Instructed client to breathe slowly and relax.
    6. Gently inserted thermometer into anus in direction of umbilicus 3.5 cm adult. Did not force thermometer.
    7. Withdrew thermometer immediately if resistance felt during insertion.
    8. Held probe in place until audible signal and client’s temperature appeared on display; removed probe from anus.
    9. Pushed ejection button to discard probe cover.
    10. Wiped client’s anal area to remove lubricant or feces. Assisted client to comfortable position.
    11. Removed and disposed of gloves. Performed hand hygiene. Returned thermometer to base.

Faculty Comments
Assessment Nursing Diagnosis Planning Implementation Evaluation
Attempt Number &
Outcome Number
Student Signature  
 

 Faculty Signature
 
 		 Date
 
 
The student was unable to perform the skill competently and will be retested.
 
 

 Faculty Signature
 
 		 Date
 
 

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Practical Nursing Program Skills Checklist Copyright © 2023 by Nova Scotia Community College. All Rights Reserved.

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