Assessing Body Temperature

References:

Kozier, Fundamentals of Nursing

Ellice/Nowlis/Bentz, Modules for Basic Nursing Skill
Taylor, Fundamentals of Nursing
CEU, Manual of Nursing Procedures
Purposes

1.To determine any alteration in body temperature.

2. To monitor for effectiveness of body temperature-lowering

or body temperature-elevating interventions.
Assessing Body Temperature
Range of oral temperatures during 24 hours for a healthy young adult.
Assessing Body Temperature

Body temperature - is the balance between heat

produce and heat lost by the body
Febrile (Pyrexia) is when body temperature is
elevated, has fever (lay terms)
Hyperpyrexia when temperature is at 41C
Afebrile is when body temperature is normal,
without fever
It is measured in heat units, called degrees
Assessing Body Temperature

Two types of Body temperature

1. CORE Temperature 2. SURFACE temperature

>it is the temperature of the deep  >is the temperature of the

tissues of the body, such as the skin, the subcutaneous tissues
cranium, thorax, abdominal cavity and fat
and pelvic cavity.  It constantly rises and falls in
It remains relatively constant (37 relation to the environment
°C/ 98 °F)  It varies from 20 °C (68 °F) to
40 °C (104 °F)

measured thru tympanic and measured thru oral and

rectal routes axillary routes
 Different Types of Thermometer:

Standard Glass Thermometers: Electronic Thermometers:

 Oral Glass Thermometer – has a 1. Digital thermometer
slender bulb designed to provide a
large surface for exposure when it is 2. Tympanic thermometer
placed under the tongue 3. Temporal thermometer
 Rectal Glass Thermometer – pear- 4. Chemical dot thermometer
shaped bulb
 Multiuse glass thermometer –
blunt, stubby tip; maybe used at the 1
oral, rectal, or axillary site and is
commonly used for children
because it is considered the safest.

2
4
3
 Advantages & Disadvantages of Four Sites for Body
Temperature Measurement
SITE ADVANTAGES DISADVANTAGES

ORAL Accessible Glass thermometers can break if bitten

and
Inaccurate if client has just ingested hot or cold
convenient
food or fluid or smoked
Could injure the mouth following oral surgery
CONTRAINDICATIONS:
Infants and very young children
Patients with oral surgery
Unconscious or irrational patients
Seizure-prone patients
Mouth breathers and pts. with oxygen
 Advantages & Disadvantages of Four Sites for Body
Temperature Measurement
SITE ADVANTAGES DISADVANTAGES

RECTAL Reliable Inconvenient and more unpleasant for clients;

measurement difficult for client who cannot turn to the side
Could injure the rectum following rectal surgery
Presence of stool may interfere with thermometer
placement. If the stool is soft, the thermometer may
be embedded in stool rather than against the wall of
the rectum
CONTRAINDICATIONS:

Rectal abnormalities
Diarrhea
Certain heart conditions
 Advantages & Disadvantages of Four Sites for Body
Temperature Measurement
SITE ADVANTAGES DISADVANTAGES

AXILLARY Safe and non- The thermometer must be left in place a long
invasive time to obtain an accurate measurement
SITE ADVANTAGES DISADVANTAGES

TYMPANIC Readily Can be uncomfortable and involves risk of injuring the

MEMBRANE accessible; membrane if the probe is inserted too far
reflects the Repeated measurements may vary. Right and left
core measurements can differ.
temperature.
Presence of cerumen can affect the reading
Very fast.
CONTRAINDICATIONS:
• Presence of ear ache
• Significant ear drainage
• Sleeping with the head turned on one side
Temperature Scales
 Converting Fahrenheit to Celsius
Formula: C = (F – 32) X 5/9
Example: F reading = 100
C = (100 – 32) X 5/9 = (68) X .555556
C = 37.7
 Converting Celsius to Fahrenheit
Formula: F = (C X 9/5) + 32
Example: C reading = 40
F = (40 X 9/5) + 32
F = (72) + 32
F = 104
ASSESSMENT:
1.Site most appropriate for measurement 3. Assess the patient’s readiness
for the procedure.
2. Factors that might alter core body
temperature: If the patient is smoking, eating,
 Age or drinking a hot or cold beverage,
 Infection the reading will be altered, so wait
 Temperature of the environment at least 15 minutes before
 Diurnal variations (circadian rhythms) proceeding.
 Amount of exercise Sometime, because of a change in
 Metabolism the patient’s condition, you will
 Emotional status have to change the route for taking
 Hormones the temperature
 Stress
PLANNING:

1. Prepare the necessary equipment/ materials to be used and check their

functionality

◦ Digital Thermometer
◦ Disposable gloves (optional)
◦ Cotton balls soaked in alcohol/ alcohol swabs
◦ Warm water & soap
◦ Flow sheet/Notebook
◦ Disposable plastic cover for probe (if available)

2. Introduce self and verify client identity.

3. Establish rapport with the client
IMPLEMENTATION:
PROCEDURE RATIONALE

1. Explain the procedure to the client: >Explaining the procedure encourages

how temperature will be obtained and client participation. It also facilitates
importance of maintaining proper client education of the significance of
positioning. such procedure.
2. Draw privacy curtain, or close door. >This ensures client privacy.
3. Perform hand hygiene. >Hand washing is the single, most
effective way for preventing the
transmission of microorganisms and
infectious diseases.
4. Wipe the thermometer with cotton >This ensures that the thermometer is
balls soaked in alcohol from stem to clean and ready to be used by the
the bulb/tip of probe in an upright client.
position using a firm, twisting motion.
IMPLEMENTATION:
PROCEDURE RATIONALE

5. Press button to turn on the >This is a “function check” and it means

thermometer. A beep signal will sound the thermometer is working properly.
and will show a display.
6. Axillary Temperature Measurement > Positioning the client in this manner
Assist the client to assume supine or allows easy access of the axilla.
sitting position.
7. Move the clothing or gown away >Exposes the axilla for correct
from shoulder or arm. thermometer placement
8. Raise the patient’s arm away from >It may be necessary to wipe dry the
torso. Inspect for skin lesions and axilla. If lesions are present, check the
excessive perspiration. Insert the other axilla.
thermometer probe into center of Maintains proper position of probe
axilla, lower arm over thermometer, against blood vessels in axilla.
and place arm across client’s chest.
IMPLEMENTATION:
PROCEDURE RATIONALE
9. Listen for the “completion” beeps. >Although the number of beeps may vary
Normally, the steady beep will continue depending on manufacturer, the beeps
for about one minute, then you will hear confirm that the temperature
the thee rapid “completion” beeps. measurement is complete.

10. After hearing the beeps that signal >The display indicates the temperature
completion, remove thermometer from assessed.
mouth/ axilla and read temperature on
display. Temperature reading will not
change while the power remains on.
11. Press the power button of the >This turns the thermometer off and
thermometer. conserves its battery when not used.
12. Cleanse the thermometer from stem >Ensures that thermometer is clean and
to the bulb/tip of probe in an upright will be ready for next use.
position using a firm, twisting motion.
IMPLEMENTATION:
PROCEDURE RATIONALE
13. Dispose off used cotton swab/ >Prevents transmission of
cotton balls in the appropriate microorganisms.
receptacle or according to agency
protocol/ policy and wash hands.
14. Inform the client about the data >This ensures that the client is well
obtained. informed about changes in his status.
EVALUATION
• Determine alterations by comparing with acceptable temperature ranges/ values
• Document client’s temperature in the Vital Signs Flow Sheet or notebook
• Notify the primary care provider for any significant change in the body temperature

NURSING CONSIDERATIONS
• When taking oral temperature, wait for 20 to 30 minutes before measuring temperature if client has
smoked or ingested hot or cold foods or liquid.
• Do not use axilla if skin lesions are present because local temperature may be altered and area may
be painful to touch
• If the patient has any abnormal vital signs, consider retaking if you think there is any possibility of
inaccuracy