Nanda, Nursing Care Plan, Nursing Assessment, Nursing Diagnosis, Nursing Interventions

How to Take Rectal, Oral and Axillary Temperature


The body temperature is the heat of the body measured in degrees.
The average temperature of an adult measured orally is between36.7 oC and 37 oC.

A temperature higher than the usual average is called a fever or hyperthermia. At its first appearance, the signs a fever include :
  • an increased pulse
  • increased breathing
  • shivering
  • cold skin
  • feelings of being cold (having a chill)
During the course of the fever, clinical signs include:
  • skin that feels warm to the touch
  • continued increased pulse rate and breathing
  • thirst
  • dehydration
  • loss of appetite
  • a general feeling of unease
  • drowsiness, restlessness and, in severe cases, delirium.
When a fever begins to go down, the patient still feels warm and isflushed and sweating; the person may also be dehydrated but doesnot have chills.

A body temperature which is lower than the average is called hypothermia. The clinical signs include:
  • severe shivering
  • pale, cool, waxy skin
  • low blood pressure (hypotension)
  • decreased urinary output20
  • disorientation
  • in severe cases, drowsiness and coma.
The nurse routinely takes the patients temperature to check for infection. Fever is a sign of infection. If a patient has a fever, the nurse checks the temperature to see whether fever is continuing, getting worse, or whether the medication has reduced the temperature. The nurse also takes the temperature to see whether the care given has changed it.

The body temperature can be measured at oral, rectal and axillary (under the arm) sites. It can also be measured in the ear at the tympanic membrane (ear drum).

A mercury thermometer is generally used to measure temperature. The thermometer may have a long slender tip or a rounded tip. The slender tip is best for oral or axillary temperature; the rounded tip isused to take rectal temperature.

To read a mercury thermometer, hold it at eye level and turn it until you can see the mercury line. The upper end of the line, the highest point the mercury has reached, gives the temperature.

How to Take an Oral Temperature

How to Take an Oral Temperature

A person’s temperature is usually measured in the mouth, or orally. This is the easiest way to take a temperature. If the patient is under five years old or is confused, the temperature must be taken anothe rway in case he or she bites the thermometer and breaks it. If a patient has had cold or hot fluids or has been smoking, you must wait 15 to 30 minutes before taking an oral temperature to make sure that the temperature reading is accurate.
  • Wash your hands.
  • Shake the thermometer down to below 35 oC.
  • Put the thermometer under the patients tongue, to the right or left of the pocket at the base of the tongue.
  • Tell the patient to close his or her lips, but not the teeth, around the thermometer. Leave the thermometer in place for at least three minutes.
  • Take out the thermometer and read the temperature.
  • Wash the thermometer in soapy lukewarm water (never hot), rinse it in cold water, wipe it with disinfectant and store it dry.
  • Wash your hands and record the temperature.

How to Take an Axillary Temperature

How to Take an Axillary Temperature

To take an axillary temperature, the thermometer is put under the patients arm (in the axilla). This is not the most accurate way to take a temperature, but it is done for adults who have inflammatio nof the mouth and patients who are confused. An axillary temperature is usually a half degree lower than an oral temperature.
  • Wash your hands.
  • Prepare the thermometer just as you would to take an oral temperature.
  • Put the thermometer under the patients arm in the axilla.
  • Ask the patient to hold the arm tight against the chest and leave the thermometer in place for five minutes in children and nine minutes in adults.
  • Take out the thermometer, read the temperature and clean and store the thermometer. Wash your hands and record the temperature.

How to Take a Rectal Temperature

How to Take a Rectal Temperature

Rectal temperatures are considered the most accurate. They are usually taken only with infants and children who cannot yet hold a thermometer in their mouth without breaking it. A rectal temperatureis usually a degree higher than an oral temperature. When you take a rectal temperature, use a thermometer with a rounded tip.
  • Wash your hands.
  • Ask the patient to lie on his or her side, with knees flexed. A child should lie on one side or prone, on your lap.
  • Check the temperature recorded on the thermometer. If it reads more than 35oC, shake it down.
  • Put some lubricant on a tissue and then onto the first 2.5 cm of the thermometer. The lubricant makes it easier not to irritate the membranes when you put in the thermometer.
  • Ask the patient to take a deep breath and put the thermometer into the anus from 1.5 to 4 cm depending on the patients age and size. Do not force the thermometer.
  • Hold the thermometer in place for two minutes.
  • Remove the thermometer, wipe it with a tissue, and discard the tissue. Read the thermometer.
  • Wash and rinse the thermometer, wipe it with disinfectant, dry it and store it dry. Wash your hands.
  • Record the temperature.

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