ASSESSING BODY TEMPERATURE

DEFINITION:
The body temperature is simply a measurement of how hot the body is. The body temperature can be
measured from several different areas of the body. There are four sites for measuring body temperature,
these includes Oral, Rectal, Axillary, and Tympanic membrane. Assessing body temperature is a nursing
procedure that provide a baseline data for subsequent evaluation and nurses to determine changes in the
core temperature of patient in response to a specific medical intervention such giving an antipyretic drug,
a therapy and minor or invasive procedure.

PURPOSES:
 To establish baseline data for subsequent evaluation
 To identify whether the core temperature is within normal range
 To determine changes in the core temperature in response to specific therapies (e.g., antipyretic
medication, immunosuppressive therapy, invasive procedure)
 To monitor clients at risk for imbalanced body temperature (e.g., clients at risk for infection or
diagnosis of infection; those who have been exposed to temperature extremes)

PRINCIPLES:
 Wash hands before and after taking body temperature.
 Provide client privacy
 Before taking the vital signs, be sure that the patient has rested
 Check equipment is in good condition to prevent inaccurate readings

EQUIPMENT:
 Thermometer
 Thermometer probe cover
 Water-soluble lubricant for rectal temperature
 Clean gloves for rectal temperature
 Towel for auxiliary temperature
 Tissue/wipes

STEPS:
1. Check that the equipment is functioning
normally.
2. Introduce self, identify the client (ask the
complete name, check the wristband, and bed
tag) and explain the procedure.
RATIONALE:
To have an accurate result. Replace battery if
needed.
Checking physician’s order can help the nurse to
know what specific part of the body to be treated.
Introducing oneself helps build trust and rapport
with the patient. And explaining the procedure
helps the patient understand, prepare for the
procedure, and reduces anxiety.

3. Wash hands before starting the procedure. Don To prevent the spread of microorganism. This
gloves if taking a rectal temperature. serves as a standard precaution.

4. Provide for client's privacy. For the patient to be comfortable and ease anxiety.

5. Place the client in the appropriate position. Ensures both patient’s comfort and accuracy of
(Sitting or supine position for oral and axillary, temperature reading.
Sim's or lateral position for inserting a rectal
thermometer).

6. Place the thermometer. Oral

a. Oral-Place the bulb on either side of the  Promoting contact with superficial blood
frenulum.
 b. Rectal - apply clean gloves. Instruct the
client to take a slow deep breath during
insertion. Never force the thermometer if
resistance is felt, insert 3.5 cm (1½ in
adults). For pediatric client, 1.5-2.5 cm (1
in).
c. Axillary- pat the axilla dry with tissue paper
if very moist. The bulb is placed in the
center of the axilla.
d. Tympanic - For clients ages 4 years and
above, pull the pinna slightly upward and
backward. For 3 years and below clients,
pull the pinna slightly downward and
backward. Point the probe slightly anterior,
toward the eardrum. Insert the probe slowly
using a circular motion until snug.
e. Temporal artery - brush hair aside if
covering the temporal area. With the probe
flush on the center of the forehead, depress
the red button. Keep depressed. Slowly slide
the probe midline across the forehead to the
hair line, not down the side of the face. Lift
the probe from the forehead and touch on
the neck just behind the earlobe. Release the
button.
vessels and contributing to accurate reading
(Kluwer, Williams &Wilkins, 2010)
Rectal
 Relaxes anal sphincter. Gentle insertion
decreases discomfort to client and prevents
trauma to mucous membrane.
Axillary
 Excessive moisture will cool the skin and could
result in an inaccurate temperature reading.
Tympanic
 Provides access to ear canal. Gentle insertion
prevents trauma to external canal. (Berman,
Snyder &Frandsen, 2016)
Temporal artery
 This action will never lose track of the location
of the temporal artery. (Berman, Snyder &
Frandsen, 2016)

7. Apply a protective sheath or probe cover if Probe cover prevents thermometer from getting
appropriate. Note: Always lubricate a rectal soiled. Lubrication promotes ease insertion of
thermometer unless contraindicated. thermometer or probe

8. Wait for the appropriate amount of time.
Electronic and tympanic thermometers will
indicate that reading is complete through a light
or tone.
9. Remove the thermometer. Discard the probe
cover and wipe the thermometer with a tissue
paper if necessary.
10. Read the temperature and record it on your
worksheet.
11. Cleanse and disinfect the thermometer. Return
it to the proper place.
Device must stay in place long enough to ensure
accurate reading. Signal indicated final temperature
reading.
Reduces transmission of microorganisms
For documentation and charting
Reduces transmission of microorganisms and to
ready the thermometer for next use.

12. Document the temperature reading in the client For documentation and charting
record.
REFERENCE:
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2017a). Fundamentals of Nursing. Elsevier
Gezondheidszorg.
Berman, A. T., Snyder, S., & Msn Rn, F. G. E. (2020). Kozier & Erb’s Fundamentals of Nursing:
Concepts, Process and Practice (11th ed.). Pearson.