TEMPERATURE TEMPERATURE MEASURINGMEASURING

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

frequent data obtained by health care practitioners.frequent data obtained by health care practitioners.

When to measure the temperatureWhen to measure the temperature On a client's admission to a health care facilityOn a client's admission to a health care facility In a hospital or care facility on a routine schedule In a hospital or care facility on a routine schedule

ace physician's order or institution's standards of ace physician's order or institution's standards of practicepractice

When assessing the client during home health visitsWhen assessing the client during home health visits Before and after a surgical or invasive diagnostic Before and after a surgical or invasive diagnostic

procedureprocedure Before and after the administration of medications Before and after the administration of medications

or therapies that affect cardiovascular, respiratory or therapies that affect cardiovascular, respiratory functionsfunctions

When the client's general physical condition changes When the client's general physical condition changes (econsciousness, increased severity of pain)(econsciousness, increased severity of pain)

When the client reports specific symptoms of physic When the client reports specific symptoms of physic (e.g., feeling "funny" or "different")(e.g., feeling "funny" or "different")

Body temperature is depended to the external Body temperature is depended to the external environment. The core temperature, or temperature environment. The core temperature, or temperature of the deep body tissues, is under control of the of the deep body tissues, is under control of the hypothalamus and is maintained within a narrow hypothalamus and is maintained within a narrow range. Skin or body surface temperature rises and range. Skin or body surface temperature rises and falls as the tempera ture of the surrounding falls as the tempera ture of the surrounding environment changes and can fluctu ate dramatically.environment changes and can fluctu ate dramatically.

The body tissues and cells function best within a The body tissues and cells function best within a rela tively narrow temperature range, from 36° C to rela tively narrow temperature range, from 36° C to 38° C (96.8° F to 100.4° F), but no single 38° C (96.8° F to 100.4° F), but no single temperature is normal for all peo ple. An acceptable temperature is normal for all peo ple. An acceptable temperature range for adults depends on age, temperature range for adults depends on age, gender, range of physical activity, and state of gender, range of physical activity, and state of health.health.

Many factors affect body temperature. Physiological Many factors affect body temperature. Physiological and behavioral control mechanisms act to maintain a and behavioral control mechanisms act to maintain a constant core temperature. For example, the constant core temperature. For example, the mechanism of peripheral vasodilation increases blood mechanism of peripheral vasodilation increases blood flow to the skin, which in creases the amount of heat flow to the skin, which in creases the amount of heat radiated to the environment. Clients who lack sweat radiated to the environment. Clients who lack sweat gland function are unable to tol erate warm gland function are unable to tol erate warm temperatures because they cannot cool them selves temperatures because they cannot cool them selves adequately. Fever occurs when heat loss mechanisms adequately. Fever occurs when heat loss mechanisms are unable to keep pace with excess heat production, are unable to keep pace with excess heat production, result ing in an abnormal rise in body temperature. result ing in an abnormal rise in body temperature. When an indi vidual has a febrile condition, pyrexia, When an indi vidual has a febrile condition, pyrexia, the nurse initiates temperature-control measures such the nurse initiates temperature-control measures such as controlling environ mental temperatures, removing as controlling environ mental temperatures, removing external coverings, and ad ministering ordered external coverings, and ad ministering ordered antipyretics to achieve better tempera ture control.antipyretics to achieve better tempera ture control.

Average usual temperature varies Average usual temperature varies depending on the measurement site used. depending on the measurement site used. Research findings from numerous studies Research findings from numerous studies are contradictory; however, it are contradictory; however, it is generally is generally accepted that rectal temperatures are accepted that rectal temperatures are usually 0.5° C (0.9° F) higher than oral usually 0.5° C (0.9° F) higher than oral temperatures, and axillary and temperatures, and axillary and tympanic tempera tures are usually 0.5° tympanic tempera tures are usually 0.5° C (0.9° F) lower than oral tempera tures. C (0.9° F) lower than oral tempera tures.

Each site has advantages and Each site has advantages and disadvantages. The nurse determines the disadvantages. The nurse determines the safest and most accurate site for the client.safest and most accurate site for the client.

Core and Surface Temperature Core and Surface Temperature Measurement SitesMeasurement SitesCORE SITECORE SITE SURFACE SITE SURFACE SITE

Rectum Scin

Tympanic Oral

Esophagus Axilla

Pulmonary

Urinary bladder

Two types of thermometers are commonly Two types of thermometers are commonly available to measure body temperature: electronic available to measure body temperature: electronic and chemical dot sin gle use or reusable. Each type and chemical dot sin gle use or reusable. Each type has advantages and limita tions. The mercury-in-has advantages and limita tions. The mercury-in-glass thermometer, a standard device for glass thermometer, a standard device for temperature measurement for nearly years, has temperature measurement for nearly years, has been eliminated from most hospitals because of been eliminated from most hospitals because of the environmental hazards of mercury-contains. the environmental hazards of mercury-contains. However, mercury-in-glass thermometer may be However, mercury-in-glass thermometer may be found in client's homes. The electronic found in client's homes. The electronic thermometer consists of a battery-powered thermometer consists of a battery-powered display unit, a thin wire cord, and temperature-display unit, a thin wire cord, and temperature-processing probe covered by a disposable sheath. processing probe covered by a disposable sheath. Separate probes are available for oral and rectal Separate probes are available for oral and rectal temperature measuring. The oral probe has a blue temperature measuring. The oral probe has a blue tip, and the rectal a red tip. tip, and the rectal a red tip.

Advantages and Limitations of Select Advantages and Limitations of Select

Temperature MeasurementTemperature Measurement SitesSites OralOral AdvantagesAdvantages Easily accessible—requires no position change.Easily accessible—requires no position change. Comfortable for clientComfortable for client Provides accurate surface temperature reading.Provides accurate surface temperature reading. Reflects rapid change in core temperature. Reflects rapid change in core temperature. Shown to be reliable route to measure temperature in Shown to be reliable route to measure temperature in

intubated clients.intubated clients. LimitationsLimitations Causes delay in measurement if client recently ingested Causes delay in measurement if client recently ingested

hot/cold fluids or foods, smoked, or receive oxygen by hot/cold fluids or foods, smoked, or receive oxygen by mask/cannula.mask/cannula.

Should not be used with clients who have had oral surgery, Should not be used with clients who have had oral surgery, trauma, history of epilepsy, or shaking chills.trauma, history of epilepsy, or shaking chills.

Should not be used with infants, small children, uncon scious, or Should not be used with infants, small children, uncon scious, or uncooperative clientsuncooperative clients

Tympanic Membrane SensorTympanic Membrane Sensor

AdvantagesAdvantages Easily accessible site.Easily accessible site. Can be obtained without disturb ing of client.Can be obtained without disturb ing of client. Can be used for clients with tachypnea without affecting breathing.Can be used for clients with tachypnea without affecting breathing. Provides accurate core reading because eardrum is close to hypothal amus; Provides accurate core reading because eardrum is close to hypothal amus;

sensitive to core temperature changes sensitive to core temperature changes Very rapid measurement (2 to 5 seconds).Very rapid measurement (2 to 5 seconds). Unaffected by oral intake of food or fluids or smoking Unaffected by oral intake of food or fluids or smoking Can be used in newborns Can be used in newborns LimitationsLimitations More variability of measurement than with other core temperature devicesMore variability of measurement than with other core temperature devices Requires disposable sensor cover with only one size availableRequires disposable sensor cover with only one size available Otitis Otitis media and cerumen impaction can distort readings media and cerumen impaction can distort readings Should not be used with clients who have had surgery of the ear or Should not be used with clients who have had surgery of the ear or

tympanic membranetympanic membrane Does not accurately measure core temperature changes during and af ter Does not accurately measure core temperature changes during and af ter

exerciseexercise Cannot obtain continuous measurementCannot obtain continuous measurement Affected by ambient temperature devices such as incubators, radiant Affected by ambient temperature devices such as incubators, radiant

warmers, and facial fans warmers, and facial fans

RectalRectal

AdvantagesAdvantages Argued to be more reliable when oral temperature Argued to be more reliable when oral temperature

cannot be obtained cannot be obtained LimitationsLimitations May lag behind core temperature during rapid May lag behind core temperature during rapid

temperature changes temperature changes Should not be used for clients with diarrhea, clients Should not be used for clients with diarrhea, clients

who have had rec tal surgery, rectal disorders, who have had rec tal surgery, rectal disorders, bleeding tendenciesbleeding tendencies

Requires positioning and may be source of client Requires positioning and may be source of client embarrassment and anxietyembarrassment and anxiety

Requires lubricationRequires lubrication Should not be used for routine vital signs in Should not be used for routine vital signs in

newbornsnewborns

AxillaAxilla

AdvantagesAdvantages Safe and inexpensiveSafe and inexpensive Can be used with newborns and unconscious clientsCan be used with newborns and unconscious clients LimitationsLimitations Long measurement timeLong measurement time Requires continuous positioning by nurseRequires continuous positioning by nurse Measurement lags behind core temperature during rapid Measurement lags behind core temperature during rapid

temperaturetemperature changeschanges Not recommended to detect fever in infants and young Not recommended to detect fever in infants and young

children children Requires exposure of thorax, which can result in Requires exposure of thorax, which can result in

temperature loss,temperature loss, especially in newbornsespecially in newborns

SkinSkin AdvantagesAdvantages InexpensiveInexpensive Provides continuous reading Provides continuous reading Safe and noninvasive Safe and noninvasive Can be used for neonatesCan be used for neonates LimitationsLimitations Measurement lags behind other sites during temperature Measurement lags behind other sites during temperature

changes,changes, especially during hyperthermiaespecially during hyperthermia Sweat can impair adhesion Sweat can impair adhesion Another form of electronic thermometer is used exclu sively for Another form of electronic thermometer is used exclu sively for

tympanic temperature. An otoscope-like specu lum with an tympanic temperature. An otoscope-like specu lum with an infrared sensor tip detects heat radiated from the tympanic infrared sensor tip detects heat radiated from the tympanic membrane of the ear. Within 2 to 5 seconds after placement in membrane of the ear. Within 2 to 5 seconds after placement in the auditory canal and depressing the scan button, a value the auditory canal and depressing the scan button, a value appears on the display unit. A sound signals when the peak appears on the display unit. A sound signals when the peak temperature reading has been measured.temperature reading has been measured.

Chemical dot single-use or reusable Chemical dot single-use or reusable thermometers are disposable thin strips of thermometers are disposable thin strips of plastic with a temperature sensor at one end. plastic with a temperature sensor at one end. The sensor consists of a matrix of chemically The sensor consists of a matrix of chemically im pregnated dots that are formulated to im pregnated dots that are formulated to change color at differ ent temperatures. each change color at differ ent temperatures. each representing temperature increments of 0.1° representing temperature increments of 0.1° C over a range of 35.5° C to 40.4° C. The C over a range of 35.5° C to 40.4° C. The Fahrenheit version has 45 dots with Fahrenheit version has 45 dots with increments of 0.2° F and a range of 96.0° F to increments of 0.2° F and a range of 96.0° F to 104.8° F. Chemical dots on the thermometer 104.8° F. Chemical dots on the thermometer change color to reflect temperature reading, change color to reflect temperature reading, usually within 60 seconds. Most are designed usually within 60 seconds. Most are designed for single use. for single use.

Electronic thermometerElectronic thermometer AdvantagesAdvantages Disposable, easy to store Disposable, easy to store Used for clients in isolation Used for clients in isolation Useful for screening tempera tures, especially for infants and during Useful for screening tempera tures, especially for infants and during

invasive procedures ( during surgery)invasive procedures ( during surgery) LimitationsLimitations Can be difficult to readCan be difficult to read Has been shown to underesti mate and overestimate temper ature can Has been shown to underesti mate and overestimate temper ature can

be reused for a single client the chemical dots return to the original be reused for a single client the chemical dots return to the original color within a few seconds. The chemical thermometers are most color within a few seconds. The chemical thermometers are most commonly used for oral tempera tures. They can also be used at commonly used for oral tempera tures. They can also be used at axillary or rectal sites, cov ered by a plastic sheath at the latter, with a axillary or rectal sites, cov ered by a plastic sheath at the latter, with a placement time of 3 minutes.placement time of 3 minutes.

Not appropriate for monitoring temperature therapiesNot appropriate for monitoring temperature therapies Plastic sheath unbreakable;Plastic sheath unbreakable; Ideal for children Ideal for children Very rapid measurementVery rapid measurement LimitationsLimitations Probe or sensor covers are expensiveProbe or sensor covers are expensive

The skill of temperature measurement can be The skill of temperature measurement can be delegated to as sistive personnel. Before delegating delegated to as sistive personnel. Before delegating this skill the nurse may:this skill the nurse may:

Inform assistive personnel if any precautions are Inform assistive personnel if any precautions are needed in positioning the client during needed in positioning the client during measurementmeasurement

Instruct assistive personnel of appropriate route Instruct assistive personnel of appropriate route and de vice to measure temperatureand de vice to measure temperature

Provide assistive personnel the frequency of Provide assistive personnel the frequency of temperature measurement for select clienttemperature measurement for select client

Determine that assistive personnel are aware of the Determine that assistive personnel are aware of the client's previous temperature measuresclient's previous temperature measures

Instruct assistive personnel in the need to report Instruct assistive personnel in the need to report abnor malities that should be reconfirmed by the abnor malities that should be reconfirmed by the nursenurse

1.1. Determine need to measure client's Determine need to measure client's

body temperaturebody temperature:: a.a. Note client's risks for temperature Note client's risks for temperature

alterations: expected or diagnosed infection, alterations: expected or diagnosed infection, open wounds or burns, white blood cell count open wounds or burns, white blood cell count below 5000 or above 12,000, immunosuppressive below 5000 or above 12,000, immunosuppressive drug therapy, injury to hypothalamus, exposure drug therapy, injury to hypothalamus, exposure to temperature extremes, blood product infusion, to temperature extremes, blood product infusion, hypothermia or hyperthermia therapy, or hypothermia or hyperthermia therapy, or postoperative status.postoperative status.

b.b. Assess for signs and symptoms that may Assess for signs and symptoms that may accomany temperature alteration:accomany temperature alteration:

Fever: Fever: (depending on stage) pale or flushed skin; (depending on stage) pale or flushed skin; skin warm or hot to touch; skin dry or di aphoretic; skin warm or hot to touch; skin dry or di aphoretic; dry mucous membranes; tachycardia; muscle or dry mucous membranes; tachycardia; muscle or joint pain; nausea, vomiting, or diarrhea; feeling joint pain; nausea, vomiting, or diarrhea; feeling hot or cold; restlessness.hot or cold; restlessness.

2.2. Assess for factors that normally Assess for factors that normally influence temperature:influence temperature:

a. Agea. Age No single temperature is normal for all people. A No single temperature is normal for all people. A

temperature within an acceptable range in an temperature within an acceptable range in an adult may reflect a fever in an older adult. adult may reflect a fever in an older adult. Undeveloped temperature control mechanisms in Undeveloped temperature control mechanisms in in fants and children can cause temperature to in fants and children can cause temperature to rise and fall rapidlyrise and fall rapidly

b. b. Exercise Exercise c.c. HormonesHormones d.d. Stress Stress e.e. Environmental temperatureEnvironmental temperature f. Medicationsf. Medications g. Daily fluctuationsg. Daily fluctuations

Physical signs and symptoms may alert nurse to alteration in body Physical signs and symptoms may alert nurse to alteration in body temperature.temperature.

Hyperthermia: Hyperthermia: Decreased skin turgor, tachycardia; hypoten Decreased skin turgor, tachycardia; hypoten sion; decreased venous filling; concentrated urine.sion; decreased venous filling; concentrated urine.

Heatstroke: Heatstroke: Hot, dry skin; tachycardia; hypotension; exces Hot, dry skin; tachycardia; hypotension; exces sive thirst; muscle cramps; visual disturbances; confusion sive thirst; muscle cramps; visual disturbances; confusion or delirium.or delirium.

Hypothermia: Hypothermia: Pale skin; skin cool or cold to touch; brady Pale skin; skin cool or cold to touch; brady cardia and dysrhythmias; uncontrollable shivering; re duced cardia and dysrhythmias; uncontrollable shivering; re duced level of consciousness; shallow respirations.level of consciousness; shallow respirations.

Older adults have a narrower range of temperature than Older adults have a narrower range of temperature than do younger adults.do younger adults.

Muscle activity raises heat production.Muscle activity raises heat production. Women have wider temperature fluctuations than men be Women have wider temperature fluctuations than men be

cause of menstrual cycle hormonal changes; body cause of menstrual cycle hormonal changes; body temperature change can vary during menopause.temperature change can vary during menopause.

Stress elevates temperature.Stress elevates temperature. Infants and older adults are more sensitive to environmental Infants and older adults are more sensitive to environmental

temperature changes.temperature changes.

Drugs may impair or promote sweating, Drugs may impair or promote sweating, vasoconstriction, vasodilation change vasoconstriction, vasodilation change temperature.temperature.

Body temperature normally changes 0.5 to 1° C Body temperature normally changes 0.5 to 1° C during a 24- hour period. Temperature is lowest during a 24- hour period. Temperature is lowest during early morning. Most clients have during early morning. Most clients have maximum temperature elevation around 6 pm; maximum temperature elevation around 6 pm; temperature falls gradually during night.temperature falls gradually during night.

Determines if client's status contraindicates Determines if client's status contraindicates selection of a' specific method or site.selection of a' specific method or site.

Body temperature is within acceptable range Body temperature is within acceptable range for client's age-group.for client's age-group.

Body temperature returns to baseline range Body temperature returns to baseline range follow ing therapies for abnormal temperature.follow ing therapies for abnormal temperature.

IMPLEMENTATIONIMPLEMENTATION

1. Perform hand hygiene.1. Perform hand hygiene. 2. Assist client to comfortable position that provides 2. Assist client to comfortable position that provides

easy access to temperature measurement site.easy access to temperature measurement site. 3. Obtain temperature reading.3. Obtain temperature reading. a. Oral temperature measurement with electronic a. Oral temperature measurement with electronic

thermometerthermometer (1) Apply disposable gloves (optional).(1) Apply disposable gloves (optional). 2. Remove thermometer pack from charging unit. 2. Remove thermometer pack from charging unit.

Attach oral thermometer probe stem (blue tip) to Attach oral thermometer probe stem (blue tip) to thermometer unit. thermometer unit.

3. Remove thermometer pack from charging unit. 3. Remove thermometer pack from charging unit. Attach rectal thermometer probe stemAttach rectal thermometer probe stem(red tip) to thermometer unit. Grasp top of probe (red tip) to thermometer unit. Grasp top of probe stem, being careful not to apply pres stem, being careful not to apply pres sure on the ejection button.sure on the ejection button.

(3) Slide disposable plastic probe cover over ther mometer (3) Slide disposable plastic probe cover over ther mometer probe stem until cover locks in place.probe stem until cover locks in place.

(4) Squeeze liberal portion of lubricant on tis sue. Dip (4) Squeeze liberal portion of lubricant on tis sue. Dip thermometer's blunt end into lubri thermometer's blunt end into lubri cant, covering 2.5 to 3.5 cm (1 to 1cant, covering 2.5 to 3.5 cm (1 to 1V2 V2 inches) for adult.inches) for adult.

(5) With nondominant hand, separate client's but tocks to (5) With nondominant hand, separate client's but tocks to expose anus. Ask client to breatheexpose anus. Ask client to breatheslowly and relax.slowly and relax.

(6) Gently insert thermometer into anus in di rection of (6) Gently insert thermometer into anus in di rection of umbilicus 3.5 cm (l'/2 inches) for adult. Do not force umbilicus 3.5 cm (l'/2 inches) for adult. Do not force thermometer.thermometer.

(7) If resistance is felt during insertion, with draw (7) If resistance is felt during insertion, with draw immediately. Never force thermometer.immediately. Never force thermometer.

Once positioned, hold thermometer probe in place until Once positioned, hold thermometer probe in place until audible signal indicates comple tion and client's audible signal indicates comple tion and client's temperature appears on dig ital display; remove temperature appears on dig ital display; remove thermometer probe from anus (see illustrationthermometer probe from anus (see illustration

Push ejection button on thermometer stem to discard plastic Push ejection button on thermometer stem to discard plastic probe cover into an appropri ate receptacle.probe cover into an appropri ate receptacle.

Return thermometer stem to storage position of recording Return thermometer stem to storage position of recording unit.unit.

Wipe client's anal area with soft tissue to remove lubricant Wipe client's anal area with soft tissue to remove lubricant or feces, and discard tissue. Assist client in assuming a or feces, and discard tissue. Assist client in assuming a comfortablecomfortableposition.position.

Remove and dispose of gloves in appropri ate receptacle. Remove and dispose of gloves in appropri ate receptacle. Perform hand hygiene.Perform hand hygiene.

Return thermometer to charger.Return thermometer to charger. c. Axillary temperature measurement with electronic c. Axillary temperature measurement with electronic

thermometerthermometer (1) Draw curtain around bed and/or close room door. Assist (1) Draw curtain around bed and/or close room door. Assist

client to supine or sitting posi tion. Move clothing or gown client to supine or sitting posi tion. Move clothing or gown away from shoulder and arm.away from shoulder and arm.

button releases plastic cover from probe stem.button releases plastic cover from probe stem.

Probe cover prevents transmission of Probe cover prevents transmission of microorganisms b<microorganisms b<

tween clients. Lubrication minimizes trauma to tween clients. Lubrication minimizes trauma to rectal mucosa during iirectal mucosa during ii

sertion. Tissue avoids contamination of remainingsertion. Tissue avoids contamination of remaining cant in container.cant in container. Fully exposes anus for thermometer insertion. Fully exposes anus for thermometer insertion.

Relaxes Relaxes i i sphincter for easier thermometer sphincter for easier thermometer insertion.insertion.

Ensures adequate exposure against blood vessels Ensures adequate exposure against blood vessels in i wall.in i wall.

Prevents trauma to mucosa.Prevents trauma to mucosa. Probe must stay in place until signal occurs to Probe must stay in place until signal occurs to

ensure accu rate readingensure accu rate reading

STEP 3b(9) STEP 3b(9) Probe removed smoothly from anus. Probe removed smoothly from anus. Reduces transmission of microorganisms.Reduces transmission of microorganisms.

Returning thermometer stem automatically Returning thermometer stem automatically causes digital reading to disappear. causes digital reading to disappear. Provides for comfort and hygiene.Provides for comfort and hygiene.

Reduces transmission of microorganisms. Reduces transmission of microorganisms. Maintains battery charge of thermometer Maintains battery charge of thermometer unit.unit.

Maintains client's privacy, minimizes Maintains client's privacy, minimizes embarrassment, and promotes comfort. embarrassment, and promotes comfort. Exposes axilla for correct thermometer Exposes axilla for correct thermometer probe placement.probe placement.