NUR 102: BASIC

NURSING
LECT: GEORGE DASSAH
(MN,BSc,RN)

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TAKING VITAL SIGNS

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Definition Of Vital Signs
• Vital signs are measures of various physiological
status, in order to assess the most basic body
functions.
• When these values are not zero, they indicate that
a person is alive.
• All of these vital signs can be observed, measured
and monitored.
• Normal ranges of measurements of vital signs
change with age and medical condition. If any
abnormality occurs in the body, vital signs
change immediately.

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Vital Signs
• Vital signs are useful in detecting or monitoring
medical problems.
• Vital signs can be measured in a medical setting, at
home, at the site of a medical emergency, or
elsewhere.
• Purpose of checking vital signs;
• To assess the client’s condition
• To determine the baseline values for future
comparisons
• To detect changes and abnormalities in the
condition of the client
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Vital Signs
• Vital Signs includes the following;
• Body temperature (Temp).
• Pulse / heart rate.
• Respiration.
• Blood pressure (BP).

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Times to Assess Vital Signs
• Upon admission to any healthcare agency.
• Based on agency institutional policy and
procedures.
• Any time there is a change in the patient’s
condition.
• Before and after surgical or invasive diagnostic
procedures.
• Before and after activity that may increase risk.
• Before and after administering medications that
affect cardiovascular or respiratory functioning.

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Times to Assess Vital Signs
• Before, during, and after transfusion of blood and
blood products.
• When a patient reports nonspecific symptoms of
physical distress (e.g., feeling “funny” or
“different”)
• Before, during and after nursing interventions
influencing a vital sign (e.g., before and after a
patient currently on bed rest ambulates, before and
after a patient performs range-of-motion exercises).

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 Body Temperature
• Body temperature is the balance between the heat
production due to chemical activities by the body
and heat lost from the body through radiation,
conduction, convection, and
vaporization( evaporation).
• It is measured in heat units called degree Celsius °C
or degree Fahrenheit °F.
• The instrument used to measure temperature is the
clinical thermometer

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 Types Of Body Temperature
• There are two kinds of body temperature: core
temperature and surface temperature.
• Core temperature is the temperature of the deep
tissues of the body, such as the abdominal cavity
and pelvic cavity.
• It remains relatively constant.
• Assessed by using a thermometer
• The normal core body temperature is a range of
temperatures from 97 F (36.1 C) and 99 F (37.2 C) .

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 Body Temperature

• The surface temperature is the temperature of

the skin, the subcutaneous tissue and fat
tissues.

• In contrast, rises and falls in response to the

environment.

• Body temperature can vary depending on how

active one is or the time of day.

• Assessed by touching the skin

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 Body Temperature

• The body continually produces heat as a by-

product of metabolism.

• When the amount of heat produced by the body

equals the amount of heat lost, the person is in
heat balance.

• A number of factors affect the body’s heat

production.
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 Factors Affecting Heat Production

• The most important are these five:

• Basal metabolic rate: The basal metabolic rate
(BMR) is the rate of energy utilization in the body
required to maintain essential activities such as
breathing.
• Metabolic rates decrease with age. The younger
the person, the higher the BMR.
• Muscle activity: Muscle activity, including shivering,
increases the metabolic rate.

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 Factors Affecting Heat Production

• Thyroxin output: Increased thyroxin output

increases the rate of cellular metabolism
throughout the body.
• Epinephrine, norepinephrine, and sympathetic
stimulation/ stress response :These hormones
immediately increase the rate of cellular
metabolism in many body tissues.
• Age: Very young and very old are more sensitive to
change in environmental temperature due to
decreased thermoregulatory controls

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 Heat Loss From The Body
• Heat is lost from the body through radiation,
conduction, convection and evaporation.
• Radiation: is the transfer of heat from the surface
of one object to the surface of another without con
tact between the two objects, mostly in the form of
infrared rays.
• Conduction: is the transfer of heat from one
molecule to a molecule of lower temperature.

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 Heat Loss From The Body

• Convection is the dispersion of heat by air currents.

• The body usually has a small amount of warm air
adjacent to it.
• This warm air rises and is replaced by cooler air, so
people always lose a small amount of heat through
convection.
• Evaporation is continuous vaporization of moisture
from the respiratory tract and from the mucosa of
the mouth and from the skin.
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Heat Loss From The Body cont’d

• This continuous and unnoticed water loss is called

insensible water loss, and the accompanying heat
loss is called insensible heat loss.

• Insensible heat loss accounts for about 10% of

basal heat loss.

• When the body temperature increases,

vaporization accounts for greater heat loss.
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Heat production and loss

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Body Temperature Regulation

• Physiological and behavioural mechanisms precisely regulate and

control body temperature mechanisms.

• For the body temperature to stay constant and within an acceptable

range, the body needs to maintain the relationship between heat
production and heat loss.

• The body uses some of these mechanisms to maintain heat balance.

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 Body Temperature Regulation cont’d

• Neural and Vascular Control. The hypothalamus, located between

the cerebral hemispheres of the brain and below the thalamus,
controls body temperature by attempting to maintain a comfortable
temperature or set-point.

• When the hypothalamus senses an increase in body temperature, it

sends out impulses for the release of hormones to reduce body
temperature by sweating and vasodilation (widening of blood
vessels).

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 Body Temperature Regulation cont’d

• Vasodilation increases blood flow to the skin, which enables heat

loss through radiation.

• If the hypothalamus senses that body temperature is lower than

the set-point, it triggers hormone release to increase heat
production by muscle shivering or heat conservation by
vasoconstriction (narrowing of surface blood vessels).

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 Body Temperature Regulation cont’d

• Disease or trauma to the hypothalamus or spinal cord, which

carries hypothalamic messages, decreases the ability of the body to
control body temperature.

• Heat Production. Temperature regulation relies on normal heat

production processes.

• Heat is produced as a by-product of metabolism.

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Body Temperature Regulation cont’d

• As metabolism increases the body produces additional heat.

• When metabolism decreases, the body produces less heat.
• Heat production occurs during rest, voluntary movement, involuntary
shivering, and non-shivering thermogenesis.
• Metabolism increases during activity, resulting in increased heat
production up to 50 times normal.
• Shivering is an involuntary body response to temperature differences in
the body.
• Shivering can increase heat production four or five times higher than
normal.
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 Body Temperature Regulation cont’d

• However, in a neonate the immature temperature regulation system

does not allow for shivering.

• Instead a neonate metabolizes vascular brown adipose tissue for

heat production until 6 to 12 months of age, a process called non-
shivering thermogenesis.

• Premature infants less than 32 weeks of age have insufficient stores

of brown fat placing them at highest risk for hypothermia.

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 Body Temperature Regulation cont’d

• Heat Loss. Heat loss and production occur at the same time.

• The exposure of the skin to the environment results in constant,

normal heat loss through radiation, conduction, convection, and
evaporation.

• Infants and young children have a greater ratio of surface area to

body weight; thus they lose more heat to the environment than
adults.

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Body Temperature Regulation cont’d

• Radiation is the transfer of heat between two objects without

physical contact.

• Heat radiates from the skin to any surrounding cooler object.

• Up to 85% of the surface area of the human body radiates heat to

the environment.

• During surgery patients often lose excessive amounts of heat in the

cool environment of the operating room; thus you need to closely
monitor your patient’s temperature during and after surgery.

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 Body Temperature Regulation cont’d

• A small amount of heat loss occurs through conduction, which is the

transfer of heat from one object to another with direct contact.

• When warm skin touches a cooler object, heat transfers from the
skin to the object until temperatures equalize.

• In patients with fevers, heat loss increases with the application of ice
packs or bathing with tepid water.

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 Body Temperature Regulation cont’d

• Applying several layers of clothing reduces conductive loss.

• The body gains heat by conduction when it contacts
materials warmer than skin temperature such as pre-
warmed blankets.
• Convection is the transfer of heat away from the body by
air movement.
• Fans promote heat loss through convection.

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 Body Temperature Regulation cont’d

• Diaphoresis (i.e., excessive sweating) drastically lowers

body temperature and typically manifests on the
forehead, upper chest, and arms.
• Skin in Temperature Regulation. Skin, subcutaneous
tissue and fat tissues help to maintain body temperature
through insulation.
• Therefore people with more body fat have more natural
insulation than slim or muscular individuals.

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 Body Temperature Regulation cont’d

Behavioural Control. When the environmental

temperature falls, a person adds clothing, moves to a
warmer place, raises the thermostat setting on a furnace,
increases muscular activity by running in place, or sits with
arms and legs tightly wrapped together.

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 Body Temperature Regulation cont’d

• In contrast, when the temperature becomes hot, a person removes

clothing, stops activity, turns on a fan or lowers the thermostat
setting on an air-conditioner, seeks a cooler place, or takes a cool
shower.

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 Factors Affecting Body Temperature

• Nurses should be aware of the factors that can affect a client’s body
temperature so that they can recognize normal temperature
variations and understand the significance of body temperature
measurements that deviate from normal.

• Among the factors that affect body temperature are the following:

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 Factors Affecting Body Temperature cont’d

1. Age

• Infants are greatly influenced by the temperature of the

environment and must be protected from extreme changes.

• Children’s temperatures vary more than those of adults do until

puberty.

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 Factors Affecting Body Temperature cont’d

• Many older people, particularly those over 75 years, are at risk of

hypothermia (temperatures below 36°C, or 96.8°F) for a variety of
reasons, such as inadequate diet, loss of subcutaneous fat, lack of
activity, and reduced thermoregulatory efficiency.

• Older adults are also particularly sensitive to extremes in the

environmental temperature due to decreased thermoregulatory
controls.

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 Factors Affecting Body Temperature cont’d

2. Diurnal variations (circadian rhythms)

• Body temperatures normally change throughout the day, varying as

much as 1.0°C (1.8°F) between the early morning and the late
afternoon.

• The point of highest body temperature is usually reached between

1600 and 1800 hours (4:00 pm and 6:00 pm), and the lowest point is
reached during sleep between 0400 and 0600 hours (4:00 am and
6:00 am).

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 Factors Affecting Body Temperature cont’d
3. Exercise
Hard work or strenuous exercise can increase body temperature
to as high as 38.3°C to 40°C (101°F to 104°F) measured rectally.
4. Hormones
• Women usually experience more hormone fluctuations than
men.
• In women, progesterone secretion at the time of ovulation
raises body temperature by about 0.3°C to 0.6°C (0.5°F to
1.0°F) above basal temperature.

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 Factors Affecting Body Temperature cont’d

5. Stress
• Stimulation of the sympathetic nervous system can
increase the production of epinephrine and
norepinephrine, thereby increasing metabolic activity and
heat production.
• Nurses should anticipate that a highly stressed or anxious
client could have an elevated body temperature for that
reason.

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 Factors Affecting Body Temperature cont’d

6. Environment.

• Extremes in environmental temperatures can affect a

person’s temperature regulatory systems.

• If the temperature is assessed in a very warm room and

the body temperature cannot be modified by convection,
conduction, or radiation, the temperature will be elevated.

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 Factors Affecting Body Temperature cont’d

• Similarly, if the client has been outside in cold weather

without suitable clothing, or if a medical condition
prevents the client from controlling the temperature in
the environment (e.g., the client has altered mental status
or cannot dress self), the body temperature may be low.

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 Alterations in Body Temperature

• The normal range for adults is considered to be

between 36°C and 37.5°C (96.8°F to 99.5°F).
Aveargely= 37.2 °C

• There are two primary alterations in body

temperature: pyrexia and hypothermia.

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Alterations in Body Temperature cont’d

PYREXIA

• A body temperature above the usual range is called pyrexia,

hyperthermia, or (in lay terms) fever. Eg 38.0 °C

• A very high fever, such as 41°C (105.8°F), is called hyperpyrexia.

• The client who has a fever is referred to as febrile; the one who does

not is afebrile.

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 Alterations in Body Temperature cont’d

• Four common types of fevers are intermittent, remittent, re-

lapsing, and constant.

• During an intermittent fever, the body temperature alternates at

regular intervals between periods of fever and periods of normal or

subnormal temperatures.

• An example is with the disease malaria.

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Alterations in Body Temperature cont’d

• During a remittent fever, such as with a cold or influenza, a wide

range of temperature fluctuations (more than 2°C [3.6°F]) occurs
over a 24-hour period, all of which are above normal.

• In a relapsing fever, short febrile periods of a few days are

interspersed with periods of 1 or 2 days of normal temperature.

• During a constant fever, the body temperature fluctuates minimally

but always remains above normal. This can occur with typhoid fever.

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 Alterations in Body Temperature cont’d

• A temperature that rises to fever level rapidly following a normal

temperature and then returns to normal within a few hours is called
a fever spike.

• Bacterial blood infections often cause fever spikes.

• In some conditions, an elevated temperature is not a true fever.

• Two examples are heat exhaustion and heat stroke.

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Alterations in Body Temperature cont’d

• Heat exhaustion is a result of excessive heat and dehydration. Signs

of heat exhaustion include paleness, dizziness, nausea, vomiting,
fainting, and a moderately increased temperature (38.3°C to 38.9°C
[101°F to 102°F]).

• Persons experiencing heat stroke generally have been exercising in

hot weather, have warm, flushed skin, and often do not sweat.

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Alterations in Body Temperature cont’d

• They usually have a temperature of 41.1°C (106°F) or higher, and

may be delirious, unconscious, or having seizures.

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46
Assessing Body Temperature

• The most common sites for measuring body temperature are oral,
rectal, axillary, tympanic membrane, and skin/temporal artery.

• Each of the sites has advantages and disadvantages .

• The body temperature may be measured orally.

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 Assessing Body Temperature cont’d

• If a client has been taking cold or hot food or fluids or smoking, the
nurse should wait 30 minutes before taking the temperature orally
to ensure that the temperature of the mouth is not affected by the
temperature of the food, fluid, or warm smoke.

• Rectal temperature readings are considered to be very accurate.

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 Assessing Body Temperature cont’d

• Rectal temperatures are contraindicated for clients who are

undergoing rectal surgery, have diarrhea or diseases of the rectum,
are immunosuppressed, have a clotting disorder, or have significant
hemorrhoids.

• The axilla is often the preferred site for measuring temperature in

newborns because it is accessible and safe.

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 Assessing Body Temperature cont’d

• Axillary temperatures are lower than rectal temperatures.

• Some clinicians recommend re- checking an elevated axillary

temperature with one taken from another site to confirm the degree
of elevation.

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 Assessing Body Temperature cont’d

• Adult clients for whom the axillary method of temperature

assessment is appropriate include those for whom other
temperature sites are contraindicated.

• The tympanic membrane, or nearby tissue in the ear canal, is a

frequent site for estimating core body temperature.

• However, tympanic temperature measurements have been shown to

be imprecise.

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 Assessing Body Temperature cont’d

• If the probe fits too loosely in the ear canal, the reading can be
lower than the true value.

• Electronic tympanic thermometers are found extensively in both

inpatient and ambulatory care settings.

• The temperature may also be measured on the forehead using a

chemical thermometer or a temporal artery thermometer.

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 Assessing Body Temperature cont’d

• Forehead temperature measurements are most useful for infants

and children when a more invasive measurement is not necessary.

• However, temporal artery temperature measurements have shown

inconsistent reliability.

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 Advantages and Disadvantages of Sites Used for Body
Temperature Measurements
Site Advantages Disadvantages
Oral Accessible Thermometers can break if bitten. Inaccurate if client has
and just ingested hot or cold food or fluid or smoked. Could
convenient. injure the mouth following oral surgery.

Rectal Reliable Inconvenient and more unpleasant for clients; difficult for
measurement client who cannot turn to the side. Could injure the
rectum. Presence of stool may interfere with
thermometer placement.

Axillary Safe and The thermometer may need to be left in place a long
noninvasive time to obtain an accurate measurement.

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 Advantages and Disadvantages of Sites Used for
Body Temperature Measurements
Site Advantages Disadvantages
Tympanic Readily Can be uncomfortable and involves risk of injuring the
membrane accessible; membrane if the probe is inserted too far. Repeated
reflects the measurements may vary. Right and left
core measurements can differ. Presence of cerumen can
temperature affect the reading
; very fast

Temporal Safe and Requires electronic equipment that may be expensive

artery noninvasive; or unavailable. Variation in technique needed if the
very fast client has perspiration on the forehead.

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Sites for Assessing Body Temperature

• Contraindications of oral thermometer

1. The child under 6 years .
2. Unconscious patients .
3. Psychiatric patients .
4. Patient who cannot breath from his nose
5. Mouth surgery or infection .
6. Patient on oxygen mask.

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Sites for Assessing Body Temperature

• Contraindications of rectal thermometer

1. rectal surgery .
2. rectal disorders ( hemorrhoids. Rectal fissure..etc.).
3. diarrhea
•

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Types of thermometers

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Types of thermometers
• Digital thermometers. (fastest and most accurate )
• Electronic ear thermometers
• Forehead thermometers.
• Plastic strip thermometers.
• Pacifier thermometer
• Glass and mercury thermometers

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 TYPES OF THERMOMETERS

• Traditionally, body temperatures were measured using mercury-in-

glass thermometers.

• Such thermometers, however, can be hazardous due to exposure to

mercury, which is toxic to humans, and broken glass should the
thermometer crack or break.

• Hospitals no longer use mercury-in-glass thermometers, and several

cities have banned the sale and manufacture of them.

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 TYPES OF THERMOMETERS cont’d

• However, the nurse may still encounter this type of thermometer,

especially in the home.

• In some cases, plastics have replaced glass and safer chemicals (e.g.,
gallium) have replaced mercury in modern versions of the
thermometer.

• Although the amount of mercury in a thermometer (or in a fluorescent

light bulb) is minimal, should it break, cleanup involves several “dos and
don’ts.”

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 TYPES OF THERMOMETERS cont’d

• Unsealed mercury slowly vaporizes into the air and these mercury
vapors are toxic.

• Electronic thermometers can provide a reading in only 2 to

60 seconds, depending on the model.

• The equipment consists of an electronic base, a probe, and a probe

cover, which is usually disposable.

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 Types Of Thermometers cont’d

• Two special types of oral thermometers are basal and hypothermia.

• A basal thermometer is calibrated with 0.1°F intervals and is for

fertility purposes, indicating the temperature rise that is associated
with ovulation.

• Hypothermia thermometers have a greater low range than everyday

thermometers, usually measuring temperatures from 27.2°C to
42.2°C (81°F to 108°F).

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 TYPES OF THERMOMETERS cont’d

• Chemical disposable thermometers are also used to measure body

temperatures.

• Chemical thermometers have liquid crystal dots or bars that change

color to indicate temperature.

• Some of these are single use and others may be reused several
times.

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 TYPES OF THERMOMETERS cont’d
• To read the temperature, the nurse notes the highest reading
among the dots that have changed color.

• These thermometers can be used orally, rectally, or in the axilla.

• Temperature-sensitive tape may also be used to obtain a general

indication of body surface temperature.

• It does not indicate the core temperature.

• The tape contains liquid crystals that change color ac- cording to
temperature.

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Types Of Thermometers Cont’d

• When applied to the skin, usually of the forehead or abdomen, the

temperature digits on the tape respond by changing color.

• The skin area should be dry.

• After the length of time specified by the manufacturer (e.g., 15

seconds), a color appears on the tape.

• This method is particularly useful at home and for infants whose

temperatures are to be monitored.

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Types Of Thermometers cont’d

• Infrared thermometers sense body heat in the form of infrared

energy given off by a heat source, which, in the ear canal, is
primarily the tympanic membrane.

• The infrared thermometer makes no contact with the tympanic

membrane.

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 Types Of Thermometers cont’d

• Temporal artery thermometers determine temperature using a

scanning infrared thermometer that compares the arterial
temperature in the temporal artery of the forehead to the
temperature in the room and calculates the heat balance to
approximate the core temperature of the blood in the pulmonary
artery.

• The probe is placed in the middle of the forehead and then drawn
laterally to the hairline.

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 Types Of Thermometers cont’d

• If the client has perspiration on the forehead, the probe is also

touched behind the earlobe so the thermometer can compensate
for evaporative cooling.

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 TEMPERATURE SCALES

• Sometimes a nurse needs to convert a body temperature reading in

Celsius (centigrade) to Fahrenheit, or vice versa.

• Although the conversion can be accomplished using several different

formulas, the most common is described here.

• To convert from Fahrenheit to Celsius, deduct 32 from the

Fahrenheit reading and then multiply by the fraction 5/9; that is:

• C = (Fahrenheit temperature -32) x 5/9

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 TEMPERATURE SCALES cont’d

• For example, when the Fahrenheit reading is 104 (1000F-32) x 5/9 =

(72) x 5/9 = 400c

• To convert from Celsius to Fahrenheit, multiply the Celsius reading

by the fraction 9/5 and then add 32; that is: F = (Celsius temperature
x 9/5) + 32

• For example, when the Celsius reading is 40: F = (400c x 9/5) + 32 =

(72 1 32) = 1040F.

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 Thermometers.

• Four types of thermometers are commonly available for measuring

body temperature: electronic, infrared, digital, and disposable
chemical dot.

• Mercury-in-glass thermometers are outmoded in the health care

setting because of the environmental hazards of mercury.

• However, some patients may still use mercury-in-glass

thermometers at home.

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 Thermometers cont’d

• If you find a mercury-in-glass thermometer in the home, teach the

patient about safer temperature devices and encourage appropriate
disposal of the hazardous device.

• Each device measures temperature in either the Celsius or the

Fahrenheit scale.

• Electronic thermometers allow you to convert scales by activating a

switch.

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Part of a mercury thermometer

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Part of a electronic thermometer

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Mercury-in-glass Thermometers

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 Electronic Thermometers

• Electronic thermometers have a rechargeable battery-powered

display unit, a thin wire cord, and a temperature-processing probe
or sensor covered by a disposable probe cover.

• Separate probes are available for oral (blue tip) and rectal (red tip)
use.

• You obtain axillary temperatures with the oral probe.

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 Electronic Thermometers

• Electronic thermometers provide two modes of operation, 4-second

predictive temperatures and 3-minute standard temperatures.

• In daily clinical situations the 4-second predictive is more commonly

used.

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Electronic Thermometers

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 Infrared Thermometer

• An infrared thermometer relies on thermal radiation to measure

body temperature.

• The tympanic membrane thermometer has an otoscope-like

speculum with an infrared sensor tip that detects heat radiated
from the tympanic membrane of the ear.

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 Infrared Thermometer Cont’d

• Temporal artery thermometers determine temperature using a

scanning infrared thermometer that compares the arterial
temperature in the temporal artery of the forehead to the
temperature in the room and calculates the heat balance to
approximate the core temperature of the blood in the pulmonary
artery.

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 Infrared Thermometer cont’d

• Within seconds after placement in the ear canal and pressing the
scan button, a sound signals when the peak temperature has been
measured, and a reading appears on the display unit.

• The temporal artery thermometer measures blood flow through the

superficial temporal artery.

• Proper technique involves sweeping an infrared handheld scanner

across the forehead then just behind the ear.

• After scanning is complete, a reading appears on the display unit.

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Infrared Thermometer

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 Digital Thermometer

• A digital thermometer contains a probe connected to a

microprocessor chip, which translates signals into degrees and sends
a temperature measurement to a digital display.

• You use a digital thermometer for oral, rectal, and axillary

measurements.

• The rectal temperature is still the gold standard for estimating core
body temperature, but the thermometer is difficult to use in older
adults.

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Digital Thermometer

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 Chemical Thermometers cont’d

• Single-use or reusable chemical thermometers are thin strips of

plastic with a temperature sensor on one end (Fig. 15.4).

• The sensor consists of chemically impregnated dots that change

colour at different temperatures.

• In the Celsius version there are 50 dots, each representing

temperature increments of 0.1° C over a range of 35.5° C to 40.4° C.

86
Chemical Thermometers cont’d

• The Fahrenheit version has 45 dots with increments of 0.2° F over a

range of 96° F to 104.8° F.

• Chemicals on the thermometer change colour to reflect

temperature reading, 3 minutes for axilla and 1 minute for oral.

• Single-use chemical thermometers are useful in caring for patients in

emergency departments or in protective isolation and screening
temperatures, especially in infants and young children.

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 Chemical Thermometers cont’d

• You need to confirm readings with electronic thermometers when making

treatment decisions.

• Another form of disposable chemical thermometer is a temperature-

sensitive patch or tape.

• Applied to the forehead or abdomen, temperature-sensitive areas of the

patch change color at different temperatures. Home disposable
thermometers are useful for temperature screening but are not as
accurate as non-disposable electronic thermometers (Counts et al.,
2014).

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Chemical Thermometers.

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Procedure for assessing body temperature

1.Wash your hands.

2. Confirm patient

3. Prepare all required equipment

4. Explain the purpose and the procedure to the client.

5. Close doors and/or use a screen.

6. Take the thermometer and wipe it with cotton swab from bulb
towards the tube.

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 Procedure for assessing body temperature
cont’d
7.Shake the thermometer with strong wrist movements until the
mercury line falls to at least 95 ℉ (35 ℃).

8.Assist the client to a supine or sitting position.

9. Move clothing away from shoulder and arm.

10.Be sure the client’s axilla is dry. If it is moist, pat it dry gently before
inserting the thermometer.

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 Procedure For Assessing Body Temperature
cont’d
11. Place the bulb of thermometer in hollow of axilla at anterior
inferior with 45 degree or horizontally.

12. Keep the arm flexed across the chest, close to the side of the body.

13.Hold the glass thermometer in place for 3minutes.

14.Remove and read the level of mercury of thermometer at eye level.

15. Shake mercury down carefully and wipe the thermometer from the
stem to bulb with spirit swab.

92
 Procedure For Assessing Body Temperature
cont’d

16. Explain the result and instruct him/her if he/she has fever or
hypothermia.

17. Dispose of the equipment properly. Wash your hands.

18. Replace all equipment in proper place.

19. Record in the client’s chart and give signature on the chart.

20. Report an abnormal reading to the senior staff.

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 Special considerations

INFANTS

• The body temperature of new-borns is extremely labile, and new-

borns must be kept warm and dry to prevent hypothermia.

• Using the axillary site, you need to hold the infant’s arm against the
chest.

• The axillary route may not be as accurate as other routes for

detecting fevers in children.

94
 Special Considerations cont’d

• The tympanic route is fast and convenient.

• Place the infant supine and stabilize the head.

• Pull the pinna straight back and slightly downward.

• Remember that the pinna is pulled upward for children over 3 years
of age and adults, but downward for children younger than age 3.

• Direct the probe tip anteriorly and insert far enough to seal the canal.

• The tip will not touch the tympanic membrane.

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 Special Considerations cont’d

• Avoid the tympanic route in a child with active ear infections or

tympanic membrane drainage tubes.

• The tympanic membrane route may be more accurate in

determining temperature in febrile infants.

• When using a temporal artery thermometer, touching only the

forehead or behind the ear is needed.

• The rectal route is least desirable in infants.

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Variation In Temperature

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• THANK YOU !

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