Definition
Assessing body temperature is a core component of vital signs monitoring it reflects the body’s ability to maintain thermal balance and can be an early indicator of infection, inflammation, or systemic dysfunction.
Common Method
- Oral
- Rectal
- Axillary
- Tympanic membrane
Indications
- It is a routine part of assessment for establishing baseline data upon admission.
- Any change in patient’s condition should be monitored according to the agency policy.
- Temperature should be checked before, during, and after administration of any drug that affects temperature control function
- If there is any change in the general condition of the patient.
- It should be checked before and after any nursing intervention that affects the body temperature of the patient.
Purposes
- To assess the general health status of the patient.
- To assess for any alteration in the health status
Contraindications
A. Oral method:
- Patients who are not able to hold a thermometer in their mouth
- Patients who may bite the thermometer, such as psychiatric patients
- Infants and small children
- Surgery/infection in oral cavity
- Trauma to face/mouth
- Mouth breathers
- Patients with history of convulsion
- Unconscious/semiconscious/disoriented patients
- Patients having chilis
- Uncooperative patients
- Patients who cannot follow instructions.
B. Rectal method
- Patients after rectal surgery
- Any rectal pathology (piles/tumor)
- Patients having difficulty in assuming the required position
- Acute cardiac patients
- Patients having diarrhea
- Patients with reduced platelet count.
C. Axillary method:
Patients with any surgery/lesion in axilla.
Articles
Clean tray containing
- A bottle with disinfectant solution (Dettol 1:40/Savlon 1:20)
- A bottle with water
- Thermometer (rectal thermometer in case of rectal method)
- A small bowl with cotton swabs
- Paper bag/kidney tray
- Pen
- Flow sheet/graphic chart/paper
- Lubricant (for rectal method)
Use two bottles of antiseptic solution and one bottle of water if more than one thermometer is used.
9. A bowl containing dry gauze pieces to wipe axilla.
Procedure
| Nursing action | Rationale | |
| 1 | Ascertain the method of taking temperature, explain the procedure to patient, and instruct him/her how to cooperate. In case of oral method, ensure that the patient had not taken any hot or cold food and fluids orally or smoked about 15-30 Position of the min prior to the procedure. For rectal method, provide privacy and position the patient in a Sim’s position. Position young children laterally with knees flexed or prone across lap. In axillary method, expose axilla and pat dry with a towel. Avoid vigorous rubbing. | Causes alteration in temperature reading. Position of the body ensures easy access to insert the thermometer. Friction produced by rubbing can cause increase in the temperature. |
| 2 | During procedure Wash hands | |
| 3 | Prepare equipment If the glass thermometer is placed in disinfectant solution, transfer it to a container containing plain water using dominant hand. Wipe the thermometer dry, using a clean cotton swab by rotatory motion from bulb to stem. Shake the thermometer to bring down the mercury level (if needed) by holding it between the thumb and forefinger at the tip of the stem. Shake till the mercury is below 35°C (95°F), | Ensures complete removal of disinfectant and reduces irritation to tissues. Usage of dominant hand reduces chances of accidental breakage. Wiping down the thermometer from an area of least contamination to an area of highest contamination prevents spread of organisms. Reduces chances of erroneous reading of temperature. |
| 4 | Checking the temperature a. Oral method Place the thermometer bulb at the base of tongue at the side of frenulum in the posterior sublingual pocket. Instruct the patient to close the lips and not the teeth around the thermometer. Leave the thermometer in place for 2-3 min. b. Rectal method Don clean pair of gloves. Apply lubricant on the bulb of thermometer using a cotton ball. With nondominant hand, expose the anus raising upper buttocks. Instruct patient to breathe deeply and insert thermometer into anus. 3.5-4 cm in adults 1.5 cm in infant 2.5 cm in child Do not force the insertion. Hold the thermometer in place for 1-2 min. c. Axillary method Place the thermometer bulb in the center of the axilla. Place the arm tightly across the chest to hold the thermometer in place. Hold the thermometer in place for 3-5 minutes. | Blood supply is more in this area and the reading reflects the temperature of blood in the larger blood vessels. Clenching the teeth may break the thermometer and cause injury. Ensures accurate recording. Lubricant facilitates easy insertion of thermometer without irritating the mucous membrane. Deep breath helps to relax the external sphincter, thereby facilitating easy insertion. Deep breath helps to relax the external sphincter, thereby facilitating easy insertion. Ensures accurate recording. Prevents the thermometer from falling down. ensure accurate recording. |
| 5 | Removal of thermometer Wipe down the thermometer using a cotton ball from stem to bulb in a rotatory manner. | wiping from an area of least contamination to an area of most contamination will help in preventing spread of microorganisms. |
| 6 | Read the temperature by holding the thermometer at eye level and rotate it till reading is visible; read it accurately. | Holding at eye level prevents error in reading. |
| 7 | Shake the thermometer to bring down the mercury level | |
| 8 | After procedure Clean the thermometer using soap and water. | This removes any organic material sticking to the thermometer. |
| 9 | Dry and store it in a disinfectant solution. | |
| 10 | Document the temperature readings. | Normal body temperature is 37°C (98.4°F). |
| 11 | Wash hands. | Reduces the risk of transmission of microorganisms |
| 12 | Replace articles. |
Preparation of a Child Patient
- Talk to the child and explain what will be done.
- Perform the examination in an appropriate and nonthreatening manner.
- Place all strange and potentially frightening articles out of sight.
- Provide privacy especially for school age and adolescent children.
- Encourage child to handle/use actual equipment/article on a doll, family member, or staff.
- Observe behaviors that signal child’s readiness to cooperate.
- Involve child in the procedure.
- Explain each step in a simple language.
- Reassure the child throughout the procedure.
- Discuss the findings with family at the end.
- Praise the child for cooperation and give small rewards, such as a sticker.
Normal Temperature in Children
| Age | centigrade | Fahrenheit |
| 3-11 months | 37.4 | 99.0 |
| 1-3 year | 37.6 | 99.04 |
| 4-7 year | 37 | 98.6 |
| 8-13 year | 36.8-37 | 98-98.4 |
Special Considerations
- It is always best to use separate thermometers for each patient
- When individual thermometer is not used in patient care-units (wards), axillary method is recommended.
- For converting temperature from centigrade to Fahrenheit, following conversion formula can be used. C=5/9x(F-32) C-centigrade; F = Fahrenheit
- Document the reading on the graph chart with blue pen.
- A normal axillary temperature is between 90.6°F and 98°F
- Normal axillary temperature is usually a degree lower than the oral temperature and 2° lower than the rectal temperature.
Paediatric Variations
Methods for assessing body temperature in pediatric patients include:
- Skin temperature sensors
- Tympanic thermometer.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884.
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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