Assessing Body Temperature

This skill is related to: Vital Signs

Assessing body temperature is done to:

• Establish baseline data.
• Evaluating deviations of core temperature.
• Evaluating changes in core temperature in response to specific therapies.
• Monitoring clients at risk for imbalanced body temperature.

Phase	Nursing Activities
Assessment	Check for clinical signs of fever and hypothermia, appropriate sites for assessment, and factors that may alter core body temperature.
Planning	Assign: routine measurements may be delegated to APs or even family members or caregivers in nonhospital settings. The nurse bears the responsibility of educating delegates for the type of thermometer to use, site to use, how to record findings, and when to report abnormal temperatures to the nurse. The nurse interprets abnormal temperatures and determines appropriate responses. Equipment: thermometer and its sheath or cover, water-soluble lubricant (if rectal), towel (if axillary), and tissues or wipes.
Implementation	Make sure all gathered equipment are functioning normally. Prior to performing the procedure, the nurse must introduce themselves and verify the client’s identity using agency protocol. Explanation of the nurse’s purpose, the procedure, and how the patient will participate. Perform hand hygiene and apply appropriate infection prevention procedures. Gloves are used for rectal temperatures. Provide client privacy. Position the client appropriately (e.g., lateral or Sims’ position for inserting a rectal thermometer. Place the thermometer, with a protective sheath or probe cover if appropriate. If rectal, lubrication is required. Wait the appropriate amount of time. A light or tone appears in electronic or digital thermometers, while some disposable methods such as chemical dots or tape thermometers should be used based on package instructions. Remove the thermometer and discard the cover or wipe with a tissue if necessary. Gloves are also removed and discarded if used. Read the temperature and record it on your worksheet. If deviations are present, recheck with a thermometer known to be functioning properly. Wash the thermometer if necessary and return it to its storage location. Document the temperature in the client record. Follow protocol for specifying the site used for temperature assessment.
Evaluation	Compare the temperature measurement to baseline data, normal range for age of client, and client’s previous temperatures. Time of day and any additional influencing factors and other vital signs should be analyzed with the body temperature. Appropriate follow-up such as notifying the primary care provider if a temperature is outside of a specific range or is not responding to interventions, giving a medication, or altering the client’s environment. This includes teaching the client how to lower an elevated temperature through actions such as increasing fluid intake, coughing and deep breathing, cool compresses, or removing heavy coverings. Interventions for hypothermia include intake of warm fluids and use of warm or electric blankets.