TAKING AXILLARY TEMPERATURE

HOW TO TAKE AXILLARY TEMPERATURE

Nursing procedure: taking body temperature (axillary temperature)

EQUIPMENT

• Thermometer
• Two pairs of nonsterile gloves
• Tissues

NURSING ACTION:

TAKING AXILLARY TEMPERATURE

• Review medical record for baseline data factors that influence vital signs. Rationale: Establishes parameters for client’s normal measurements, provides direction in device selection, and helps determine site to use for measurement. Vital signs are measured in the order of temperature, pulse, and respiration (TPR) and blood pressure (BP), usually without interruptions, to provide the nurse with an objective clinical database to direct decision making.
• Explain to the client that vital signs will be assessed. Encourage the client to remain still; refrain from drinking, eating, and smoking; and avoid mouth breathing, if possible. Rationale: Encourages participation, allays anxiety, and ensures accurate measurements. Cold or hot liquids and smoking alter circulation and body temperature. Mouth breathing can alter temperature.
• Assess client’s toileting needs, and proceed as appropriate. Rationale: Prevents interruptions during measurements, communicates caring, and promotes client’s comfort.
• Gather equipment. Rationale: Facilitates organized assessment and measurement.
• Provide for privacy. Rationale: Decreases embarrassment.
• Perform hand hygiene/wash hands, and apply gloves when appropriate. Rationale: Reduces transmission of microorganisms. Hands are washed before and after every contact with a client. Gloves are worn to avoid contact with bodily secretions and to reduce transmission of microorganisms.
• Remove client’s arm and shoulder from one sleeve of gown. Avoid exposing chest. Exposes axillary area.
• Make sure axillary skin is dry; if necessary, pat dry. Removes moisture and prevents a false low reading.
• Place probe into center of axilla. Fold the client’s upper arm straight down, and place arm across the client’s chest. Puts device into contact with axillary blood supply. Maintains the device in proper position.
• Thermometer will signal (beep) when a constant temperature registers. Rationale: Signal indicates final temperature reading.
• Read measurement on digital display of electronicthermometer. Push ejection button to discard disposable sheath into receptacle, and return to storage well. Rationale: Reduces transmission of microorganisms. Ensures that the electronic system is ready for next use.
• Inform client of temperature reading. Rationale: Promotes client’s participation in care.
• Remove gloves and perform hand hygiene. Rationale: Reduces transmission of microorganisms.
• Record reading according to institution policies. Rationale: Accurate documentation by site allows for comparison of data.
• Return electronic thermometer unit to charging base. Rationale: Ensures charging base is plugged into electrical outlet and ready for next use.
• Wash hands/hand hygiene. Rationale: Reduces transmission of microorganisms.