Vital Signs
Taking a Temperature
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- » Taking a Temperature
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- » Assessing Apical-Radial Pulse
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- » Obtaining Blood Pressure by the Two-Step Method
- » Measuring Oxygen Saturation with Pulse Oximetry
- » Assessing Pain
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Take the Review Test:
Safety
- Do not use a particular route if the patient has a contraindication to it. Contraindications include the following:
- Oral—Oral surgery or trauma, history of epilepsy, shaking, chills, age (infants and small children), confusion, unconsciousness, and uncooperativeness.
- Rectal—Diarrhea, rectal surgery or disorders, bleeding tendencies, and routine vital signs in newborns. If the thermometer cannot be adequately inserted into the rectum, or if you feel resistance during insertion, remove the thermometer and try using an alternative route to measure the patient’s temperature.
- Axillary—Age (infants and small children) and axillary lesions.
- Tympanic—Cerumen in ear canal, tympanic membrane or other ear surgery, exceptionally young age (infants and children younger than 3 years of age).
- Temporal artery/skin—Allergy to adhesive.
Equipment
(Roll cursor over items to see labels)
Electronic thermometer plus (depending on type of thermometer)
- Disposable speculum covers (tympanic)
- Disposable probe or sensor covers (oral or rectal)
- Plastic thermometer sleeve (mobile vital signs device)
Electronic thermometer plus (depending on type of thermometer)
- Disposable speculum covers (tympanic)
- Disposable probe or sensor covers (oral or rectal)
- Plastic thermometer sleeve (mobile vital signs device)
Electronic thermometer plus (depending on type of thermometer)
- Disposable speculum covers (tympanic)
- Disposable probe or sensor covers (oral or rectal)
- Plastic thermometer sleeve (mobile vital signs device)
Alcohol swab
Alcohol swab
Alcohol swab
Water-soluble lubricant packet (for rectal measurement only)
Clean gloves (optional)
Towel
Electronic thermometer plus (depending on type of thermometer)
- Disposable speculum covers (tympanic)
- Disposable probe or sensor covers (oral or rectal)
- Plastic thermometer sleeve (mobile vital signs device)
PrintableDelegation
The skill of taking a temperature can be delegated to nursing assistive personnel (NAP). Be sure to inform NAP of the following:
- The appropriate route, device, and frequency of temperature measurement
- Any precautions for patient positioning, especially for rectal, tympanic, or temporal measurements
- The usual temperature values and significant changes to report to the nurse
Preparation
- Consider the normal daily fluctuations in the patient’s temperature.
- Determine the patient’s risk for temperature alteration, and assess for signs and symptoms that may accompany such an alteration.
- Identify medications and treatments (anti-inflammatory drugs, steroids, warming or cooling blankets, and fans) that may raise or lower the patient’s temperature.
- Assess for patient factors (age, activity level, hormonal fluctuations, and stress) and external factors (environmental temperature) that may influence the patient’s temperature.
- Determine which route is most appropriate for measuring the patient’s temperature.
- Identify factors that may interfere with accurate oral temperature measurement (e.g., smoking, consuming hot or cold food or fluids, or chewing gum).
- Remember that tympanic temperature will not accurately reflect a change in body temperature during and after exercise, and that the temperature will be affected by devices that warm or cool the ambient environment, such as incubators, radiant warmers, and facial fans.
- Identify factors that may interfere with accurate tympanic temperature measurement (e.g., otitis media, impacted cerumen, hearing aids, ear surgery).
- Assess pertinent laboratory values, such as white blood cell (WBC) count.
- If the patient’s record is available, determine the previous baseline temperature and the route by which it was measured.
- Assess the patient’s knowledge of the procedure.
Follow-up
- If the patient’s temperature was assessed for the first time, establish this temperature as the baseline. Compare this temperature with the acceptable range for the patient’s age group.
- If this was not the first temperature measurement, compare this measurement with the patient’s baseline and with the acceptable temperature range for his or her age group.
- If the patient has a fever, repeat the temperature measurement about 30 minutes after administering prescribed antipyretics and again every 4 hours until the temperature stabilizes.
- Report abnormal findings to the nurse in charge or health care provider.
Documentation
- Record temperature and route.
- Record temperature measurement after administration of specific therapies.
- Report abnormal findings to the nurse in charge or to the health care provider.
Review Questions
1. What will the nurse instruct nursing assistive personnel (NAP) to do when measuring a patient’s rectal temperature using an electronic thermometer?
Place the patient in the Fowler’s position.- Wear sterile gloves during the process.
- Insert the probe in the direction of the knees.
Use the probe with the red tip.
INCORRECT. The patient should be placed in the side-lying Sims’ position when measuring a rectal temperature.
INCORRECT. Sterile gloves are not necessary. Clean gloves are necessary when measuring a rectal temperature.
INCORRECT. The probe should be inserted in the direction of the umbilicus.
CORRECT. The probe with the red tip is used when measuring a rectal temperature.
2. Which of the following is contraindicated with taking a rectal temperature measurement?
- Patient requires assistance to move to a side-lying position.
- Patient has painful and swollen hemorrhoids.
- Patient is incontinent of urine.
- The last temperature recorded was 0.2° F above baseline.
INCORRECT. Needing assistance to move into a side-lying position does not contraindicate rectal temperature measurement.
CORRECT. Rectal temperature measurement should not be performed if the patient has hemorrhoids.
INCORRECT. Incontinence of urine and feces does not contraindicate rectal temperature measurement.
INCORRECT. A slight elevation in temperature from baseline does not contraindicate rectal temperature measurement.
3. Which nursing action best evaluates the effectiveness of an antipyretic medication in a patient with an oral temperature of 101.6° F?
- Assess for physical aches.
- Assess skin temperature by touching the forehead.
- Assess oral temperature 30 minutes after the agent is administered.
- Assess skin color for signs of fever-related flushing.
INCORRECT. Assessing for physical aches is not the best action to evaluate the effectiveness of an antipyretic medication.
INCORRECT. Touching the skin on the forehead is not the best action to determine the effectiveness of the antipyretic medication.
CORRECT. Assessing the oral temperature 30 minutes after an antipyretic medication is administered is a direct measurement of effectiveness of the antipyretic medication.
INCORRECT. Although assessing the skin color for fever-related flushing is important, this is not the best action to determine the effectiveness of the antipyretic medication.
4. Which instruction might the nurse give to nursing assistive personnel (NAP) that is applicable only to tympanic temperature assessment?
- Leave the probe in place until the reading is complete.
- Put on a new disposable probe cover for each patient.
- Gently tug the pinna backward, up, and out before inserting the probe.
- Check for any impacted cerumen in the ear.
INCORRECT. Leaving the probe in place until the reading is complete would be appropriate for other methods of temperature measurement, not just the tympanic route.
INCORRECT. Putting on a new disposable probe cover would be appropriate for other methods of temperature measurement, not just the tympanic route.
CORRECT. Placement of the tympanic thermometer probe is fundamental to the effective measurement of tympanic temperature in an adult patient.
INCORRECT. Checking for impacted cerumen is a nursing responsibility and cannot be delegated to the NAP.
5. Which instruction might the nurse give to nursing assistive personnel (NAP) that is applicable only to temporal artery temperature assessment?
- An accurate temperature reading is obtained with moisture on the forehead.
- Put on a disposable sensor cover before taking the temporal artery temperature.
- Place the sensor flush on the patient’s forehead.
- Obtain the temperature reading on the lower neck.
INCORRECT. The temporal artery reading is affected by skin moisture, and NAP must ensure that the forehead is dry.
INCORRECT. Putting on a new disposable sensor cover is not required to use the temporal artery thermometer. The sensor should be cleaned before and after use with an alcohol swab.
CORRECT. Placement of the sensor on a temporal artery thermometer is flush on the patient’s forehead. The thermometer remains flush on the skin as the NAP slides it across the forehead.
INCORRECT. The sensor confirms the highest temperature reading behind the earlobe.
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