how to take body temperatoure in nursing

in this note you will learn how to

Body temperature is the degree of heat of the body measured by a body thermometer.

Or 

Body temperature is how hot the body is.

How hot the body is reflects on the mechanism of the body’s function and the health status of the body. Change in body in body temperature, whether high or low, communicates something about the health.

Common terms use in body temperature

Thermometer is a instrument use for taking temperature

Fever is when the body temperature is high

Pyrexia is a term use to describe abnormal elevation of body temperature

Hyperpyrexia is a term use to describe high body temperature of 40 and above (high fever)

Subnormal temperature is a body temperature below 35℃

Hyperthermia is a term use to describe elevated body temperature above normal

Hypothermia is a term use to describe the body temperature below normal

Ranges of normal body temperature.

The normal body temperature is 37 ℃ or 98°F 

The body temperature is put in to ranges, the normal body temperature ranges from 36 ℃ to 37.5 ℃ or 97°F to 99°F

Sites for taking the temperature

Oral 

Taking the temperature from the mouth

 Axillar 

Taking the temperature from the armpit

rectal

 Taking the temperature from the Anas

groin

 Taking the temperature from the groin

factors affecting the temperature of the body.

These are conditions that may alter the findings of temperature different from normal circumstances. Those factors are as mentioned below

condition of the environment

When the temperature is taken on the cold weather, the result will be relatively low because of the coldness compared to when taken at room temperature.

When the temperature is taken on a hot when weather, it will be relatively high because of the heat.

time 

the time of the day at which the temperature is being taken ie is morning, evening or night some time you will find variation in the finding this is due to metabolic rate and muscle activity.in the night the metabolic rate is low compere to day time.

Gender

Men has lower temperature than women, the reason why women has higher body temperature than men is because of ovulation. During ovulation there is a lot of body changes in happening in a woman.

The site 

The site which has been use to take the temperature eg mouth,axilla,groin or Anas

Axillary temperature is lower compere when taken from the other sites. Rectal site is the best for taking temperature because it bring the accurate result

Age 

The neonate has higher body temperature compare to elder.

In neonate the metabolism is faster while in elderly the metabolism is slower because the changes in elderly body,

The body condition

The infection in the body increase body temperature because of increase metabolism due to toxin release by the microorganism.

Instrument use to measure temperature or what is used for taking temperature 

Temperature is taken using an instrument called a thermometer

 Types of thermometers

Mercury 

This is a thermometer with mercury inside, and it is in glass, it is sometimes referred to as a manual thermometer because it does not require electricity.

An electric thermometer or digital thermometer.

This is a thermometer which uses power eg battery

Rectal thermometer.

This is a special thermometer with a blund end.it is the thermometer use for taking temperature from the rectum (anas)

Monitor

This is a machine that monitor all the vital signs of a patient including the temperature.it is the one use in critical care.

Taking temperature

Temperature taking is a process of using a thermometer to determine how hot the body is

We take the temperature because we want to know how hot or cold the body is, both indicate something

Requirements for taking the temperature

A tray containing the following

  • A thermometer in a jar containing a solution of disinfectant
  • Galipot with water
  • Galipot containing swab
  • Receiver (kidney dish), which will be for used swabs
  • Nurses watch for timing or other timers, like a pulsometer, a second-hand watch
  • A chart for recording the temperature or a book for recording vitals
  • Pen for recording
  • Flannel for wiping the armpit

How to take body temperature from the mouth or from the oral site 

Taking temperature from the mouth can be embarrassing .even attendant and the patient can not believe the finding because most of them know the temperature is taken from the axilla.

Who is fit for taking the temperature from the mouth or oral site

  • When a person is alert, not unconscious
  • When the person is not mentally ill 
  • The person is older than five years
  • If ordered by the doctor
  • When there are no oral infections

Contraindication of taking temperature from the mouth(contra-indication of taking oral temperature) 

In the following condition, taking the temperature from the mouth can be disturbing or not allowed to take temperature from the mouth.

  • children under five. Children under five they don not understand. This makes it difficult to take oral temperature because you have to use a lot of effort to calm them down. Another site can be the alternative.
  • Mentally sick patient. Mentally ill patients are not in their right state of mind. When you put a thermometer in their mouth, they might bite and break the thermometer.
  • Confused patient.  
  • Unconscious patient. They can not open their mouths, so it is very difficult to put and maintain the thermometer in place for the three minutes.
  • Coughing or difficulty breathing 
  • Intubated patient
  • Oral infections 

NB

When taking oral temperature, the thermometer should be individual, not to be shared with other patients to prevent cross-infection

Oral temperature should not be taken immediately after the following 

  • Smoking
  • Hot drink
  • Taking a hot bath
  • Eating food

Those factors affect the thermometer reading hance making it to likely record wrong temperature

Requirements for taking oral temperature

A tray containing the following

  • A thermometer in a jar containing a solution of disinfectant
  • Galipot with water
  • Galipot containing swab
  • Receiver (kidney dish), which will be for used swab
  • Nurses watch for timing or other timers, like a pulsometer, a second-hand watch
  • Chart for recording the temperature or a book for recording vitals
  • Pen for recording

The procedure on how to take body temperature from the mouth

This is the process of talking temperature from the mouth.

Procedure

  • Explain the procedure to the patient to obtain his or her consent and build trust.
  • Screen the bed to provide privacy
  • Wash your hands to prevent cross-infection
  • Get the thermometer from the jar 
  • Rinse the thermometer with water to remove the disinfectant.
  • Shake the thermometer until the mercury falls below 35 °C
  • Inspect the thermometer for any cracks
  • Ask the patient to open the mouth and lifts the tongue for easy insertion of the thermometer
  • Place the bulb of the thermometer in the pocket under the tongue
  • Ask the patient to close the lips around the thermometer, but not to bite the thermometer while in position to prevent it from being broken by the teeth
  • Leave the thermometer in place for at least one minute
  • Remove the thermometer, wipe it, and read the temperature of the patient
  • Give the findings to the patient
  • Thank and leave the patient comfortably
  • Wash hand
  • Record the temperature in the patient’s chart

How to take a body temperature from the axilla

It is also called axillary temperature because it is taken from the axilla

Contraindication of taking the temperature from axilla

Sore at the axilla. Putting a thermometer in the axilla with a sore can instil pain to the patient and infect the thermometer

Wound at the axilla. Putting a thermometer in the wounded axilla can cause pain to the patient and infect the thermometer

An emaciated patient, this is a patient with very low weight. It is very difficult to maintain a thermometer in place in patients who are very thin.

Requirements for taking a body temperature from the axilla

A tray containing the following

  • A thermometer in a jar containing a solution of disinfectant
  • Galipot with water
  • Galipot containing swab
  • Receiver (kidney dish), which will be used for swabs
  • Nurses watch for timing or other timers, like a pulsometer, a second-hand watch
  • A chart for recording the temperature or a book for recording vitals
  • Pen for recording
  • Flannel for wiping the armpit

Procedure of taking body temperature from the axilla

  • Explain the procedure to the patient to obtain his or her consent and build trust.
  • Screen the bed to provide privacy
  • Wash your hands and put on gloves to prevent cross-infection
  • Inspect the axilla to detect any wounds or sores
  • Dry the axilla thoroughly with the flannel to dry the sweat from the armpit
  • Get the thermometer from the jar 
  • Rinse the thermometer with water to remove the disinfectant.
  • Shake the thermometer until the mercury falls below 35 °C
  • Inspect the thermometer for any cracks
  • Place the thermometer in the armpit(axilla) with the tip pointing at the head of the patient. The bulb should be at the centre of the armpit
  • As the patient places the hand over the chest and holds the opposite shoulder to hold the thermometer in place, preventing it from falling
  • Leave the thermometer in place for at least three minutes for effective reading of the body temperature.
  • Remove the thermometer and read the temperature of the patient 
  • Wipe the thermometer using a swab and put it back in the jar
  • Give the findings to the patient
  • Thank and leave the patient comfortably
  • Wash hand 
  • Record the temperature in the patient’s chart

How to take a body temperature from the groin

Groin is also called inguinal region. Groin temperature is when the temperature is taken from the groin.

Contraindication for taking the temperature from the groin (inguinal region)

Sore at the groin. Putting a thermometer in the axilla with a sore can instil pain to the patient and infect the thermometer

Wound at the groin. Putting a thermometer in the wounded axilla can cause pain to the patient and infect the thermometer

Emaciated patient, this is a patient with very low weight. It is very difficult to maintain a thermometer in place in patients who are very thin.

Requirement for taking the temperature from the groin

A tray containing the following

  • A thermometer in a jar containing a solution of disinfectant
  • Galipot with water
  • Galipot containing swab
  • Receiver (kidney dish), which will be for used swabs
  • Nurses watch for timing or other timers, like a pulsometer, a second-hand watch
  • Chart for recording the temperature or a book for recording vitals
  • Pen for recording
  • Flannel for wiping the groin

Procedure for taking the temperature from the groin

  • Explain the procedure to the patient to obtain his or her consent and build trust.
  • Screen the bed to provide privacy
  • Bring the tray near the patient’s bedside for easy accesses
  • Position the patient in a recumbent position to prevent disturbance of the patient
  • Wash your hands and put on a glove
  • Inspect the groin for any wounds or sores
  • Dry the groin thoroughly with the flannel to dry the sweat.
  • Get the thermometer from the jar 
  • Rinse the thermometer with water to remove the disinfectant.
  • Shake the thermometer until the mercury falls below 35 °C
  • Inspect the thermometer for any cracks
  • Place the thermometer in the groin(inguinal) and place the thigh over the opposite side to hold the thermometer in place
  • Leave the thermometer in place for at least three minutes for effective reading of the body temperature by the thermometer.
  • Remove the thermometer and read the temperature of the patient 
  • Wipe the thermometer using a swab and put it back to the jar
  • Give the findings to the patient
  • Thank and leave the patient comfortably
  • Wash hand 
  • Record the temperature in the patient’s chart

Taking temperature from the rectum (how to take a body temperature from the Anas)

Rectal temperature is when the temperature is taken from the anas

Requirement for taking the temperature from the rectum

A tray containing the following

  • A thermometer in a jar containing a solution of disinfectant
  • Galipot with water
  • Galipot containing swab
  • Galipot containing gauze
  • Lubricant eg KY Jelly, Vaseline
  • Receiver (kidney dish), which will be for used swabs
  • Nurses watch for timing or other timers, like a pulsometer, a second-hand watch
  • Chart for recording the temperature or a book for recording vitals
  • Pen for recording

Procedure for taking the temperature from the rectum

  • Explain the procedure to the patient or attendant to obtain his or her consent and build trust.
  • Screen the bed to provide privacy
  • Bring the tray near the patient’s bedside for easy access to the instrument
  • Position the patient in a lateral position for easy access to the Anas
  • Wash your hands and put on gloves to prevent cross-infection
  • Fold back the bed linen 
  • Get the thermometer from the jar 
  • Rinse the thermometer with water to remove the disinfectant.
  • Shake the thermometer until the mercury falls below 35 °C
  • Inspect the thermometer for any cracks
  • Lubricate the thermometer with KY Jelly to reduce the friction
  • Place the thermometer in the rectum and leave it there for one minute
  • Carefully remove the thermometer and read the temperature of the patient 
  • Wipe the thermometer using a swab and put it back in the jar
  • Give the findings to the patient
  • Thank and leave the patient comfortably
  • Wash hand 
  • Record the temperature in the patient’s chart

NB

The rectal thermometer is for an individual patient

The thermometer must be kept in the jar with disinfectant

Conversion from Fahrenheit to degrees centigrade.

Fahrenheit ranges from 32°F to 212°F

When converting Fahrenheit to degrees centigrade, we use this formula

F-32 X 5/9 = degree centigrade

Example 

Okello is a male of 6 years. He came to complain of a headache. The temperature was taken. The nurse found out that the temperature was 99°F. The nurse is used to degrees centigrade.As a senior nurse, help these nurses understand.

Senior nurse 

We first have to convert the Fahrenheit to degree centigrade

Using the formula

F-32 X 59

99-32 x 59

 99-32=69 × 59

=3339

=37.2℃

Conversion from degree centigrade to Fahrenheit

Example 

Okello is a male of 6 years. He came to complain of a headache the temperature was taken. The nurse found out that the temperature was 36°F. The nurse is used to degrees Fahrenheit. As a senior nurse, help these nurses understand.

Senior nurse 

We first have to convert the Fahrenheit to degree centigrade

Using the formula

C X  95 +32 =°F

36 .0℃ x   95 + 32 =°F

36.0 x 9  ÷ 5 +32

=324 ÷ 5 + 32 

=96.8°F

 TAKING TEMPERATURE CHECKLIST.

At this station, there is a patient admitted in bed. You are asked to take his temperature.
Instructions:
1. Set and carry out the temperature.
2. Move to the next station when the bell rings.

Procedure

  • Creates rapport and explains the procedure to the patient
  • Washes hands and sets the following:
    The thermometer in its jar of lotion
    Gallipot of cotton swabs
    Receiver for used swabs
    Watch with ticker timer
    A temperature chart and a pencil/ a pen.
  • Screens the bed for privacy.
  • Inspects the thermometer for cracks and cleans it with a swab.
  • Cleans the axilla with a dry swab and inserts the thermometer correctly.
  • Remove the thermometer after three minutes and takes the readings at eye level.
  • Gives the findings to the patient
  • Records the findings and clears away

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