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SOLANO RURAL HEALTH UNIT WITH

Rev.: MHO-MOP 5
LABORATORY AND LYING-IN CLINIC
0
Name of the Procedure:
MEASURING THE BODY TEMPERATURE

1. GENERAL POLICY STATEMENT

Body temperature is the difference between the amount of heat produced by body
processes and the amount of body heat lost to the outside environment. Average
temperature or deep tissue temperature is under the control of the hypothalamus and moves
within a narrow range. The range of normal body temperature measured axillary method is
from 36.0-37.20C. Changes in body temperature during a day depend on a number of
factors: time of the day, physical effect, emotional status, menstrual cycle, pregnancy,
illness and the like. At primary healthcare level, body temperature is most often measured
by axillary and/or rectal method. The procedure is performed by a nurse/midwife.
The purpose of the procedure is to measure the body temperature in a proper and safe
manner using a uniform procedure.
2. PROCEDURE
2.1 Measuring body temperature by axillary method
The temperature is measured axillary using a mercury thermometer or a digital
thermometer. Contraindications of axillary measurement of body temperature are:
inflammatory process in the armpit, inaccessibility, disability and very thin persons.

2.1.1 Preparation of material

-thermometer,
-clock,
-towel or cotton pads,
-disinfectant,
-kidney dish.

2.1.2 Patient preparation

-Identify the patient,
-Explain to the patient the measurement procedure and position him/her
comfortably,
- Ask the patient to wipe the armpit with a paper towel; help the patient if
necessary.

2.1.3 Measurement procedure

2.1.3.1 If it is a mercury thermometer, check whether the mercury in the column is below
360C.
2.1.3.2 Place the top of the thermometer in the central part of the axilla between the skin
folds, so that it does not come to the opposite.

2.1.3.3 Instruct the patient to place the arm where the thermometer is positioned towards
the opposite shoulder.
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SOLANO RURAL HEALTH UNIT WITH
Rev.: MHO-MOP 5
LABORATORY AND LYING-IN CLINIC
0
Name of the Procedure:
MEASURING THE BODY TEMPERATURE

2.1.3.4 If the condition of the patient does not allow it, the nurse shall hold that arm.

2.1.3.5 If using a mercury thermometer measure the temperature for 3-5 minutes, if
using an electronic thermometer wait for it to signal the measured temperature.

2.1.3.6 The temperature is read and the value is entered into medical records.

2.1.3.7 After measurement, wash the thermometer with lukewarm water and liquid
detergent, drain and store or disinfect with the disinfectant.

2.2 Measuring body temperature by rectal method

Indications for rectal temperature measurement are: in small children, contraindication of
axillary temperature measurement and suspected inflammatory process in the abdomen.
Contraindications for rectal temperature measurements are: inflammatory process in the
rectum, diarrhea and agitated patients.
2.2.1 Preparation of material
-Rectal thermometer,
-Clock,
-Petroleum jelly or paraffin oil,
-Towel or cotton pads,
-Disinfectant,
-Kidney dish.

2.2.2 Patient preparation

Explain to the patient the measurement procedure and place him/her in the appropriate
position (lateral position with legs bent towards the abdomen; children take the supine
position with raised legs held by the nurse).
2.2.3 Procedure for rectal measurement of body temperature
2.2.3.1 Put on the gloves. Using one hand spread the gluteuses, and using the other
hand with the cotton pads soaked in liquid soap, wipe the anal opening.
2.2.3.2 Apply petroleum jelly or paraffin oil to the top of thermometer and slowly insert
the top of the thermometer into the rectum, in the newborn up to 1.5 cm, in small
children up to 2.5 cm, and in adults from 3 to 5 cm.
2.2.3.3 Hold the thermometer during the measurement; mercury thermometer for 3-5
minutes; electronic until an acoustic signal.

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SOLANO RURAL HEALTH UNIT WITH
Rev.: MHO-MOP 5
LABORATORY AND LYING-IN CLINIC
0
Name of the Procedure:
MEASURING THE BODY TEMPERATURE

2.2.3.4 Remove the thermometer, wipe it with the cotton pad and read the measured
value.
2.2.3.5 After measurement, wash the thermometer with lukewarm water and liquid
detergent, drain and store or disinfect with the disinfectant.
2.2.3.6 Remove the gloves and wash your hands.

2.3 Records
Upon the completion of measurement, the nurse/midwife records in the existing valid
medical documentation of the institution:
-General patient information,
-Date and time of measurement,
-Value of the pressure obtained by measuring,
-Signature of the nurse/midwife who conducted the procedure.

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