TEMPERATURE ASSESSMENT

Name: Floremer F. Guimalan Grade: ____________________

Year and Section: BSN – 1H Date: March 03, 2021

DEFINITION:
It is the measurement of the body’s physiological function of heat regulation.

PURPOSE:
Provides clinical data regarding the thermoregulation of the patient.

EQUIPMENT NEEDED: LEGEND:

Digital Thermometer 1 - Excellent
- Oral or rectal at client’s bedside. 2 – Very Satisfactory
Lubricant for route 3 - Satisfactory
Two pairs of non – sterile gloves (as needed) 4 – Needs Improvement
Tissue paper 5 – Poor

STEPS RATIONALE 1 2 3 4 5
PREPARATION
1. Review patient’s medical record for baseline data and factors • To know underlying
that influence vital signs. issues that would
somehow affect the
results of vital signs
assessment.
2. Explain to the client that vital signs will be assessed. • Providing
Encourage client to remain still and refrain from drinking, information fosters
eating, and smoking. cooperation and
understanding.
3. Assess client’s toileting needs. • To give assistance to
the patient.
4. Wash hands before preparing materials. • To prevent the
spread of bacteria
that would cause
infection.
5. Gather equipment. • To promote time
efficiency and being
organized facilitates
accurate skill
performance.
6. Provide for privacy. • The client has a
right for his/her
privacy.
7. Wash hands again apply gloves if needed. • To avoid the spread
of bacteria and
viruses.
8. Position the client in a sitting or lying position with the head • To provide easy
of the bed elevated 40 to 60 degrees for measurement of all access to the area
vital signs except those designated otherwise. that is to be
examined.
ORAL TEMPERATURE
9. Remove thermometer from storage container and cleanse • Cleanse to avoid
probe under cool water. the spreading of
the bacteria and to
remove the dust (if
there is).
10. Use a tissue paper to dry thermometer from probe to end. • Wipe from the area
where few
organisms are
present to the area
where more
 organisms are
present to limit
spread of infection.
11. Turn on thermometer • To begin the oral
temperature
assessment.
12. Place tip of the thermometer under the client’s tongue and • Place to proper
along the gum line to the posterior sublingual pocket lateral to area. Let the client
center of lower jaw. Instruct client to hold lips closed. know to hold the
thermometer using
the lips to avoid
damaging the
thermometer, and
to avoid swallowing
small pieces if there
is breakage.
13. Leave in place. Thermometer will signal (beep) when a • The healthcare
constant temperature register. provider will be
notified when the
temperature has
been taken.
PREPARATION
14. Remove thermometer and wipe with a tissue away from • Cleansing it would
fingers toward the thermometer. avoid bacterial
contamination.
15. Read the temperature. Read measurement on digital • Read the level of
display of thermometer. mercury of
thermometer at
eye level. Electronic
thermometers
provide a digital
display of the
temperature
reading.
16. Inform client temperature reading. • Keep the client
informed of his/her
data and provide
immediate care if
needed.
17. Remove and dispense of gloves in a receptacle and wash • To prevent the
hands. spread of infection.
18. Record reading according to institution’s policies. • Documentation
provides ongoing
data collection.
Giving signature
maintains
professional
accountability.
AXILLARY TEMPERAURE

Do STEPS 1 – 8 first
19. Remove gown’s arm and shoulder on one sleeve. Avoiding • To provide client’s
exposing chest. privacy and
minimize
embarrassment.
20. Make sure axillary skin is dry. If necessary, pat dry. • Moisture will alter
the reading. Under
the condition
moistening,
temperature is
generally measured
lower than the real.
21. Prepare thermometer. Cleanse with alcoholised cotton • Cleansing the
from probe to tip. thermometer
prevents the
spreading of
inspection.
22. Turn on and place thermometer or probe into center to • Place the
axilla. Fold client’s upper arm straight down and place arm thermometer’s bulb
across client’s chest in the center of the
axilla. Angle the
thermometer so
that the stem is
pointed up and in
the direction of the
patient’s head.
23. Wait until thermometer will signal (beep) when a constant • The healthcare
temperature registers. provider will be
notified when the
temperature has
been taken.
24. Remove and read thermometer. • Inform patient in
removing the
thermometer to
keep it from falling.
Read the level of
mercury of
thermometer at
eye level. Electronic
thermometers
provide a digital
display of the
temperature
reading.
25. Inform client temperature reading. • Keep the client
informed of his/her
data and provide
immediate care if
needed.
26. Cleanse thermometer from tip to probe, turn off and return • Cleanse it to avoid
to storage container. spread of infection.
Put it to its proper
place to avoid
damage.
27. Assist client temperature reading. • To inform the client
of the temperature
reading.
28. Record reading according to institution’s policies. • Documentation
provides ongoing
data collection.
Giving signature
maintains
professional
accountability.
RECTAL TEMPERAURE
Do STEPS 1 – 8 first
29. Place client in Sim’s position with upper knee flexed. Adjust • Privacy minimizes
sheet to expose only anal area. embarrassment
from exposing
buttocks. Lateral
position exposes
anal area for
thermometer
placement.
30. Place tissues in ease reach. • To prevent spread
of infection and
avoid transmission
of microorganisms.
31. Prepare the thermometer. • Being prepared
saves time and
organization
facilitates accurate
skill performance.
32. Lubricate tip of rectal thermometer. • Lubricant facilitates
insertion of
thermometer
without irritating or
traumatizing the
anus.
33. With dominant hand, grasp thermometer. With other hand, • Visual exposure of
separate buttocks to expose anus. anus ensures
accurate placement
of probe.
34. Instruct client to make a deep breath. Turn on and insert • Allow client to relax
thermometer probe gently into anus: infant, 1.27 cm or 0.5 external sphincter.
inches; adult, 3.81 cm to 1.5 inches. If resistance is felt, do not Insertion depth
force insertion. allows adequate
exposure of probe
to blood vessels in
rectal wall.
35. Hold in place up until thermometer signals (beep) when a • Holding
constant temperature registers. thermometer
prevents rectal
damage. The
healthcare provider
will be notified
when the
temperature has
been taken.
36. Wipe secretions of probe with a tissue paper. Dispose tissue • Proper disposal of
paper in a receptacle. tissue prevents
transmission of
microorganisms.
37. Read measurement and inform client of temperature • Keep the client
reading. informed of his/her
data and provide
immediate care if
needed.
38. While holding the thermometer in one hand, use other • Proper hygiene
hand to wipe anal area with tissue to remove lubricant or feces. prevents spread of
Dispose of soiled tissue paper. Cover client. infection. Cover
client with blanket,
the client has a
right for his/her
privacy.
39. Cleanse the probe of the thermometer with soap & water, • Cleansing the probe
rinse under cold water, and return to storage container. would avoid the
bacterial
contamination. Put
it to its original
place and container
to avoid damage.
40. Remove and dispose of gloves in receptacle. • Proper disposal of
used gloves avoids
transmission of
microorganisms
and infection.
 POST – PROCEDURE ACTIVITY:
41.After care. • To prepare for the
next procedure and
to have an
organized
assessment area.
42. Wash Hands. • To prevent the
spread of infection
and ensures safety.
43. Record. • Documentation
provides ongoing
data collection.
Giving signature
maintains
professional
accountability.
ATTITUDE OF THE STUDENT:
44. Accepts constructive suggestions and criticisms. • To be open for any
suggestions in
order to improve,
develop, and to do
and be better.
45. Assumes accountability. • To be responsible
and accountable in
everything that you
do.
Source:
Daniel, Ricks. Nursing Fundamentals: Caring and Clinical Decision Making. Thomson Asian Edition. United States:
Delmar, 2004, pp. 566 – 571

Scoring: 1X __________ = __________

2X __________ = __________
3X __________ = __________
4X __________ = __________
5X __________ = __________

Total divided by no. of items = ________________

Comments:
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Student’s Signature Over Printed Name Clinical Instructor’s Signature and
Date over Printed Name