DEFINITION

Measuring Body Temperature is a clinical procedure to assess the heat produced by the body which is measured using a clinical thermometer, that provides a baseline data for subsequent Medical Intervention

COMMON ROUTES FOR ASSESSING BODY TEMPERATURE

• Oral
• Rectal
• Axilla
• Tympanic Membrane

INDICATIONS

• As a routine Assessment on Admission of the patient to establish the baseline data
• To monitor the patient’s condition regularly & identify any changes in health status or progress of the client
• Temperature is assessed before & after any Nursing Intervention to monitor its effectiveness
• Before transferring & receiving the client from another ward or area
• To assess the General Health Condition of the patient

PURPOSES

• To identify the general health status of the client
• To monitor for any changes in health
• To provide accurate Nursing Intervention by evaluating degree of body temperature
• Measuring body temperature is important as number of diseases are characterized by change in body temperature

CONTRAINDICATION

• ORAL TEMPERATURE

1. Inability to hold thermometer in the mouth
2. Psychiatric or unconscious/ disoriented patients as they can bite the thermometer
3. Infants & small children
4. Surgery/ Trauma in the Oral cavity
5. Patients with Dental & Oral Infections
6. Dyspneic & Breathless clients
7. Intubated & Ventilated Clients
8. Agitated/ violent or restless clients who do not co-operate
9. Trauma in the face & Mouth
10. Patient who had taken hot or cold drink within 30 mins

• RECTAL TEMPERATURE

1. Rectal Surgeries
2. Rectal Disorders like piles, fistula & fissures
3. Diarrheal diseases
4. Clients with bleeding disorders & low platelet count
5. Acute Cardiac client

• AXILLARY TEMPERATURE

1. Axillary Surgeries
2. Lesions in the Axilla
3. Fracture or trauma of the upper arm

S.No	Equipment	Rationale
1.	A clean tray containing – Thermometer	To Check the temperature
2.	A bottle containing Antiseptic Solution Dettol 1:40 Savlon 1:20 Alcohol Swabs	To disinfect the thermometer as needed
3.	A bottle Containing Clean water	To wipe the thermometer before placing in patient’s body
4.	Two S.S bowl (1 containing wet cotton & another dry cotton)	To wipe the thermometer before & after recording Temperature
5.	A Lubricant like K-Y Jelly	In case of checking Rectal Temperature to prevent Injury to the rectum
6.	A Sweep Second Watch	To Calculate the time while using mercury thermometer
7.	Kidney Tray/ Paper Bag	To Collect the wastes
8.	Vital Signs Chart	To record the temperature

Formulas for Conversion of Temperature

       Conversion of Fahrenheit to Celsius:

• C= (F-32) X 5/9

Conversion of Celsius to Fahrenheit:

• F= C X 9/5 + 32

Procedure/Techniques
Mercury (Glass) Thermometer:

• Wash hands thoroughly
• Remove the thermometer out of the holder
• Hold the thermometer by the end opposite the colored (red, blue, or silver) tip.
• Clean the thermometer with antiseptic/ soap solution or rubbing alcohol.
• Rinse/ rub with wet cotton in a circular motion from the bulb to the stem
• Turn the thermometer in your hand until the red, blue, or silver line is seen. The line should read less than 96° F (35.6° C). If the line reads more than 96° F (35.6° C), firmly shake the thermometer downward several times over a couch or bed. This will keep it from breaking if it slips out of your hand.
• Check the thermometer again to make sure it reads less than 96°F (35.6°C).
• Explain the Procedure to the Client
• Make Sure the client has not drunk hot/ cold drinks atleast 30 minutes prior to the procedure.
• Place the bulb of the thermometer under the patient’s tongue
• Close the lips gently around the thermometer. Do not bite the glass thermometer.
• The thermometer should be placed under the tongue for 3 minutes.
• Remove the thermometer without touching the tip.
• Gently wipe the thermometer with dry cotton in a straight manner.
• Hold the thermometer at eye level.
• Slowly turn the thermometer until the red, blue, or silver-colored line is seen. Each long mark on the thermometer is the same as 1 degree. Short marks are the same as 0.2 degree.
• Document the readings in the Vital Signs Chart.
• Wash the thermometer with soap and warm water. Do not use hot water because it may break the thermometer.

Procedure/Techniques
Digital Thermometer:

• Take the thermometer out of its holder.
• Put the tip into a new throw-away plastic cover if one is available. If there is no cover clean the pointed end (probe) with antiseptic solution or rubbing alcohol and clean with wet cotton.
• Place the tip of the thermometer under the tongue by pressing the button.
• Close the lips gently around the thermometer.
• The thermometer is kept under the tongue until the digital thermometer beeps.
• Remove the thermometer when numbers show up in the “window
• The number in the window shows the body temperature.
• Document the readings in Vital Signs Chart with date & Time.
• Remove or eject the throw-away cover if you used one.
• Place the thermometer back in its holder.

Special Considerations:

• In case of Axillary Temperature the armpit has to be cleaned and pat dry before placing the thermometer and the temperature must be checked for 5 minutes in axilla and the readings must be added with 1ᵒ F to obtain accurate readings.
• In case of Rectal temperature rectal thermometers must be used and should be lubricated with K-Y Jelly before Inserting in to the rectum to prevent Injury and the readings must be subtracted with 1ᵒF to obtain accurate readings because of its rich blood Supply
• Any deviations from the normal Temperature must be immediately reported & recorded to take Therapeutic Action.