Wednesday, July 25, 2012



Nursing procedure: taking body temperature (rectal).




  • 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.
  • Place client in the Sims’ position with upper knee flexed. Adjust sheet to expose only anal area. Rationale: Proper positioning ensures visualization of anus. Flexing knee relaxes muscles for ease of insertion.
  • Place tissues in easy reach. Apply gloves. Rationale: Tissue is needed to wipe anus after device is removed.
  • Lubricate tip of rectal probe (a rectal probe usually has a red cap). Rationale: Promotes ease of insertion of thermometer or probe.
  • With dominant hand, grasp top of the probe’s stem. With other hand, separate buttocks to expose anus. Rationale: Aids in visualization of anus.
  • Instruct the client to take a deep breath. Insert the probe gently into anus: infant, 1.2 cm (0.5 inches); adult, 3.5 cm (1.5 inches). If resistance is felt, do not force insertion. Relaxes anal sphincter. Rationale: Gentle insertion decreases discomfort to client and prevents trauma to mucous membranes.
  • 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.


  1. Nursing procedure: taking body temperature (rectal). ...

  2. I came here because my new rehab physician ordered rectal temperatures in the office and a temperature diary with orders to record rectal temperatures every 2 to 4 hours. Any tips on doing this? I have a home health nurse coming for treatments 2x/wk. She has called to tell me that she will train me in rectal temps. Would it be acceptable to ask her to train a friend who's offered to help me as she'll be taking my temp several times. I have MS and some mobility issues