TAKING/MEASURING ORAL TEMPERATURE (ELECTRONIC THERMOMETER)

HOW TO TAKE ORAL TEMPERATURE USING ELECTRONIC THERMOMETER

This is a sample of nursing procedure how to take oral temperature.

EQUIPMENT

• ·         Thermometer: Electronic thermometer with disposable protective sheathing
•        Two pairs of nonsterile gloves and 
•         Tissues

Oral (Electronic) Thermometer

NURSING ACTION:

TAKING/MEASURING ORAL TEMPERATURE (ELECTRONIC THERMOMETER)

1.     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.

2.     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.

3.     Assess client’s toileting needs, and proceed as appropriate. Rationale: Prevents interruptions during measurements, communicates caring, and promotes client’s comfort.

4.     Gather equipment. Rationale: Facilitates organized assessment and measurement.

5.     Provide for privacy. Rationale: Decreases embarrassment.

6.     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.

7.     Place disposable protective sheath over probe. Rationale: Reduces transmission of microorganisms.

8.     Grasp top of the probe’s stem. Avoid placing pressure on the ejection button. Rationale: Pressure on the ejection button releases the sheath from the probe.

9.     Place tip of thermometer under the client’s tongue and along the gumline to the posterior sublingual pocket lateral to center of the lower jaw. Rationale: Sublingual pocket contains superficial blood vessels.

10.  Instruct client to keep mouth closed around thermometer. Rationale: Maintains thermometer in proper place and decreases amount of time required for an accurate reading.

11.  Thermometer will signal (beep) when a constant temperature registers. Rationale: Signal indicates final temperature reading.

12.  Read measurement on digital display of electronic thermometer. 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.

13.  Inform client of temperature reading. Rationale: Promotes client’s participation in care.

14.  Remove gloves and perform hand hygiene. Rationale: Reduces transmission of microorganisms.

15.  Record reading according to institution policies. Rationale: Accurate documentation by site allows for comparison of data.

16.  Return electronic thermometer unit to charging base. Rationale: Ensures charging base is plugged into electrical outlet and ready for next use.

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