Measuring Body Temperature & Stethoscope Use (4)
Measuring Body Temperature
Initial Steps (Applicable to all methods)
Perform hand hygiene. This reduces the spread of microorganisms.
Assess for signs and symptoms of temperature alterations and factors influencing body temperature. This enables accurate assessment of variations.
Introduce yourself to the patient to decrease their anxiety.
Identify the patient using their ID band to ensure the correct patient.
Explain the procedure, including the site of temperature reading and the importance of maintaining proper position until completion, to gain the patient's cooperation.
Prepare for the procedure:
Assemble the thermometer, disposable tissues, lubricant (for rectal temperature only), pen and notepad, disposable gloves, plastic sleeve, or disposable probe cover to promote efficiency.
Provide for patient privacy to decrease anxiety.
Inquire whether the patient has consumed hot or cold beverages/food or has been smoking; if so, wait 20-30 minutes before measuring oral temperature to ensure accuracy.
Oral Temperature (Electronic Thermometer)
Follow steps 1-6.
Hand hygiene and don disposable gloves (optional) to reduce spread of microorganisms.
Remove thermometer pack from charging unit for maneuverability, ensuring battery power.
Remove probe from storage well, grasping the top of the stem carefully to avoid the eject button to ensure proper working order.
Insert probe snugly into probe cover, using a blue probe for oral readings to reduce spread of microorganisms.
Inspect the digital display to ensure the unit is ready.
Request the patient to open their mouth; gently insert the probe into the posterior sublingual pocket. Instruct the patient to hold the thermometer in place with lips closed to ensure an accurate reading.
Wait for the audible signal, which indicates the temperature reading is complete.
Remove probe from patient's mouth and eject the probe cover into the trash receptacle to reduce spread of microorganisms.
Provide for patient comfort.
Read and write down the reading from the digital display before reinserting the probe into the holder to ensure accurate recording.
Perform hand hygiene to reduce spread of microorganisms, and return the electronic unit to the charger to maintain battery charge.
Complete procedure by following Step 12, a through d (see the 'Completing the Procedure' section).
Rectal Temperature (Electronic Thermometer)
Caution: If unable to insert the thermometer adequately into the rectum, remove the thermometer and consider an alternative method for obtaining temperature. Never force the thermometer.
Follow steps 1-6b.
Don gloves to maintain standard precautions.
Assist patient to the Sims position with the upper leg flexed. Move aside the bed linens to expose only the rectal area to ensure correct thermometer placement and prevent unnecessary exposure of the patient.
Remove the thermometer pack from the charging unit. Ensure the rectal (red) probe is attached to the unit and slide the disposable plastic cover over the thermometer probe until it locks into place to reduce spread of microorganisms.
With the thermometer in the probe cover, lubricate 1 inch of the tip to ease insertion.
For an adult, with the patient in the Sims position, gently spread the buttocks and insert the thermometer probe 1.5 inches into the rectum. Hold onto the thermometer throughout procedure to ensure safety.
Hold the electronic probe until the audible signal occurs; only then read the temperature on the digital display (keep the probe in place until signal occurs) to ensure an accurate reading.
Carefully remove the probe from the rectum; push the eject button to remove the probe cover and dispose into an appropriate receptacle to reduce the spread of microorganisms.
Return the probe to the storage unit, and later return the unit to its charging device to prevent damage to the unit and ensure accurate working for the next assessment.
Clean the anal area of lubricant and possible feces. Remove and dispose of gloves and perform hand hygiene to provide comfort and hygiene and reduce the spread of microorganisms.
Assist the patient to a position of comfort to restore self-esteem.
Write down the reading for later documentation to ensure accurate recording.
Complete procedure by following Step 12, a through d (see the 'Completing the Procedure' section).
Axillary Temperature (Electronic Thermometer)
Follow steps 1-6b.
Don gloves to maintain standard precautions.
Assist patient to supine or sitting position to provide easy access to the axilla.
Expose the axilla; be certain the area is clean and dry to ensure an accurate reading.
Prepare the electronic thermometer following Step 7, c through e (oral temperature steps).
Insert the probe into the center of the axilla; lower arm over the thermometer, placing arm across the patient's chest. In an infant or young child, it is sometimes necessary to hold the arm against the child's side when using the axillary method. If the infant is in a side-lying position, the lower axilla records the higher temperature to maintains proper positioning of the temperature probe.
Hold the electronic probe until an audible signal occurs. A reading appears on the digital display. The probe must stay in place for an accurate reading to occur.
Remove the probe from the patient’s axilla. Push the eject button to remove the probe cover and dispose of it in the trash container to reduce the spread of microorganisms.
Return the electric probe to the storage well of the recording unit to prevent damage to the unit.
Assist the patient to re-gown and position for comfort to restore a sense of well-being.
Remove and dispose of gloves in proper receptacle and perform hand hygiene to reduce the spread of microorganisms.
Return the thermometer to the charger base to maintains battery charge.
Write down the reading for later documentation to ensure accurate recording.
Complete procedure by following Step 12, a through d (see the 'Completing the Procedure' section).
Tympanic Temperature (Electronic Thermometer)
Follow Steps 1 through 6a.
Assist patient to a comfortable position with head turned toward the side, away from you to ensures comfort and exposes auditory canal for accurate temperature reading.
Remove thermometer handheld unit from charging base to provides easy access to thermometer.
Slide disposable plastic speculum cover over otoscope-like tip until it locks into place to prepares the unit to measure temperature; the plastic speculum reduces spread of microorganisms.
Follow manufacturer's instructions for tympanic probe positioning:
Gently tug ear pinna upward and back for an adult, down and back for a child (Difference is because of age-related anatomic differences).
Gently insert thermometer into ear to ensures correct placement.
Fit ear probe snugly into canal. Do not allow further movement to ensures correct reading.
Point digital readout toward you, following manufacturer's positioning recommendations. (Steps [1] through [4] ensure correct positioning of the probe with respect to ear canal; the ear tug straightens the external auditory canal, allowing maximum exposure of the tympanic membrane.)
Depress scan button on handheld unit and read assessment. Temperature reading appears on digital display.
Carefully remove sensor from ear and push release button to eject plastic speculum cover; discard into proper receptacle to reduces spread of microorganisms.
Return handheld unit to charging base to maintains battery charge.
Assist patient to a comfortable position to restores sense of well-being.
Perform hand hygiene. Dispose of gloves, if worn, into proper receptacle to reduces spread of microorganisms.
Write down reading (for documentation later).
Complete procedure by following Step 12, a through d (see the 'Completing the Procedure' section).
Temporal Artery Temperature
(This skill can be delegated to unlicensed assistive personnel who are knowledgeable in the procedure, but it is the nurse's responsibility to assess the significance of the findings.)
Follow steps 1-6a.
Ensure the forehead is dry to decreases chance of moisture interfering with temperature measurement.
Place probe flush on patient's forehead to prevents measuring ambient temperature by mistake.
Press the scan button. (Continuous scanning for the highest temperature occurs until you release the scan button.)
Keeping the probe flush on the skin, slowly brush the thermometer straight across the forehead to promotes accuracy in measurement.
Keeping the scan button pressed, sweep the probe across the forehead and continue to just behind the earlobe.
The thermometer makes a clicking sound when the highest temperature is reached. Read and document temperature.
Wipe probe with alcohol, or remove and dispose of the probe cover.
Complete procedure by following Step 12, a through d (see the 'Completing the Procedure' section).
Completing the Procedure (All Methods)
Compare temperature findings with baseline and normal temperature range for patient's age group. Comparison reveals the presence of abnormalities.
If the temperature is abnormal, repeat procedure. If indicated, choose an alternate site or instrument. The second reading confirms initial findings of abnormal body temperature.
Record temperature on vital sign flow sheet, graphic flow sheet, or nurse's notes and report abnormal findings to the nurse in charge or health care provider. Recording promptly prevents omissions from the record. Abnormalities often necessitate immediate therapy. When recording an axillary temperature, write Ax above your documentation. When recording a rectal temperature, write R above the reading.
Do patient teaching (see patient teaching in the Health Promotion box on vital signs).
Additional Considerations for Temperature Measurement
Assessment guides the choice of method.
The method chosen must be documented with the reading.
Oral temperature should not be attempted on comatose or disoriented patients, or in small infants, because this method requires patient cooperation.
Rectal measurements are contraindicated for patients with recent rectal surgery or certain conditions of the perineum.
Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic thermometer.
Rectal readings are normally higher, and axillary readings lower, than oral readings.
Privacy is typically not needed for oral or tympanic readings.
Temporal artery scanner is appropriate in almost all situations.
If the patient has diaphoresis, brush the scanner across the forehead through to behind the ear to increase accuracy.
Assessing Tympanic Temperature Accurately
Ensure the patient has been indoors for at least 10 minutes and has not been lying on the ear. Remove hearing aids and assess temperature after a few minutes.
If the reading seems too low, replace the probe cover and repeat the procedure. Ensure the lens and probe cover are clean and intact. Follow manufacturer's recommendations.
Be alert to temperature variations from ear to ear. Document which ear was used.
If there's a significant variation from normal, a second measurement is necessary for comparison. Ensure the probe is not improperly placed or moved.
Clean the unit between patients with a recommended product.
Elimination of Mercury-Containing Devices
In 1714, Fahrenheit invented the constant reference point thermometer using mercury in glass.
In 1868, Wunderlich established the normal range of body temperatures in humans as , using Fahrenheit's constant reference point thermometer. This remains the standard today.
Mercury-in-glass thermometers were the only instrument available for over 200 years but are now considered dangerous due to the threat of mercury exposure if broken. One gram of mercury can contaminate a 20-acre lake.
The American Academy of Pediatrics recommends pediatricians stop using all mercury-containing devices.
If a mercury thermometer breaks, the vapor can be inhaled, causing toxicity. Healthcare facilities in the United States have discontinued the use of mercury thermometers and sphygmomanometers.
Obtaining Temperature Measurements
Peripheral temperature gives a good estimate of core temperature when the patient has a normal body temperature. Touch the patient's skin and observe its moisture and warmth.
Heat-sensitive patches can be placed on the skin to indicate temperature.
If the patient's temperature is rising or falling rapidly, peripheral temperatures can lag significantly behind true core temperature.
Experts no longer recommend the use of mercury-containing thermometers.
Electronic thermometers consist of a rechargeable battery-powered display unit, a thin wire cord, and a temperature-processing probe that should be used only with a disposable cover. Separate probes are available for oral (blue tip) and rectal (red tip) temperature measurement.
Tympanic thermometers scan the tympanic membrane. They are likely more accurate than traditional thermometers when placed correctly because measurement is from an enclosed cavity unaffected by environmental temperatures. The tympanic membrane shares its blood supply with the hypothalamus and is a good source for obtaining core-temperature readings. The sensor measures infrared heat.
The temporal artery method provides a reliable noninvasive measurement using an infrared sensor brushed over the temporal artery.
Auscultating with the Stethoscope
A stethoscope is used to measure the apical rate of the heart.
Stethoscope Parts:
Earpieces: Plastic or rubber, fitting snugly and comfortably.
Binaurals: Angled and strong enough to hold earpieces firmly without discomfort.
Tubing: Flexible polyvinyl, 12 to 18 inches (30 to 40 cm) long. Longer tubing decreases the transmission of sound waves. Thick-walled and rigid to eliminate environmental noise and prevent kinking.
Chest Piece: Consists of a bell and a diaphragm. Rotate into proper position to hear sounds. Test by lightly tapping to determine which side is functioning.
Diaphragm: The circular, flat-surfaced portion covered with a thin plastic disk.