[WJA202 : Temperature

Check Methods
(Techniques For One
Rescuer and More Than
One Rescuer) and CPR]
Body • Body temperature is the degree of warm or
coldness of a body compared to a
Temperature, standard. It is measure by an apparatus
known as a thermometer:
Pulse Rate, • Clinical thermometer: used to measure
Respiration body temperature.

Rate • Normal body temperature (36.8c – 37.0 c).

• Pyrexia – 37.5 c – 39.0 c).
• Hyperexia – (39.0 c – 42.0 c )
 Normothermia: Body temperature within Pyrexia: An elevated body temperature
normal values.  due to an increase in the body
Exact normal temperature ranges differ temperature’s set point. This is usually
between individuals and can be caused by infection or inflammation.
influenced by some genetic and chronic Pyrexia is also known as fever or febrile
medical conditions. It is important to response. 
ascertain the baseline for individual Some causes of fevers do not require
patients in order to identify abnormal medical treatment, whilst other causes
body temperature deviations.  need to be identified and treated. 

Definition
Heat stroke: A presentation of
severe hyperthermia.
Hyperthermia: An elevated body
Thermoregulation is overwhelmed
temperature due to failed
by excessive metabolic production
thermoregulation. This occurs when

of Terms
and environmental heat, in
the body produces and/or absorbs
combination with impaired heat
more heat than it can dissipate. 
loss. This is uncommon within an
inpatient setting.

Hypothermia: An abnormally low

Low temperature: A lowered body body temperature, where the body
temperature, where the body loses temperature drops below a safe
heat faster than it can produce level. Both low temperatures and
heat.  hypothermia can be caused by
environmental factors, metabolic
complications, disease processes,
or can be medically induced. 
 Increase:
Infection.
Exercise.
Effects of After a hot bath.
Body Decrease:
Shock
Temperature Bleeding.
Collapse.
Sleep.
Starvation.
Exposed to cold.
 The method chosen or used must be the same
throughout so as to avoid incorrect recording.

Where possible, each patient should have his

Principle in own thermometer, that is to prevent infection.

Taking Before taking the temperature, the patient

Temperature must be at rest at least 10- 15 mints. He

should not be smoking; neither should you
take his temperature after a cold drink.

Instruction must be given to patient not to bite

the thermometer, to remove the thermometer
on his own as well as to open his mouth
when thermometer is inside his mouth. He
must also be discouraged from when having
conversation when the thermometer is inside
his mouth,
Assessment
• Body temperature should be measured on
admission and four hourly with other vital signs,
unless clinically indicated for more frequent
measurements. 
Body temperatures falling outside normal ranges
should be monitored and further managed where
appropriate until normothermia is achieved. 

When assessing body temperatures, it is important

to consider patient-based and environmental-based
factors, including prior administration of antipyretics
and recent environmental exposures. 
Body temperature should always be evaluated in the
context of other vital signs and overall patient
presentation. 
What type of thermometer
should I use?

• A digital thermometer is best for taking

temperatures by the armpit and
mouth.
• Fever strips and pacifier
thermometers do not give an accurate
temperature. Do not use a mercury
thermometer. Mercury is toxic and the
thermometer could break.
 Mouth - (Oral Temperature)

Ways Body
Axilla – (Skin Temperature)
Temperature
Can be Taken Groin – The part where your flax
the leg,

Rectum - is known as rectal

temperature.
 Oral method (in the mouth)
• The mouth method can be used for children who are older than 5
years of age. It is not recommended for children younger than 5
years of age, because it is hard for them to hold the thermometer
under their tongue long enough.
Ways Body • Carefully place the tip of the thermometer under your child’s
tongue

Temperature • With your child’s mouth closed, leave the thermometer in place
for about 1 minute until you hear the “beep”

Can be • Remove the thermometer and read the temperature

Taken Axillary method (under the armpit)

• The armpit method is usually used to check for fever in newborns and
young children.
• Place the tip of the thermometer in the centre of the armpit
• Tuck your child’s arm snugly (closely) against their body
• Leave the thermometer in place for about 1 minute, until you hear the
“beep”
• Remove the thermometer and read the temperature
 Tympanic method (in the ear)
• The ear method is recommended for children older than 2 years old. Though quick
to use, the ear method can produce temperature readings that are incorrect, even
when the manufacturer’s directions are followed.
• Use a clean probe tip each time, and follow the manufacturer’s instructions carefully

Ways Body • Gently tug on the ear, pulling it back. This will help straighten the ear canal, and
make a clear path inside the ear to the ear drum

Temperature • Gently insert the thermometer until the ear canal is fully sealed off
• Squeeze and hold down the button for 1 second

Can be • Remove the thermometer and read the temperature

Taken • Rectal method (in the rectum or bum)

• The rectal method can be used to check for fevers in newborns and young
children. Use a rectal thermometer only if you are comfortable doing so and a
health care provider has shown you how to do it safely.
• Cover the silver tip with petroleum jelly (such as Vaseline)
• Place your baby on their back with their knees bent
• Gently insert the thermometer in the rectum, about 2.5 cm (1 inch), holding it in
place with your fingers
• Leave the thermometer in place for about 1 minute until you hear the “beep”
• Remove the thermometer and read the temperature
 From birth to age 5, the most common way to
take a temperature is under the armpit.

How should I For children older than 2, temperatures can also be

take a child’s taken by ear or, if the child is able to sit still long
enough, by mouth.

temperature? The most accurate way to take a temperature is

in the bum (rectal method).

Always wash your hands before and after taking

your child’s temperature.
How should I take an adult’s temperature?

Take an adult’s temperature by mouth, in the ear or

under the armpit.

The armpit method is less accurate and is normally only used if the
person is extremely drowsy or not clear mentally.

Follow the same methods used for taking a child’s

temperature.
Signs Respiration
increased.
Pulse rate is
increased
Cold extremities.

and Tongue is dirty and

Symptom Mouth is dry.

coated.
Loss of appetite.

Patient complain of

Fever Nausea.
Urine is
concentrated and
diminished.
malaise and fatigue,
general aches and
pain, headache,
restlessness,
insomnia (cannot
sleep).

The skin feels hot

and dry.
Nursing A well
ventilation
Plenty of
fluids, a lot of
room. cold drinks.
Patient
with Tepid
sponging.
Drugs as
ordered by the
Fever doctor.

Cold
Compress.
Pulse
Pulse is the heart rate at which your heart
beats. Your pulse is usually called heart
rate, which is the number of times your
heart beats each minutes (bpm).

Pulse Rate
Normal Pulse Rate 60 bpm-80 bpm(beats
per minute)

Observation.
• Rhythm – Regular or irregular.
• Rate – Rapid or slow.
• Noisy or quite.
 The respiration rate is the number of breaths a person takes per minute.
The rate is usually measured when a person is at rest and simply
involves counting how many times the chest rises.

Respiration
Respiration rate may increase with fever and illness and with
medical conditions. When checking respiration, it is important to
also note whether a person has any difficulty breathing

Normal respiration rates for an adult person at rest range

from 12 to 16 breaths per minute.
 Emergency lifesaving procedure performed
What is CPR? when the heart stops beating.
CPR:
Cardiopulmo
Immediate CPR can double or triple
nary chances of survival after cardiac arrest.
Resuscitation
Keeping the blood flow active – even
partially – extends the opportunity for a
successful resuscitation once trained
medical staff arrive on site.
General CPR Steps

Lay the person on their Check for breathing. If

Call 911 or ask someone
back and open their they are not breathing,
else to.
airway. start CPR.

Repeat until an
Perform 30 chest Perform two rescue ambulance or automated
compressions. breaths. external defibrillator
(AED) arrives.
 CPR step-by-step
Preparation steps
• Before performing CPR on an adult, use the following preparation steps:
Step 1. Call 911
• First, check the scene for factors that could put you in danger, such as traffic, fire, or falling masonry. Next, check the
person. Do they need help? Tap their shoulder and shout, “Are you OK?”
• If they are not responding, call 911 or ask a bystander to call 911 before performing CPR. If possible, ask a bystander
to go and search for an AED machine. People can find these in offices and many other public buildings.

Step 2. Place the person on their back and open their airway
• Place the person carefully on their back and kneel beside their chest. Tilt their head back slightly by lifting their chin.
• Open their mouth and check for any obstruction, such as food or vomit. Remove any obstruction if it is loose. If it is
not loose, trying to grasp it may push it farther into the airway.
 CPR step-by-step
• Step 3. Check for breathing
• Place your ear next the person’s mouth and listen for no more than 10 seconds. If you do not hear breathing,
or you only hear occasional gasps, begin CPR.
• If someone is unconscious but still breathing, do not perform CPR. Instead, if they do not seem to have a
spinal injury, place them in the recovery position. Keep monitoring their breathing and perform CPR if they
stop breathing.
•

Step 4. Perform 30 chest compressions

• Place one of your hands on top of the other and clasp them together. With the heel of the hands and straight
elbows, push hard and fast in the center of the chest, slightly below the nipples.
• Push at least 2 inches deep. Compress their chest at a rate of least 100 times per minute. Let the chest rise
fully between compressions.
 CPR step-by-step
Step 5. Perform two rescue breaths
• Making sure their mouth is clear, tilt their head back slightly and lift their chin. Pinch
their nose shut, place your mouth fully over theirs, and blow to make their chest rise.
• If their chest does not rise with the first breath, re-tilt their head. If their chest still does
not rise with a second breath, the person might be choking.

Step 6. Repeat
• Repeat the cycle of 30 chest compressions and two rescue breaths until the person starts
breathing or help arrives. If an AED arrives, carry on performing CPR until the machine
is set up and ready to use.
CPR for children and infants
• Step 1. Call 911 or give 2 minutes of care
• First, check the surrounding area for factors that could put you in danger. Next, check the child
or infant to see whether they need help. For children, tap their shoulder and shout, “Are you
OK?” For infants, flick the sole of their foot to see if they respond.
• If you are alone with the child and they are not responding, give them 2 minutes of care and then
call 911. If there is a bystander, ask them to call 911 while you give 2 minutes of care.
•
Step 2. Place them on their back and open their airways
• Place the child or infant carefully on their back and kneel beside their chest. Tilt their head
backward slightly by lifting their chin.
• Open their mouth. Check for any obstruction, such as food or vomit. If it is loose, remove it. If it
is not loose, do not touch it, as this may push it farther into their airways.
CPR for children and infants
Step 3. Check for breathing
• Place your ear next to their mouth and listen for around 10 seconds. If you do not hear breathing, or you only hear
occasional gasps, begin to administer CPR.
• Changes in an infant’s breathing patterns are normal, as they usually have periodic breathing.
• Keep monitoring their breathing and perform CPR if they stop breathing

Step 4. Perform two rescue breaths

• If the child or infant is not breathing, perform two rescue breaths with their head tilted backward and their chin
raised.
• For a child, pinch their nose shut and place your mouth over theirs. Breathe into their mouth twice.
• For an infant, place your mouth over their nose and mouth and blow for 1 second to make their chest rise. Then,
deliver two rescue breaths.
• If they are still unresponsive, begin chest compressions.
 CPR for children and infants
Step 5. Perform 30 chest compressions
• Kneel beside the child or infant.
• For a child, use one of your hands. Place the heel of the hand at their sternum, which is in the
center of the chest, between and slightly below their nipples. Press down hard and fast around
2 inches deep, or one-third the depth of the chest, at least 100 times per minute.
• For an infant, use two fingers. Place your fingers in the center of their chest, between and
slightly below the nipples. Perform 30 quick compressions around 1.5 inches deep.

Step 6. Repeat
• Repeat the cycle of rescue breaths and chest compressions until the child starts breathing or
help arrives.
 Rescuer One: Chest Compressions
• Rescuer One should focus on performing high-quality chest compressions
• Compress the chest at least 2 inches (5 cm)

Two • Compress at a rate of at least 100 per minute

• Allow the chest to recoil completely after each compression

Rescuer • Minimize interruptions in compressions

• Use a compression-to-breath ratio of 30 : 2

Adult
• Count compressions aloud & switch duties with the second rescuer every 5
cycles or about 2 minutes

CPR Rescuer Two: Airway and Breathing

• Rescuer Two can maintain an open airway and give rescue breaths,
watching for chest rise and avoiding excessive ventilation or over-inflation. 
• They should switch duties with the first rescuer every 5 cycles or about 2
minutes to ensure chest compressions remain effective.