SOP

Mengukur suhu aksila, pediatrik

Introduction
A child's temperature is measured to provide a baseline or to detect a change in status, which could be
related to various conditions, such as hypothermia or infection. Normal temperature usually ranges from
97° to 100.4° F (36.1° C to 38° C). Pediatricians don't consider a fever significant unless it rises above
100.4° F.

Body temperature varies according to the time of day; the child's age, physical activity, and general
health; and the amount of clothing the child is wearing. For example, body temperature tends to be
lower early in the morning than in the late afternoon and early evening.

The axillary route may be used for temperature measurement in all age-groups. It's commonly used to
measure body temperature in the immediate, postdelivery neonate and in infants younger than age 3
months.

Don't use mercury thermometers to measure a child's temperature because of the potential risks
associated with breakage of the thermometer, including exposure to mercury (a toxic chemical) and
broken glass.103

Equipment

Electronic or chemical dot thermometer

Disposable probe cover

Implementation

Review the child's previous temperature patterns, if available.

Review the child's medical diagnosis and possible risk factors for an alteration in temperature.
Determine whether the child is taking any medications that may affect their temperature, such as
antipyretics.
Perform hand hygiene.5
Confirm the child's identity using two patient identifiers according to your facility's policy.4
Explain to the child and his family in developmentally appropriate language what you're going to do
(for example, "I'm going to see how warm your body is."), and identify what equipment you'll use.

Using an electronic thermometer

Remove the probe from the base unit and verify that it's charged.
Select a blue probe for axillary use.

Select the blue probe

Place a probe cover on the probe.

Put on a probe cover

Place the probe in the child's axilla and hold the child's arm firmly to his side.
Remove the probe when the unit emits the signal indicating measurement is complete.
Note the temperature on the display and whether it's in Celsius or Fahrenheit.
Discard the probe cover in an appropriate receptacle.

Discard the probe cover

Perform hand hygiene.211

Clean and disinfect the electronic thermometer according to your facility???s policy.8
Return the probe to the base unit to charge.
Perform hand hygiene.5211
Document the procedure.6

Using a chemical dot thermometer

Remove the thermometer from its package.

Peel off the protective tape.
Place the temperature strip in the axilla according to the manufacturer's directions.
Wait for the color to stop changing.
Read the temperature according to manufacturer's directions.
Perform hand hygiene.5
Document the procedure.6

Special Considerations
Don't leave discarded probe covers in a child's crib or bed because they pose a choking hazard.
Dispose of covers in a location where the child can't reach them.
Documentation
Document the date and time of the assessment, the temperature, the route used to obtain the
temperature, changes from previous measurements, and the child's response to interventions.

References
1. Bowden, V., and Greenberg, C.S. Pediatric Nursing Procedures, 2nd ed. Philadelphia: Lippincott
Williams & Wilkins, 2008.
2. Centers for Disease Control and Prevention. "Guidelines for Hand Hygiene in Health-Care Settings,"
MMWR Morbidity and Mortality Weekly Report 51(RR-16):1-144, October 2002. (Level I)
3. Goldman, L., et al. "American Academy of Pediatrics: Technical Report: Mercury in the Environment:
Implications for Pediatricians," Pediatrics 108(1):197-205, July 2007.
4. The Joint Commission. Comprehensive Accreditation Manual for Hospitals: The Official Handbook.
Standard NPSG.01.01.01. Oakbrook Terrace, Ill.: The Joint Commission, 2011. (Level I)
5. The Joint Commission. Comprehensive Accreditation Manual for Hospitals: The Official Handbook.
Standard NPSG.07.01.01. Oakbrook Terrace, Ill.: The Joint Commission, 2011. (Level I)
6. The Joint Commission. Comprehensive Accreditation Manual for Hospitals: The Official Handbook.
Standard RC.01.03.01. Oakbrook Terrace, Ill.: The Joint Commission, 2011. (Level I)
7. Khorshid, L. "Comparing Mercury-In-Glass, Tympanic, and Disposable Thermometers in Measuring
Body Temperature in Healthy Young People," Journal of Clinical Nursing 14(4):496-500, April 2005.
8. Rutala, W.A., et al. (2008). "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008"
[Online]. Available: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf
[2011, January 3]. (Level I)
9. Sund-Levander, M., and Grodzinsky, E. "What Is the Evidence Base for the Assessment and
Evaluation of Body Temperature?" Nursing Times 106(1):10-13, January 2010.
10. U.S. Department of Health and Human Services, Public Health Service. Agency for Toxic Substances
and Disease Registry. Toxicological Profile for Mercury. Atlanta: Agency for Toxic Substances and
Disease Registry, 1999. Available: [2010, October 1]. http://www.atsdr.cdc.gov/toxprofiles/tp46.pdf.
11. World Health Organization (2009). "WHO Guidelines on Hand Hygiene in Health Care: First Global
Patient Safety Challenge, Clean Care is Safer Care" [Online]. Available:
http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf [2011, January 3]. (Level I)
Axillary temperature assessment, pediatric
Objective: To take an axillary temperature in a child according to the standard of care.
Review the child's previous temperature patterns, if available.
Review the child's medical diagnosis and possible risk factors for an alteration in temperature.
Determine whether the child is taking any medications that may affect their temperature.
Perform hand hygiene.
Confirm the child's identity using two patient identifiers.
Explain to the child and his family in developmentally appropriate language what you're going to do,
and identify what equipment you'll use.
Using an electronic thermometer
Remove the probe from the base unit and verify that it's charged.
Select a blue probe for axillary use.
Place a probe cover on the probe.
Place the probe in the child's axilla and hold the child's arm firmly to his side.
Remove the probe when the unit emits the signal indicating measurement is complete.
Note the temperature on the display and whether it's in Celsius or Fahrenheit.
Discard the probe cover in an appropriate receptacle.
Perform hand hygiene.
Clean and disinfect the electronic thermometer.
Return the probe to the base unit to charge.
Perform hand hygiene.
Document the procedure.

Using a chemical dot thermometer

Remove the thermometer from its package.
Peel off the protective tape.
Place the temperature strip in the axilla according to the manufacturer's directions.
Wait for the color to stop changing.
Read the temperature according to manufacturer's directions.
Perform hand hygiene.
Document the procedure.
Axillary temperature assessment, pediatric

Review the child's previous temperature patterns, if available.

Review the child's medical diagnosis and possible risk factors for an alteration in temperature.
Determine whether the child is taking any medications that may affect his temperature.
Perform hand hygiene.
Confirm the child's identity.
Explain to the child and his family what you're going to do, and identify what equipment you'll use.

Using an electronic thermometer

Remove the probe from the base unit and verify that it's charged.
Select a blue probe and place a probe cover on the probe.
Place the probe in the child's axilla and hold the child's arm firmly to his side.
Remove the probe when the unit emits the signal indicating measurement is complete.
Note the temperature on the display.
Discard the probe cover in an appropriate receptacle.
Perform hand hygiene.
Clean and disinfect the electronic thermometer.
Return the probe to the base unit to charge.
Perform hand hygiene.
Document the procedure.

Using a chemical dot thermometer

Remove the thermometer from its package.

Peel off the protective tape.
Place the temperature strip in the axilla.
Wait for the color to stop changing and read the temperature according to manufacturer's directions.
Perform hand hygiene.
Document the procedure.