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Melanie Ann Rushton Adult lecturer, School of Health and Society, University of Salford, Salford, England Mike Barker Adult lecturer, School of Health and Society, University of Salford, Salford, England Why you should read this article:
Rationale and key points Temperature is a vital sign that is included in all early warning scoring tools and as part of patient observations. This article outlines the main non-invasive methods that can be used to measure a patient’s temperature. • Temperature is important in establishing a baseline to evaluate treatment, monitoring signs of any allergic reaction or infection, and recognising significant changes in temperature, for example hypothermia and hyperthermia. • Nurses should understand the pathophysiology of temperature regulation and be familiar with the various methods used to measure temperature. They should also be aware of the environmental factors that may result in inaccurate temperature readings. • It is crucial to identify any signs of clinical deterioration in patients, including elevated or lowered temperature, and respond to these in a timely manner. Reflective activity ‘How to’ articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of: 1. How reading this article will change your practice in measuring patients’ temperature. 2. How this article could be used to provide information to patients about temperature measurements. Nursing Standard. doi: 10.7748/ns.2019.e11346 Peer review This article has been subject to external double-blind peer review and checked for plagiarism using automated software Correspondence
Conflict of interest None declared Smith J, Rushton MA, Barker M (2019) How to measure a patient’s temperature non-invasively. Nursing Standard. doi: 10.7748/ns.2019.e11346 Disclaimer Please note that information provided by Nursing Standard is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed at the bedside by a nurse educator or mentor. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence Published online: 09 September 2019 Want to read more?Already subscribed? Log inORUnlock full access to RCNi Plus todaySave over 50% on your first 3 monthsYour subscription package includes:
Subscribe RCN student member? Try Nursing Standard StudentAlternatively, you can purchase access to this article for the next seven days. Buy now Or Temperature, pulse, respiration, blood pressure (BP), and oxygen saturation, are measurements that indicate a person’s hemodynamic status. These are the five vital signs most frequently obtained by health care practitioners (Perry, Potter, & Ostendorf, 2014). Vital signs will potentially reveal sudden changes in a patient’s condition and will also measure changes that occur progressively over time. A difference between patients’ normal baseline vital signs and their
present vital signs may indicate the need for intervention (Perry et al., 2014). Checklist 15 outlines the steps to take when checking vital signs. 1. Temperature: Normal (oral) = 35.8ºC to 37.3ºC Oral temperature: Place the thermometer in the mouth under the tongue and instruct patient to keep mouth closed. Leave the thermometer in place for as long as is indicated by the device manufacturer. Axillary temperature: Usually 1ºC lower than oral temperature. Place the thermometer in patient’s armpit and leave it in place for as long as is indicated by the device manufacturer. Tympanic membrane (ear) temperature:
Usually 0.3°C to 0.6°C higher than an oral temperature. The tympanic membrane shares the same vascular artery that perfuses the hypothalamus. Do not force the thermometer into the ear and do not occlude the ear canal. Rectal temperature: Usually 1ºC higher than oral temperature. Use only when other routes are not available. 2. Pulse: Normal resting heart rate = 60 to 100 beats per minute Radial pulse Apical pulse Radial pulse: Use the pads of your first three fingers to gently palpate the radial pulse at the inner lateral wrist. Apical pulse: Taken as part of a focused cardiovascular assessment and when the pulse rate is irregular. Apical heart rate should be used as the parameter indicated in certain cardiac medications (e.g., digoxin). Apical pulse rate should be taken for a full minute for accuracy, and is located at the fifth intercostal space in line with the middle of
the clavicle in adults. Carotid pulse: May be taken when radial pulse is not present or is difficult to palpate. 3. Respiration rate: Normal resting respiratory rate = 10 to 20 breaths per minute Respiratory rate 4. Blood pressure (BP): Blood pressure cuff The average BP for an adult is 120/80 mmHg, but variations are normal for various reasons. The systolic pressure is the maximum pressure on the arteries during left ventricular contraction. The diastolic pressure is the resting pressure on the arteries between each cardiac contraction. The patient may be sitting or lying down with the bare arm at heart level. Palpate the brachial artery just above the antecubital fossa medially. Wrap the BP cuff around the upper arm about 2.5 cm above the brachial artery. Palpate the radial or brachial artery,
and inflate the BP cuff until the pulse rate is no longer felt. Then inflate 20 to 30 mmHg more. Place the bell of the stethoscope over the brachial artery, and deflate the cuff slowly and evenly, noting the points at which you hear the first appearance of sound (systolic BP), and the disappearance of sound (diastolic BP). 5. Oxygen saturation (SpO2): A healthy patient will have an SpO2 of ≥ 97%. Pulse oximeter sensor When is a tympanic thermometer used?Tympanic membrane thermometers are the most sensitive noninvasive devices for measuring body temperature greater than 37.5° C and are better for detecting temperature shifts after acetaminophen than single-use or mercury-in glass-thermometers.
Where is the tympanic thermometer placed for a temperature reading?Tympanic temperature measurement
To ensure accurate temperature measurements, the tympanic thermometer probe should be positioned to fit snugly in the ear canal.
Which is the best site for a nurse to measure body temperature in an unconscious patient?Place the thermometer in the axilla (armpit). Place the forearm across the chest and ensure the upper arm is resting against the patient's side. Leave the thermometer in place for 5 minutes. This will ensure that the reading will be accurate.
What is tympanic temperature measurement?An ear (tympanic) temperature is 0.3°C (0.5°F) to 0.6°C (1°F) higher than an oral temperature. An armpit (axillary) temperature is usually 0.3°C (0.5°F) to 0.6°C (1°F) lower than an oral temperature. A forehead (temporal) scanner is usually 0.3°C (0.5°F) to 0.6°C (1°F) lower than an oral temperature.
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In which patient would the tympanic membrane be used as a site for temperature measurement
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