MEASURING ORAL TEMPERATURE USING GLASS THERMOMETER

HOW TO MEASURE ORAL TEMPERATURE USING GLASS THERMOMETER

Nursing procedure: measuring oral temperature

EQUIPMENT

• Thermometer
• Two pairs of nonsterile gloves
• Tissues

NURSING ACTION

MEASURING ORAL TEMPERATURE USING GLASS THERMOMETER

• 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.

• Hold end (tip will be blue) of glass thermometer by fingertips, rinse under cool water, and wipe dry with a tissue from bulb’s end toward fingertips. A blue tip usually denotes an oral thermometer. Rationale: Rinsing removes disinfectant, and cool water prevents expansion of the mercury. Holding the thermometer at the opposite end reduces contamination of the bulb.

• Read mercury level while gently rotating thermometer at eye level. It should read 35.5^OC (96^OF). Rationale: If the mercury is above desired level, grasp tip of thermometer securely, stand away from solid objects, and sharply flick wrist downward. Thermometer must be below normal body temperature. Briskly shaking lowers mercury level in glass tube.

• Place thermometer into oral sublingual pocket, leave thermometer in place 3 minutes. Remove thermometer, and wipe off secretions with a clean tissue, moving toward the bulb. With the thermometer at eye level, read finding. Shake thermometer down, cleanse with soapy water, rinse with cool water, and store thermometer in storage container. Ensures contact with large blood vessel under the tongue. Thermometer must stay in place long enough to obtain an accurate reading. Rationale: Mucus on the thermometer may interfere with disinfectant solution’s effectiveness. Wipe from area of least contamination to area of most contamination. Ensures accurate reading.

• Wash hands/hand hygiene. Rationale: Reduces transmission of microorganisms.

• Record temperature, indicate the method, and discard the thermometer. Nursing documentation, practice clean technique.