Taking a Temperature

Monitoring body temperature is a basic skill in nursing and medical decision making.When heat production exceeds heat loss, and body temperature rises above the normal range, pyrexia (fever) occurs. Pyrexia can  accompany any inflammatory response or prolonged exposure to high temperatures. When the body is exposed to temperatures lower than normal for a prolonged length of time, hypothermia occurs. Hypothermia generally occurs in response to prolonged exposure to cold weather or as a result of being immersed in cold water. Hospitalized clients are at particular risk for infection and accompanying fever. Clients are stressed by their presenting conditions and their bodies are further stressed by the hospital environment and are thus more susceptible to the infectious agents found there. Accurate monitoring and recording of a client’s temperature is essential for diagnosis and treatment of the client.

 

ASSESSMENT

1. Assess body temperature for changes when exposed  to pyrogens (endogenous or exogenous substances that cause fever) or to extreme hot or cold external environments because such environments may indicate the cause of an infection.

2. Assess the client for the most appropriate site to check his temperature in order to obtain an accurate reading.

3. Confirm that the client has not consumed hot or cold food or beverage nor smoked for 15 to 30 minutes before the measurement because these activities may alter the oral reading.

4. Assess for mouth breathing and tachypnea because both can cause an inaccurate oral reading

5. Assess  for oral herpetic lesions because herpes  viruses are extremely contagious and require implementation

of Standard Precautions of the Centers for Disease Control and Prevention. Clients with herpetic lesions should have their own glass thermometer to prevent transmission to others.

6. Assess for oral herpetic lesions because herpes viruses are extremely contagious and require  implementation of Standard Precautions of the Centers for Disease Control and Prevention. Clients with herpetic lesions should have their own glass thermometer to prevent transmission to others.  Four types of thermometers are commonly in used : mercury-in-glass, electronic, tympanic, and disposable.

. The most inexpensive, the mercury thermometer , consists of a glass tube at one end with a mercury-filled bulb at the other. Exposure of the bulb to heat causes the mercury to expand  and rise in the enclosed tube. These thermometers may be calibrated in either Fahrenheit or Celsius and may be used measure oral, axillary, or rectal temperature.

 

The tympanic thermometer is very popular in all clinical settings. Taking the client's temperature with this device requires less than 5 seconds and is very easy. The device works when the temperature-sensitive probe, covered with a disposable sheath, is inserted into the client's ear; the probe measures the temperature of the blood flowing near the tympanic membrane. This provides an accurate mea­surement of core body temperature. Like the electronic thermometer, tympanic thermometers may be programmed to measure temperature in either Fahrenheit or Celsius.

 

 

The electronic thermometer consists of a battery-powered display unit, a thin wire cord, and a remperature-sensitive probe. The probe must be covered with a disposable sheath before use. The probes are color coded (blue or white for oral and red for rectal) for proper use. The advantage of the electronic thermometer over the mercury thermometer is speed The electronic thermometer calculates and displays the temperature on a digital screen within 15 to 30 seconds. Many electronic thermometers have a switch on the unit to permit the measurement of temperature in either Fahrenheit or Celsius.

 

This device requires less than 5 seconds and is very easy. The device works when the temperature-sensitive probe, covered with a disposable sheath, is inserted into the client's ear; the probe measures the temperature of the blood flowing near the tympanic membrane. This provides an accurate mea­surement of core body temperature. Like the electronic thermometer, tympanic thermometers may be programmed to measure temperature in either Fahrenheit or Celsius.

 

Disposable, single-use thermometer strips are thin strips of plastic with chemically impregnated paper. They are frequently used for temperature evaluation in chil­dren. Chemical dots on the strip change color, representing the highest temperature. The strips are configured so that the examiner can identify the highest colored dot and cor­relate that with the temperature reading.