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Measuring Temperature (102.102)

Measuring Temperature (102.102) - Policies, Clinical, UWMF Clinical, UWMF-wide, Clinical Policies and Procedures, Patient Assessment

102.102

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UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE

TITLE: MEASURING TEMPERATURE

Effective Date: March, 2002 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education

Reviewed October, 2003 March, 2005 February, 2008 October 2011


PURPOSE: To provide guidelines for taking temperatures of patients at UWMF Clinics.

DEFINITION: Alterations that may affect body temperature can include disease, infection, prolonged
exposure to heat or cold, exercise, and hormonal disturbances.

POLICY: The clinical staff will utilize the following guidelines to take the temperature of a UWMF patient.
The clinical staff will take a temperature on all UWMF patients whom present to the clinic with a possible
infection, complaint of infection or related issues.

SUPPLIES: Electronic, Disposable or Tympanic Thermometer
Lubricant (if indicated), patient’s record

PROCEDURE:

1. Check provider’s order and clarify any inconsistencies (if indicated).
2. Wash hands and gather equipment.

3. Determine the most appropriate method for obtaining a temperature reading.
If the child is younger than 3 months, you'll get the most reliable reading by using a digital thermometer to take a rectal
temperature. Electronic ear thermometers aren't recommended for infants younger than 3 months because their ear canals
are usually too small.
4. Identify the patient, verifying patient’s full name and date of birth and introduce yourself to the patient.

5. Provide good light and privacy by closing curtains or door.

6. Explain procedure and the purpose for needing a temperature.

7. Measuring Temperature Using Electronic Thermometer
a. Attach oral or rectal probe to electronic display unit.
b. Slide clean disposable plastic cover over temperature probe until it locks in place.
c. Obtain oral, rectal or axillary temperature:
d. For axillary temperature – use oral probe.


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STEPS IN TAKING AN ORAL TEMPERATURE
 Ask patient to open mouth and gently place covered temperature probe under
tongue in posterior sublingual pocket lateral to center of lower jaw.
 Ask patient to hold thermometer probe with lips closed.
 Leave thermometer probe in place until audible signal occurs and patient’s
temperature appears on digital display.
 Remove thermometer probe from under patient’s tongue.
 Inform patient of temperature.
 Push eject-button on thermometer probe to discard probe cover into proper receptacle.
 Replace probe in electronic unit to charger and wash hands.

STEPS IN TAKING A RECTAL TEMPERATURE
 Put on gloves and apply lubricant to probe covered end of thermometer.
 Gently insert lubricated thermometer probe into anus in direction of umbilicus.
Adults/Children: With patient lying on his/her side, lift the buttocks up so anus can be visualized.
Insert lubricated temperature probe 3.5 cm (1 1/2 inches) for adults. (Do not force thermometer).
Infants: Expose the rectal area by laying the infant on his back and lifting both legs into the air.
Insert the lubricated thermometer probe until 1/2 to 3/4 inches has been inserted.
 Leave thermometer probe in place until audible signal occurs and patient’s temperature appears on digital
display; remove probe from patient's anus.
 Push eject-button on thermometer probe, discard probe cover into proper receptacle.
 Inform patient of temperature.
 Return thermometer probe to storage position in electronic unit.
 Wipe patient's anal area to remove lubricant or feces and discard tissue.
 Remove gloves and wash hands.
 Assist patient with clothing and help patient return to a more comfortable position.

STEPS IN TAKING AN AXILLARY TEMPERATURE
 Assist patient to a sitting or supine position.
 Move clothing away from patient's shoulder and arm. (Ensure axillary area is dry).


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 Raise patient’s arm away from torso - dry axilla if excess perspiration is present.

 Insert thermometer probe and lower patient's arm over thermometer.
 Hold electronic probe in place until audible signal occurs and patient’s temperature reading appears on
digital display. For axillary temperature – use oral probe.
 Carefully remove probe from patient's axilla.
 Read thermometer and inform patient of temperature.
 Push eject-button on thermometer probe, discard probe cover into proper receptacle.
 Replace probe in electronic unit and wash hands.

STEPS IN TAKING A TYMPANIC TEMPERATURE
*Do not use an ear thermometer when a person has a sore ear, an ear infection, or if they just had ear surgery.
*Ear thermometers will give you an incorrect and low reading if there is "wax" in the ear of the person.
 Remove thermometer handheld unit from charging base, being careful not to apply pressure on the eject-
button.
 Slide disposable speculum cover over otoscope-like tip until it locks into place.
(Be careful not to touch lens cover).
 Insert speculum into ear canal - probe positioning:

 Pull ear pinna up and back for an adult.
 Pull ear pinna down and back for a child.

 Fit probe snug into canal.


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 Point probe toward nose.
 As soon as probe is in place, depress scan button on unit (about 2 seconds later).
 Remove thermometer and dispose of probe cover and wash hands.
 Discuss findings with patient.
8. Documentation:
Within vitals section of Healthlink
Include route taken
Include last dose of medication taken for fever (if indicated0


REVIEWED BY:
LaVay Morrison, RN, BSN, Clinical Staff Educator

REVISED BY:
LaVay Morrison, RN, BSN, Clinical Staff Educator

WRITTEN BY:
Ronnie Peterson, R.N., M.S., Manager of Clinical Support

REFERENCES:

1. Kowalak, J. P. (Ed.). (2009). Lippincott’s nursing procedures (5th ed.). Ambler, PA: Lippincott Williams
& Wilkins.
2. Perry, A.G. & Potter, P.A. (2002). Clinical nursing skills & techniques. (5th ed.). St. Louis, MO: Mosby.
3. Perry, A.G. & Potter, P.A. (2009). Fundamentals of nursing. (7th ed.). Hall, A. & Stockert, P.A. (Eds.). St.
Louis, MO: Mosby Elsevier.



AUTHORIZATION:



Medical Director Date