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Assessment of surface body temperature


Measurement of body temperature via a clinical thermometer.

Objective:

To know the patient’s body temperature.

Equipment:

– Clinical thermometer. – Red pen.

Material:

– Non-sterile gauze. – Antiseptic solution – Nursing record.

Procedure:

– Perform hand washing. – Remove disinfectant residues with cold water. – Check that the clinical thermometer is in the measuring position. – Preserve the patient’s privacy. – Inform the patient – Request the collaboration of the patient and family.

AXILLARY:

a) Assess the patient’s armpit, dry if wet with touches, do not rub. b) Place thermometer in the armpit, instructing the patient to put his arm on his chest. If the patient cannot maintain the position, help him/her to hold the thermometer. c) Hold the thermometer for 8-10 minutes. d) Observations: 1. The antiseptic solution in which the thermometer is immersed should be changed every 24 hours. 2. If the patient has just washed the armpit, wait 15 minutes as the friction increases the temperature.

RECTAL:

a) Use round bulb thermometer. b) Place the patient in left lateral decubitus if the patient is an adult, if a child in supine decubitus. c) Put lubricant on a gauze and apply it to the bulb of the thermometer. d) Introduce the thermometer into the rectum: adult between 2.5 and 3.5 cm; in the child 1.5 and 2.5 cm. e) Hold the thermometer for 3 minutes. f) Wash the thermometer with soapy water and rinse with cold water. Leave the thermometer in the container with antiseptic. g) Observations: May be altered by enemas or suppositories. 2. Wait 15 minutes after administration. 2. It is contraindicated in patients with rectal surgery, rectal alterations, in patients with acute myocardial infarction (vagal reaction) and in patients with convulsions (breakage of the thermometer). – Remove and read with the thermometer at eye level and in a horizontal position. – Clean the thermometer with cold water and place in a container with antiseptic. Dry. – Leave the patient in a comfortable position. – Wash hands. – Record with red pen the temperature and the area where the thermometer was taken.

Remarks:

– There are other procedures for taking body temperature with tympanic thermometers, digital thermometers, etc. – Correlation degrees Celsius-Fahrenheit 37º C=98.6º F. – The average normal temperature: – Axillary: 36-37º C. – Buccal: 0.5º C higher than axillary. – Rectal: 1° C higher than axillary. Fever: between 37º and 38º C. Moderate fever: between 38º and 39º C. High fever: between 39º and 40º C. Hyperthermia: more than 40º C.

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