Procedure in Assessing the Body Temperature using a Mercury Thermometer

STEPS RATIONALE
ASSESSMENT:
1. Prepare the client.
• Ascertain which method
of taking the
temperature is
appropriate for the
client.
For an Oral Temperature • To obtain an accurate oral temperature
• Determine the time the reading, allow the amount of time according
client last took hot or to agency protocol to elapse between a
cold food or fluids or client’s intake or smoking and the
smoked. measurement.

ORAL METHOD
• Accurate method of
determining body
temperature.
• Used only for alert and
cooperative patients.
• Not appropriate for use
with patients requiring
nasogastric, nasal or oral
intubation.

For a Rectal Temperature

• Assist the client to
assume a lateral
position. Place newborn
in a lateral or prone
position. Place a young
child in a lateral position
with knees flexed, or
prone across the lap.
• Provide privacy before • Privacy is essential, because exposure of the
folding the bedclothes buttocks embarrasses most people
back to expose the
buttocks.

RECTAL METHOD
• Appropriate for
uncooperative, confused
or comatose patients or
for patients on seizure
 precautions.
• Used for patients on
seizure or with nasal or
oral intubation.
• Appropriate for patients
with wired jaw, facial
fractures.
• Contraindicated for
patients who have
abdominal or perineal
resection.

For an Axillary Temperature

• Expose the client’s • Friction created by rubbing can raise the
axilla. If the axilla is temperature of the axilla
moist, dry it with the
towel, using a patting
motion.

AXILLARY METHOD
• Not accurate for adults
• Used for infants in a
controlled environment
• Used in recovery rooms
to avoid turning patients.

2. Determine number of
times temperature needs
to be taken.
3. Assess temperature in
relationship to time of
day and age of patient.
4. Compare temperature
with other vital signs to
establish baseline data.

PLANNING:
5. To determine if core
temperature is within
normal range.
6. To provide baseline data
for further evaluation.
7. To determine alterations
in disease conditions.
IMPLEMENTATION:

Oral Temperature Taking

8. Wash you hands. -Infection control.
9. Prepare the Equipment. -Making sure all equipments are needed to avoid
10. Remove the delay or to minimize waste of time.
thermometer from its
package, and check the
temperature reading on
the thermometer.
11. If thermometer has been -washing/wiping removes any disinfectants which
stored in a chemical could be irritating to the mucous membrane of the
solution, rinse well in mouth and unpleasant to the taste (bitter)
cold water. Wipe it dry -cold water is used for rinsing because hot water will
with firm twisting expand the mercury and can break a glass
motion from bulb end to thermometer.
fingers. -wiping is done from the cleanest to the least clean
area.
-rotating ensures that all sides are wiped.

12. Bring to patients bedside -cooperation is gained easily when patient

and explain the understands what is to be done to him.
procedure to patient –
gain cooperation.
13. Place patient on a
comfortable position.
14. Shake down the mercury
(if necessary) by holding
the thermometer
between the thumb and
forefinger at the end
farthest from the bulb.
Snap the wrist
downward.
15. Repeat until the mercury To ensure accurate measurement.
is below 35ºC (95ºF).
16. Place the thermometer The sublingual area has an abundant blood supply
or probe at the base of from the nearby carotid arteries and the central
the tongue to the right or circulation of the heart.
left of the frenulum, the
posterior sublingual • The thermometer needs to reflect the core
pocket. temperature of the blood in the larger blood
vessels of the posterior pocket.

17. Ask the client to close • A client who bites the thermometer can break
the lips, not the teeth, it and injure the mouth.
 around the thermometer,
and breathe through the
nose.
18. Leave the thermometer
in place a sufficient time
for the temperature to
register or for the length
of time recommended by
the agency. The
recommended time is
generally either 2
minutes. If an electronic
oral thermometer is use,
the client holds the
thermometer under the
tongue 10 to 20 second
or until it completes
registering.
19. Remove the -wiping removes saliva from the thermometer. It is
thermometer and wipe done from the cleanest area to the least clean area.
with tissue from the Rotating ensures that all sides are wiped and for
nurses finger from the accurate reading.
nurses fingers (stem)
down to the bulb using a
firm twisting motion.
Discard tissue.
20. Read the thermometer at
eye level and rotate it
until the mercury comes
into view.
21. Clean and shake down
the thermometer and
replace in container.
22. Record patient’s
temperature according to
hospital procedure.

For a Rectal Temperature

1. Wash your hands,
prepare necessary
materials and bring to
patients bedside.
2. Explain the procedure to -cooperation is gained easily when patient
patient. understands what is to be done to him.
3. Place some lubricant on -a lubricant will reduce the friction encountered as
a piece of tissue. Then the thermometer is introduced into the rectum. This
 apply lubricant to the will also facilitate the insertion into the rectum.
thermometer about 2.5
cm (1 in) above the
bulb.
4. Provide privacy, wear This brings the anus into view when the buttocks are
disposable gloves on separated. If the patient cannot assume this position,
both hands. Instruct and a supine position with both knees flexed will suffice.
assist patient to turn on The supine position is satisfactory for infants.
side facing away from
you with knee slightly
flexed. With the
nondominant hand, raise
the client’s upper
buttock to expose the
anus.
5. ask the client to take a Taking a deep breath often relaxes the external
deep breath, and insert sphincter muscle, thus easing insertion. Difficulty
the thermometer into the with insertion could indicate that the rectum is not
anus anywhere from 1.5 patent (open).
to 4 cm (0.5 to 1.5 in),
depending on the age
and size of the client (
for example, 1.5 cm (0.5
in) for an infant, 2.5 cm
(0.9 in) for a child, and
3.7 cm (1.5 in) for an
adult.)
6. Do not force insertion of
the thermometer.
7. Hold the thermometer in The thermometer may become displaced inside or
place for 2 minutes or outside the anus and may cause the thermometer to
for the length of time injure the rectum if not held in place.
recommended by the
agency protocol. Hold
the young child firmly
while the probe is in the
rectum.
8. Removes the -washing and wiping removes any feces and or
thermometer and wipe it mucus.
with soft tissue from
fingers down to the bulb
using a rotating motion.
Discard tissue.
9. Read temperature. Clean
and shake down the
thermometer.
 10. assist patient back to his
comfortable position.
11. Wash thermometer in
warm, soapy water, rinse
and return to container.
12. wash your hands.
13. Record.

For an Axillary Temperature

1. Wash your hands.
Prepare all necessary
materials. Rinse
thermometer in cold
water if kept in chemical
solution and wipe dry
with tissue.
2. Bring to bedside and Cooperation is gained easily when patient
explain the procedure to understands what is to be done to him.
patient. Provide privacy.
3. Grasp the thermometer
with thumb and
forefinger and shake
vigorously by flicking
wrist in downward
motion to below 35ºC
(95ºF).
4. Expose client’s axilla Rubbing the axilla can raise temperature in that area
and pot it dry with a because of friction.
towel or tissue.
5. Assist the client to place This arm position maintains the thermometer in the
the arm tightly across axilla.
the chest to keep the
thermometer in place.
6. Leave the thermometer This time is required to obtain a valid reading.
in place for 9 minutes or
according to agency
protocol. For infants and
children, leave the
thermometer in place for
5 minutes.
7. Remain with the client,
and hold the
thermometer in place if
the clients is irrational or
very young.
8. Remove the
thermometer.
9. Remove the plastic The thermometer is wiped from the area of least
sheath, or wipe the contamination to that of greatest contamination
thermometer with a
tissue. Wipe in a rotating
manner toward the bulb.
10. Discard the tissue in a
receptacle used for
contaminated items.
11. Read the temperature.
12. Hold the thermometer at
eye level, and rotate it
until the mercury
column is clearly
visible.
13. The upper end of the
mercury column is
clearly visible. The
upper end of the
mercury column
registers the client’s
body temperature. On
the Fahrenheit
thermometer, each long
line reflects 1 degree,
and each short line 0.2
degree. On the Celsius
(centigrade)
thermometer, each long
line reflects 0.5 degree,
and each short line 0.1
degree.
14. Clean and shake down
thermometer.
15. Wash the thermometer
in tepid, soapy water.
Organic materila, such
as mucus, must be
removed before the
thermometer can harbor
microorganisms.
16. Rinse the thermometer
in cold water, dry it, and
store it dry.
17. Shake down the
 thermometer, and return
it to its container or
discard it. Some
agencies also have
special equipment for
spinning down the
mercury levels.
18. If the thermometer is to
be disinfected before
storage, use
recommended agency
disinfectant.
19. Return an electronic
thermometer to the
battery base for
recharging.
20. Document the
temperature.
21. Record the temperature
to the nearest indicated
tenth (for example, 98.4
F, 37.1 C) on a flow
sheet or in a notebook.

Variation: Using an Electronic

Thermometer
• Remove the electronic
unit from the battery
charging area.
• Remove the temperature
probe from the unit. If the
probe is not attached,
attach it to the appropriate
circuit (oral, rectal, or
axillary) in models that
have separate circuits for
each.
• Place a disposable cover
securely on the probe.
• Warm up the machine by
switching it on if removal
of the probe does not
automatically prepare the
machine for functioning.
• Take the temperature as
indicated above in step 3.
 • Listen for a sound
indicating that the
maximum measurement
has been reach, and read
the temperature on the dial
or readout.
• Remove the thermometer.
• Remove and discard the
prove cover.

Variation: Using an infrared

Thermometer
• Apply a disposable
sheath to the probe.
There are sheaths that fit
adults and infants. They
can be applies without
being touched.
• Place the probe tip into
the outer position of the
ear canal just at the
opening. The probe tip
seals the opening of the
canal.
• Press the button on the
electronic thermometer.
• Read the temperature on
the screen. In 1 to 2
seconds, the temperature
is digitalized by
computer onto the
screen.
• Remove the
thermometer.
• Remove and discard the
probe cover. Covers can
be ejected without being
touched.

EVALUATION:
1. Temperature is within
normal range.
2. The temperature
measurement in relation to
 baseline data or normal
range for age of client;
time of day and other
influencing factors;
relationship to other vital
signs.
3. Alterations in temperature
are detected early and
treatment begun.
4. Appropriate method of
temperature taking is
determined for each
patient.
5. Correct length of time is
used to obtain accurate
reading.
DOCUMENTATION:

Have to state in the charting the:

a. Method used
b. Reading obtained;
recorded on TPR sheet
c. Nursing interventions
used for alterations in
temperature
d. Signs and symptoms
associated with
alterations in
temperature.