TEMPERATURE MEASURING

1. TEMPERATURE MEASURING

2. Temperature, pulse, blood pressure (BP), and respiration are the most frequent data obtained by health care practitioners. When to measure the temperature • On a client's admission to a health care facility • In a hospital or care facility on a routine schedule ace physician's order or institution's standards of practice • When assessing the client during home health visits • Before and after a surgical or invasive diagnostic procedure • Before and after the administration of medications or therapies that affect cardiovascular, respiratory functions • When the client's general physical condition changes (econsciousness, increased severity of pain) • When the client reports specific symptoms of physic (e.g., feeling "funny" or "different")

3. Body temperature is depended to the external environment. The core temperature, or temperature of the deep body tissues, is under control of the hypothalamus and is maintained within a narrow range. Skin or body surface temperature rises and falls as the tempera­ture of the surrounding environment changes and can fluctu­ate dramatically. The body tissues and cells function best within a rela­tively narrow temperature range, from 36° C to 38° C (96.8° F to 100.4° F), but no single temperature is normal for all peo­ple. An acceptable temperature range for adults depends on age, gender, range of physical activity, and state of health.

4. Many factors affect body temperature. Physiological and behavioral control mechanisms act to maintain a constant core temperature. For example, the mechanism of peripheral vasodilation increases blood flow to the skin, which in­creases the amount of heat radiated to the environment. Clients who lack sweat gland function are unable to tol­erate warm temperatures because they cannot cool them­selves adequately. Fever occurs when heat loss mechanisms are unable to keep pace with excess heat production, result­ing in an abnormal rise in body temperature. When an indi­vidual has a febrile condition, pyrexia, the nurse initiates temperature-control measures such as controlling environ­mental temperatures, removing external coverings, and ad­ministering ordered antipyretics to achieve better tempera­ture control.

5. Average usual temperature varies depending on the measurement site used. Research findings from numerous studies are contradictory; however, it is generally accepted that rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures, and axillary and tympanic tempera­tures are usually 0.5° C (0.9° F) lower than oral tempera­tures. Each site has advantages and disadvantages. The nurse determines the safest and most accurate site for the client.

6. Core and Surface Temperature Measurement SitesCORE SITE SURFACE SITE

7. Two types of thermometers are commonly available to measure body temperature: electronic and chemical dot sin­gle use or reusable. Each type has advantages and limita­tions. The mercury-in-glass thermometer, a standard device for temperature measurement for nearly years, has been eliminated from most hospitals because of the environmental hazards of mercury-contains. However, mercury-in-glass thermometer may be found in client's homes. The electronic thermometer consists of a battery-powered display unit, a thin wire cord, and temperature-processing probe covered by a disposable sheath. Separate probes are available for oral and rectal temperature measuring. The oral probe has a blue tip, and the rectal a red tip.

8. Advantages and Limitations of Select Temperature Measurement Sites Oral Advantages Easily accessible—requires no position change. Comfortable for client Provides accurate surface temperature reading. Reflects rapid change in core temperature. Shown to be reliable route to measure temperature in intubated clients. Limitations Causes delay in measurement if client recently ingested hot/cold fluids or foods, smoked, or receive oxygen by mask/cannula. Should not be used with clients who have had oral surgery, trauma, history of epilepsy, or shaking chills. Should not be used with infants, small children, uncon­scious, or uncooperative clients

9. Tympanic Membrane Sensor Advantages Easily accessible site. Can be obtained without disturb­ing of client. Can be used for clients with tachypnea without affecting breathing. Provides accurate core reading because eardrum is close to hypothal­amus; sensitive to core temperature changes Very rapid measurement (2 to 5 seconds). Unaffected by oral intake of food or fluids or smoking Can be used in newborns Limitations More variability of measurement than with other core temperature devices Requires disposable sensor cover with only one size available Otitis media and cerumen impaction can distort readings Should not be used with clients who have had surgery of the ear or tympanic membrane Does not accurately measure core temperature changes during and af­ter exercise Cannot obtain continuous measurement Affected by ambient temperature devices such as incubators, radiant warmers, and facial fans

10. Rectal Advantages Argued to be more reliable when oral temperature cannot be obtained Limitations May lag behind core temperature during rapid temperature changes Should not be used for clients with diarrhea, clients who have had rec­tal surgery, rectal disorders, bleeding tendencies Requires positioning and may be source of client embarrassment and anxiety Requires lubrication Should not be used for routine vital signs in newborns

11. Axilla Advantages Safe and inexpensive Can be used with newborns and unconscious clients Limitations Long measurement time Requires continuous positioning by nurse Measurement lags behind core temperature during rapid temperature changes Not recommended to detect fever in infants and young children Requires exposure of thorax, which can result in temperature loss, especially in newborns

12. Skin Advantages Inexpensive Provides continuous reading Safe and noninvasive Can be used for neonates Limitations Measurement lags behind other sites during temperature changes, especially during hyperthermia Sweat can impair adhesion Another form of electronic thermometer is used exclu­sively for tympanic temperature. An otoscope-like specu­lum with an infrared sensor tip detects heat radiated from the tympanic membrane of the ear. Within 2 to 5 seconds after placement in the auditory canal and depressing the scan button, a value appears on the display unit. A sound signals when the peak temperature reading has been measured.

13. Chemical dot single-use or reusable thermometers are disposable thin strips of plastic with a temperature sensor at one end. The sensor consists of a matrix of chemically im­pregnated dots that are formulated to change color at differ­ent temperatures. each representing temperature increments of 0.1° C over a range of 35.5° C to 40.4° C. The Fahrenheit version has 45 dots with increments of 0.2° F and a range of 96.0° F to 104.8° F. Chemical dots on the thermometer change color to reflect temperature reading, usually within 60 seconds. Most are designed for single use.

14. Electronic thermometer Advantages Disposable, easy to store Used for clients in isolation Useful for screening tempera­tures, especially for infants and during invasive procedures ( during surgery) Limitations Can be difficult to read Has been shown to underesti­mate and overestimate temper­ature can be reused for a single client the chemical dots return to the original color within a few seconds. The chemical thermometers are most commonly used for oral tempera­tures. They can also be used at axillary or rectal sites, cov­ered by a plastic sheath at the latter, with a placement time of 3 minutes. Not appropriate for monitoring temperature therapies Plastic sheath unbreakable; Ideal for children Very rapid measurement Limitations Probe or sensor covers are expensive

15. The skill of temperature measurement can be delegated to as­sistive personnel. Before delegating this skill the nurse may: • Inform assistive personnel if any precautions are needed in positioning the client during measurement • Instruct assistive personnel of appropriate route and de­ vice to measure temperature • Provide assistive personnel the frequency of temperature measurement for select client • Determine that assistive personnel are aware of the client's previous temperature measures • Instruct assistive personnel in the need to report abnor­malities that should be reconfirmed by the nurse

16. 1. Determine need to measure client's body temperature: a. Note client's risks for temperature alterations: expected or diagnosed infection, open wounds or burns, white blood cell count below 5000 or above 12,000, immunosuppressive drug therapy, injury to hypothalamus, exposure to temperature extremes, blood product infusion, hypothermia or hyperthermia therapy, or postoperative status. b. Assess for signs and symptoms that may accomany temperature alteration: Fever: (depending on stage) pale or flushed skin; skin warm or hot to touch; skin dry or di­aphoretic; dry mucous membranes; tachycardia; muscle or joint pain; nausea, vomiting, or diarrhea; feeling hot or cold; restlessness.

17. 2. Assess for factors that normally influence temperature: a. Age No single temperature is normal for all people. A temperature within an acceptable range in an adult may reflect a fever in an older adult. Undeveloped temperature control mechanisms in in­fants and children can cause temperature to rise and fall rapidly b. Exercise c. Hormones d. Stress e. Environmental temperature f. Medications g. Daily fluctuations

18. Physical signs and symptoms may alert nurse to alteration in body temperature. Hyperthermia: Decreased skin turgor, tachycardia; hypoten­sion; decreased venous filling; concentrated urine. Heatstroke: Hot, dry skin; tachycardia; hypotension; exces­sive thirst; muscle cramps; visual disturbances; confusion or delirium. Hypothermia: Pale skin; skin cool or cold to touch; brady­cardia and dysrhythmias; uncontrollable shivering; re­duced level of consciousness; shallow respirations. Older adults have a narrower range of temperature than do younger adults. Muscle activity raises heat production. Women have wider temperature fluctuations than men be­cause of menstrual cycle hormonal changes; body temperature change can vary during menopause. Stress elevates temperature. Infants and older adults are more sensitive to environmental temperature changes.

19. Drugs may impair or promote sweating, vasoconstriction, vasodilation change temperature. Body temperature normally changes 0.5 to 1° C during a 24- hour period. Temperature is lowest during early morning. Most clients have maximum temperature elevation around 6 pm; temperature falls gradually during night. Determines if client's status contraindicates selection of a' specific method or site. • Body temperature is within acceptable range for client's age-group. • Body temperature returns to baseline range follow­ing therapies for abnormal temperature.

20. IMPLEMENTATION 1. Perform hand hygiene. 2. Assist client to comfortable position that provides easy access to temperature measurement site. 3. Obtain temperature reading. a. Oral temperature measurement with electronic thermometer (1) Apply disposable gloves (optional). 2. Remove thermometer pack from charging unit. Attach oral thermometer probe stem (blue tip) to thermometer unit. 3. Remove thermometer pack from charging unit. Attach rectal thermometer probe stem(red tip) to thermometer unit. Grasp top of probe stem, being careful not to apply pres­sure on the ejection button.

21. (3) Slide disposable plastic probe cover over ther­ mometer probe stem until cover locks in place. (4) Squeeze liberal portion of lubricant on tis­ sue. Dip thermometer's blunt end into lubri­cant, covering 2.5 to 3.5 cm (1 to 1V2 inches) for adult. (5) With nondominant hand, separate client's but­ tocks to expose anus. Ask client to breatheslowly and relax. (6) Gently insert thermometer into anus in di­rection of umbilicus 3.5 cm (l'/2 inches) for adult. Do not force thermometer. (7) If resistance is felt during insertion, with draw immediately. Never force thermometer. Once positioned, hold thermometer probe in place until audible signal indicates comple­tion and client's temperature appears on dig­ital display; remove thermometer probe from anus (see illustration

22. Push ejection button on thermometer stem to discard plastic probe cover into an appropri­ate receptacle. Return thermometer stem to storage position of recording unit. Wipe client's anal area with soft tissue to remove lubricant or feces, and discard tissue. Assist client in assuming a comfortableposition. Remove and dispose of gloves in appropri­ate receptacle. Perform hand hygiene. Return thermometer to charger. c. Axillary temperature measurement with electronic thermometer (1) Draw curtain around bed and/or close room door. Assist client to supine or sitting posi­tion. Move clothing or gown away from shoulder and arm. button releases plastic cover from probe stem.

23. Probe cover prevents transmission of microorganisms b< tween clients. Lubrication minimizes trauma to rectal mucosa during ii sertion. Tissue avoids contamination of remaining cant in container. Fully exposes anus for thermometer insertion. Relaxes i sphincter for easier thermometer insertion. Ensures adequate exposure against blood vessels in i wall. Prevents trauma to mucosa. Probe must stay in place until signal occurs to ensure accu­rate reading

24. STEP 3b(9) Probe removed smoothly from anus. Reduces transmission of microorganisms. • Returning thermometer stem automatically causes digital reading to disappear. Provides for comfort and hygiene. • Reduces transmission of microorganisms. Maintains battery charge of thermometer unit. • Maintains client's privacy, minimizes embarrassment, and promotes comfort. Exposes axilla for correct thermometer probe placement.