Skill 01[1].Temperature.pdf

SKILL 1

Temperature

EQUIPMENT

Thermometer appropriate for site (glass [mercury] or elec-

tronic) (Figures 1 and 2)

Lubricant (rectal)

Gloves, nonsterile (rectal)

Tissue

ORAL TEMPERATURE

SAFETY

1. Oral temperatures contraindicated in following circum-

stances:

a. Uncooperative or unconscious children.

b. Following oral surgery.

c. Children under 2 years of age.

2. Oral temperatures are inaccurate in children receiving

oxygen therapy. Oxygen cools the mouth and tachypnea

leads to a low reading.

3. Use a glass thermometer for children over 6 years of

age.

FIGURE 1 Centigrade and Fahrenheit

temperature chart.

PROCEDURE

1. Steps 1–4 of General Guidelines.

2. Select thermometer: glass with oral bulb (usually blue

tipped) or electronic.

3. Prepare thermometer.

a. Glass thermometer.

1. If stored in a chemical solution, remove from

storage container and rinse under cool water.

Removes disinfectant, which can irritate oral

mucosa and have an objectionable taste. Cool

water prevents the expansion of mercury.

2. Use tissue to dry from bulb end toward fingertips.

Wipe from least to most contaminated.

3. Check mercury level. It should be 35° C (95° F)

or below. Must be below normal body tempera-

ture to ensure accurate reading.

4. If not below 35° C (95° F), grasp the nonbulb

end of the thermometer firmly with thumb and

forefinger and shake briskly by snapping the wrist

in a downward motion.

b. Electronic thermometer.

1. Remove from charger.

2. Place disposable sheath over the probe. Reduces

transmission of microorganisms.

3. Grasp tip of probe stem, avoiding pressure on the

ejection button. Pressure on the ejection button

releases the sheath from the probe.

4. Place the tip of the thermometer under the tongue

along the gumline to the posterior sublingual pocket.

Ensures contact with the large blood vessels under the

tongue.

FIGURE 2 Oral and rectal thermometers.

GENERAL GUIDELINES FOR VITAL SIGNS

1. Check record for baseline and factors (age, illness, med-

ications, etc.) influencing vital signs. Provides parame-

ters and helps in device and site selection.

2. Gather equipment, including paper and pen, for record-

ing vital signs. Promotes organization and efficiency.

3. Wash hands. Reduces transmission of microorganisms.

4. Prepare child and family in a quiet and nonthreatening

manner. Enhances cooperation and participation;

reduces anxiety and fear, which can affect readings.

NOTE: Infants and young children may be quiet and

more cooperative if vitals signs are obtained while

child is sitting on caregiver’s lap.

continued

SKILL 1

Temperature

continued

5. Instruct the child to close mouth around the thermome-

ter. Maintains appropriate placement, decreases time

needed to obtain accurate reading. Open mouth breath-

ing produces an abnormally low reading.

6. If electronic, turn on scanner and follow manufacturer’s

instructions.

7. Leave under tongue required amount of time. Stay with

child while thermometer in place. Reduces risk of

injury.

a. Glass thermometer: 3–5 minutes as specified by

agency policy. Allows sufficient time to register accu-

rate results.

b. Electronic thermometer: Will sound tone or beep

when finished recording temperature.

8. Remove thermometer and read temperature.

a. Glass thermometer.

1. Wipe with tissue away from fingers toward bulb

end as necessary to read thermometer. Wipe from

most contaminated to least contaminated area.

2. Read at eye level. Rotate slowly until mercury

level visualized. Ensures accurate reading.

b. Electronic thermometer: read digital display.

9. Clean and store thermometer.

a. Glass thermometer.

1. Wipe toward bulb end of thermometer with soft

tissue. Dispose of tissue in accordance with

guidelines for handling body fluids. Reduces

spread of microorganisms; mucus on thermometer

may interfere with effectiveness of disinfectant

solution.

2. Cleanse with cool soapy water and rinse under

cool water. Shake down the thermometer.

Mechanical cleansing removes secretions that pro-

mote growth of microorganisms. Hot water may

cause coagulation of secretions and expansion of

mercury in thermometer.

3. Store according to agency policy.

4. Wash hands. Reduces transmission of microorgan-

isms.

b. Electronic thermometer.

1. Push ejection button and discard disposable

sheath into an appropriate receptacle. Reduces

transmission of microorganisms.

2. Return probe to storage well.

3. Wash hands. Reduces transmission of microorgan-

isms.

4. Return electronic thermometer to storage unit.

RECTAL TEMPERATURE

SAFETY

1. Rectal temperature contraindicated in the following cir-

cumstances.

a. Infants < 1 month of age.

b. Premature infants.

c. Prolapsed rectum.

d. Following rectal surgery.

e. Severe diarrhea.

f. Bleeding tendency, e.g., leukemia, thrombocytope-

nia.

g. Imperforate anus.

PROCEDURE

Taking a rectal temperature is an intrusive procedure repre-

senting an invasion of the child’s body; may cause an

increase in fear of body mutilation, especially in toddlers and

preschoolers. Take a rectal temperature only when neces-

sary.

1. Steps 1–4 of General Guidelines.

2. Select thermometer: glass with rectal bulb (usually red

tipped) or electronic.

3. Provide privacy for child.

4. Prepare thermometer as in Oral Temperature, step 3 of

Procedure.

5. Lubricate the tip of the thermometer with a water-

soluble gel. Reduces friction and promotes ease of inser-

tion. Minimizes irritation of mucus membranes in the

anal canal.

6. Place tissues in easy reach. To wipe anus after removal

of thermometer.

7. Put on nonsterile gloves. Reduces transmission of

microorganisms; protects nurse from contact with body

fluids.

8. Position child. Ensures visualization of anus.

a. Infant: prone position or supine, grasping ankles with

one hand and elevating the legs.

b. Older child: on side with upper knee flexed. Flexing

of the knee relaxes muscles and promotes ease of

insertion.

9. Separate buttocks to expose anal opening and gently

insert thermometer. Instruct older child to take a deep

breath. Gentle insertion decreases discomfort and pre-

vents trauma to mucous membranes. Taking a deep

breath relaxes the anal sphincter. (Figure 3)

continued

SKILL 1

Temperature

continued

AXILLARY TEMPERATURE

SAFETY

1. There are no age restrictions for taking an axillary tem-

perature.

FIGURE 3 Infant position when taking a

rectal temperature.

PROCEDURE

1. Steps 1–4 of General Guidelines.

2. Select thermometer: glass or electronic. Follow agency

guidelines regarding type of thermometer to use, oral or

rectal.

3. Expose axillary area.

4. Make sure axillary skin is dry. Pat dry if necessary.

Prevents a false low reading.

5. Prepare thermometer as in Oral Temperature, step 3 of

Procedure.

6. Place tip of thermometer under the child’s arm, well up

into the axilla. Bring the child’s arm down close to the

body and hold in place. Ensures more accurate measure-

ment; allows thermometer tip to rest against superficial

blood vessels in axilla; brings skin surfaces together, thus

reducing air around the tip of the thermometer that

might affect temperature reading. (Figure 4)

NOTE: If resistance is felt do not force. Remove ther-

mometer and check temperature by another route.

a. Infant: insert 1 / 4 to 1 / 2 inch. Inserting more than 1 / 2

inch may cause rectal perforation.

b. Older child: insert 1–1 1 / 2 inches.

10. If electronic, turn on scanner and follow manufacturer’s

instructions.

11. Leave thermometer in place required amount of time.

Hold thermometer in place and do not leave child

alone. Reduces risk of injury.

a. Glass thermometer: 3–4 minutes as specified by

agency policy. Allowing sufficient time for the ther-

mometer to register results in a more accurate assess-

ment of body temperature.

b. Electronic thermometer: will sound a tone or beep

when finished.

12. Remove thermometer gently in a straight line.

13. Wipe anal area to remove any lubricant and/or fecal

material.

14. Read temperature as in Oral Temperature, step 8 of

Procedure.

15. Reposition child in a comfortable position.

16. Clean and store thermometer as in Oral Temperature,

step 9 of Procedure.

FIGURE 4 Positioning when taking an axil-

lary temperature.

NOTE: Need to remove gloves before washing hands.

continued

SKILL 1

Temperature

continued

7. Leave in place required amount of time.

a. Glass thermometer: 6–10 minutes according to

agency policy. Allowing sufficient time for the ther-

mometer to register results in a more accurate assess-

ment of body temperature.

b. Electronic thermometer: will sound a tone or beep

when finished.

8. Remove thermometer and read as in Oral Temperature,

step 8 of Procedure.

9. Clean and store thermometer as in Oral Temperature,

step 9 of Procedure.

TYMPANIC TEMPERATURE

SAFETY

1. Do not use in infected or draining ear or if lesion or

incision is adjacent to ear.

2. Further study needed regarding accuracy of tympanic

temperature with otitis media, sinusitis, or in premature

infants with small ear canal.

FIGURE 5 Insertion of temperature probe

into child’s ear canal.

PROCEDURE

1. Steps 1–4 of General Guidelines.

2. Select contact infrared tympanic thermometer.

3. Remove probe cover from container and attach probe

cover to probe tip. Prevents contamination.

4. Position child for access to ear. Turn head to one side.

Pull pinna down and back for a child under 3 years of

age and up and back for a child over 3 years of age.

Provides access to ear canal.

draw down the temperature, leading to an abnormally

low reading.

7. Remove probe after temperature is displayed. Read dis-

play.

8. Remove probe cover and discard; replace probe in stor-

age container. Prevents probe damage.

9. Return tympanic thermometer to charging unit.

10. Wash hands. Reduces transmission of microorganisms.

NOTE: Do not use ear on side child has been lying on.

Ear in contact with a surface can build up heat and

give abnormally high reading.

DOCUMENTATION

1. Temperature

2. Route and for tympanic temperature which ear used.

3. Device used.

4. Who notified if finding of concern.

5. Gently insert probe tip into the external ear canal. Use

firm pressure to obtain an adequate seal. Prevents

trauma to the ear canal and ensures accurate tempera-

ture reading. (Figure 5)

NOTE: A better seal (thus a more accurate assessment

of body temperature) is generally achieved using the

right hand to take a temperature from the right ear and

the left hand to take a temperature from the left ear.

6. Quickly achieve a seal making sure the probe tip is

aimed toward the tympanic membrane. As soon as the

probe is in place press the scan button. Measures tem-

perature by measuring infrared energy from tympanic

membrane. Pressure of the probe in the ear canal can

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