Vital Signs – Temperature

Equipment:

  • Thermometer (selected on the basis of site used)
  • Soft tissue or wipe
  • Alcohol swab
  • Water-soluble lubricant (for rectal measurements only)
  • Pen and vital sign flow sheet
  • Record form or EHR
  • Clean gloves
  • Plastic thermometer sleeve
  • Disposable probe or sensor cover
  • Towel (if utilizing the temporal artery method)

Steps:

  1. WIIAPA:
    1. Wash hands
    2. Introduce self
    3. Identify patient (use 2 identifiers)
    4. Allergies – don’t forget food allergies
    5. Plan of care
    6. Assess patient
  1. Determine appropriate measurement site and device for patient.
  2. Determine previous baseline temperature and measurement site.
  3. Help patient to comfortable position that provides easy access to temperature measurement site. Provide privacy.
  4. Obtain temperature reading.

For oral temperature (electronic):

  • Apply clean gloves when there is risk for exposure to respiratory secretions or facial or mouth wound drainage
  • Remove thermometer pack from charging unit. Attach oral thermometer probe stem (blue tip) to thermometer unit. Grasp top of probe stem, being careful not to apply pressure on ejection button.
  • Slide disposable plastic probe cover over thermometer probe stem until cover locks in place.
  • Ask patient to open mouth; gently place thermometer probe under tongue in posterior sublingual pocket lateral to center of lower jaw.
  • Ask patient to hold thermometer probe with lips closed.
  • Leave thermometer probe in place until audible signal indicates completion and patient’s temperature appears on digital display; remove thermometer probe from under patient’s tongue.
  • Push ejection button on thermometer probe stem to discard plastic probe cover into appropriate receptacle.
  • If wearing gloves, remove, dispose in appropriate receptacle, and perform hand hygiene.
  • Return thermometer probe stem to storage position of thermometer unit.

For rectal temperature (electronic):

  • Draw curtain around bed and/or close room door. Assist patient to side-lying or Sims’ position with upper leg flexed. Move aside bed linen to expose only anal area. Keep patient’s upper body and lower extremities covered with sheet or blanket.
  • Apply clean gloves. Cleanse anal region when feces and/or secretions are present. Remove soiled gloves and reapply clean gloves.
  • Remove thermometer pack from charging unit. Attach rectal thermometer probe stem (red tip) to thermometer unit. Grasp top of probe stem, being careful not to apply pressure on ejection button.
  • Slide disposable plastic probe cover over thermometer probe stem until cover locks in place.
  • Using a single-use package, squeeze a liberal amount of lubricant on tissue. Dip probe cover of thermometer, blunt end, into lubricant, covering 2.5 to 3.5 cm (1 to 1.5 inches) for adult.
  • With nondominant hand separate patient’s buttocks to expose anus. Ask patient to breathe slowly and relax.
  • Gently insert thermometer into anus in direction of umbilicus 3.5 cm (1.5 inches) for adults. Do not force thermometer.
  • Once positioned, hold thermometer probe in place until audible signal indicates completion and patient’s temperature appears on digital display; remove thermometer probe from anus.
  • Push ejection button on thermometer stem to discard plastic probe cover into appropriate receptacle. Wipe probe stem with alcohol swab, paying particular attention to ridges where probe stem connects to probe.
  • Return thermometer stem to storage position of recording unit.
  • Wipe patient’s anal area with soft tissue to remove lubricant or feces and discard tissue. Help patient to assume a comfortable position.
  • Remove and dispose of gloves in appropriate receptacle. Perform hand hygiene.

For axillary temperature (electronic):

  • Draw curtain around bed and/or close room door. Help patient to supine or sitting position. Move clothing or gown away from shoulder and arm.
  • Remove thermometer pack from charging unit. Attach oral thermometer probe stem (blue tip) to thermometer unit. Grasp top of thermometer probe stem, being careful not to apply pressure on ejection button.
  • Slide disposable plastic probe cover over thermometer stem until cover locks in place.
  • Raise patient’s arm away from torso. Inspect for skin lesions and excessive perspiration; if needed, dry axilla or select alternative site. Insert thermometer probe into center of axilla, lower arm over probe and place arm across patient’s chest.
  • Once thermometer probe is positioned, hold it in place until audible signal indicates completion and patient’s temperature appears on digital display; remove thermometer probe from axilla.
  • Push ejection button on thermometer stem to discard plastic probe cover into appropriate receptacle.
  • Return thermometer stem to storage position of recording unit.
  • Help patient to assume comfortable position, replacing linen or gown.
  • Perform hand hygiene.

For tympanic membrane:

  • Help patient to assume comfortable position with head turned toward side, away from you. If patient has been lying on one side, use upper ear. Obtain temperature from patient’s right ear if you are right-handed. Obtain temperature from patient’s left ear if you are left-handed.
  • Note if there is an obvious presence of cerumen (earwax) in patient’s ear canal.
  • Remove thermometer handheld unit from charging base, being careful not to apply pressure to ejection button.
  • Slide disposable speculum cover over otoscope-like lens tip until it locks in place. Be careful not to touch lens cover.
  • Insert speculum into ear canal following manufacturer instructions for tympanic probe positioning by pulling ear pinna backward, up, and out for an adult. For a child less than three years of age, pull pinna down and back and point covered probe toward midpoint between eyebrow and sideburns. For a child older than three years, pull pinna up and back. Regardless of age, next, move the thermometer in a figure-eight pattern and fit speculum tip snug in canal, pointing toward nose.
  • Once positioned, press scan button on handheld unit. Leave speculum in place until audible signal indicates completion and patient’s temperature appears on digital display.
  • Carefully remove speculum from auditory meatus. Push ejection button on handheld unit to discard speculum cover into appropriate receptacle.
  • If temperature is abnormal or second reading is necessary, replace probe cover and wait 2 minutes before repeating in same ear or repeat measurement in other ear. Consider an alternative temperature site or instrument.
  • Return handheld unit to thermometer base.
  • Help patient assume comfortable position.
  • Perform hand hygiene.

For temporal artery:

  • Ensure that forehead is dry; dry with towel if needed.
  • Place sensor firmly on patient’s forehead.
  • Press red scan button with your thumb. Slowly slide thermometer straight across forehead while keeping sensor flat and firmly on skin. Keeping scan button depressed, lift sensor after sweeping forehead and touch sensor on neck just behind earlobe. Read temperature when clicking sound during scanning stops. Release scan button.
  • Gently clean sensor with alcohol swab, return to storage unit and perform hand hygiene.
  1. Inform patient of temperature reading and record measurement.
  2. Return thermometer to charger.
  3. Document

 

 

Reference: Laplante, N., Perry, A.G, Potter, P.A., & Ostendorf, W.R. (2022). Clinical Nursing Skills & Techniques (10th ed, pp. 73-78) Elsevier