TAKING THE PATIENT'S

TEMPERATURE
GROUP PRESENTATION:
1.ALESANDRO VIERI
2.DEBI JULIASTANTO
3.ENJELA
4.NOVITA CAROLINA
5.PITA AKTINI
6.RISKA
7.SEMULIANO
8.YUDISTIRA HASANAH
When to measure the temperature
 On a client's admission to a health care facility
 In a hospital or care facility on a routine schedule
ace physician's order or institution's standards of
practice
 When assessing the client during home health visits
 Before and after a surgical or invasive diagnostic
procedure
 Before and after the administration of medications or
therapies that affect cardiovascular, respiratory
functions
 When the client's general physical condition changes
(econsciousness, increased severity of pain)
 When the client reports specific symptoms of physic
(e.g., feeling "funny" or "different")
 Body temperature is depended to the external
environment. The core temperature, or temperature
of the deep body tissues, is under control of the
hypothalamus and is maintained within a narrow
range. Skin or body surface temperature rises and
falls as the temperature of the surrounding
environment changes and can fluctuate
dramatically.
The body tissues and cells function best
within a relatively narrow temperature range,
from 36° C to 38° C (96.8° F to 100.4° F),
but no single temperature is normal for all
people. An acceptable temperature range for
adults depends on age, gender, range of physical
activity, and state of health.
 Many factors affect body temperature. Physiological
and behavioral control mechanisms act to maintain a
constant core temperature. For example, the mechanism
of peripheral vasodilation increases blood flow to the
skin, which increases the amount of heat radiated to
the environment. Clients who lack sweat gland function
are unable to tolerate warm temperatures because they
cannot cool themselves adequately. Fever occurs when
heat loss mechanisms are unable to keep pace with
excess heat production, resulting in an abnormal rise
in body temperature. When an individual has a febrile
condition, pyrexia, the nurse initiates temperature-
control measures such as controlling environmental
temperatures, removing external coverings, and ad-
ministering ordered antipyretics to achieve better
temperature control.
 Average usual temperature varies
depending on the measurement site used.
Research findings from numerous studies
are contradictory; however, it is
generally accepted that rectal
temperatures are usually 0.5° C (0.9° F)
higher than oral temperatures, and
axillary and tympanic temperatures are
usually 0.5° C (0.9° F) lower than oral
temperatures.
Each site has advantages and
disadvantages. The nurse determines the
safest and most accurate site for the
client.
Core and Surface Temperature
Measurement Sites
CORE SITE
SURFACE SITE
Rectum Skin
Tympanic Oral
Esophagus Axilla
Pulmonary

Urinary bladder
 Two types of thermometers are commonly available
to measure body temperature: electronic and
chemical dot single use or reusable. Each type
has advantages and limitations. The mercury-in-
glass thermometer, a standard device for
temperature measurement for nearly years, has
been eliminated from most hospitals because of
the environmental hazards of mercury-contains.
However, mercury-in-glass thermometer may be
found in client's homes. The electronic
thermometer consists of a battery-powered display
unit, a thin wire cord, and temperature-
processing probe covered by a disposable sheath.
Separate probes are available for oral and rectal
temperature measuring. The oral probe has a blue
tip, and the rectal a red tip.
 Advantages and Limitations of Select Temperature Measurement
Sites
Oral
Advantages
Easily accessible—requires no position change.
Comfortable for client
Provides accurate surface temperature reading.
Reflects rapid change in core temperature.
Shown to be reliable route to measure temperature in intubated
clients.
Limitations
Causes delay in measurement if client recently ingested hot/cold
fluids or foods, smoked, or receive oxygen by mask/cannula.
Should not be used with clients who have had oral surgery, trauma,
history of epilepsy, or shaking chills.
Should not be used with infants, small children, unconscious, or
uncooperative clients
 Tympanic Membrane Sensor
Advantages
Easily accessible site.
Can be obtained without disturbing of client.
Can be used for clients with tachypnea without affecting breathing.
Provides accurate core reading because eardrum is close to hypothalamus;
sensitive to core temperature changes
Very rapid measurement (2 to 5 seconds).
Unaffected by oral intake of food or fluids or smoking
Can be used in newborns
Limitations
More variability of measurement than with other core temperature devices
Requires disposable sensor cover with only one size available
Otitis media and cerumen impaction can distort readings
Should not be used with clients who have had surgery of the ear or tympanic
membrane
Does not accurately measure core temperature changes during and after
exercise
Cannot obtain continuous measurement
Affected by ambient temperature devices such as incubators, radiant warmers,
and facial fans
 Rectal
Advantages
Argued to be more reliable when oral temperature
cannot be obtained
Limitations
May lag behind core temperature during rapid
temperature changes
Should not be used for clients with diarrhea,
clients who have had rectal surgery, rectal
disorders, bleeding tendencies
Requires positioning and may be source of client
embarrassment and anxiety
Requires lubrication
Should not be used for routine vital signs in
newborns
 Axilla
Advantages
Safe and inexpensive
Can be used with newborns and unconscious clients
Limitations
Long measurement time
Requires continuous positioning by nurse
Measurement lags behind core temperature during rapid
temperature
changes
Not recommended to detect fever in infants and young
children
Requires exposure of thorax, which can result in
temperature loss,
especially in newborns
 Skin
Advantages
Inexpensive
Provides continuous reading
Safe and noninvasive
Can be used for neonates
Limitations
Measurement lags behind other sites during temperature
changes,
especially during hyperthermia
Sweat can impair adhesion
Another form of electronic thermometer is used exclusively for
tympanic temperature. An otoscope-like speculum with an
infrared sensor tip detects heat radiated from the tympanic
membrane of the ear. Within 2 to 5 seconds after placement in
the auditory canal and depressing the scan button, a value
appears on the display unit. A sound signals when the peak
temperature reading has been measured.
 The skill of temperature measurement can be
delegated to assistive personnel. Before
delegating this skill the nurse may:
 Inform assistive personnel if any precautions are
needed in positioning the client during
measurement
 Instruct assistive personnel of appropriate route
and de vice to measure temperature
 Provide assistive personnel the frequency of
temperature measurement for select client
 Determine that assistive personnel are aware of
the client's previous temperature measures
 Instruct assistive personnel in the need to
report abnormalities that should be reconfirmed
by the nurse
1.Determine need to measure client's body
temperature:
a.Note client's risks for temperature
alterations: expected or diagnosed infection,
open wounds or burns, white blood cell count
below 5000 or above 12,000, immunosuppressive
drug therapy, injury to hypothalamus, exposure to
temperature extremes, blood product infusion,
hypothermia or hyperthermia therapy, or
postoperative status.
b.Assess for signs and symptoms that may accomany
temperature alteration:
Fever: (depending on stage) pale or flushed skin;
skin warm or hot to touch; skin dry or di-
aphoretic; dry mucous membranes; tachycardia;
muscle or joint pain; nausea, vomiting, or
diarrhea; feeling hot or cold; restlessness.
 2.Assess for factors that normally influence
temperature:
a. Age
No single temperature is normal for all people. A
temperature within an acceptable range in an
adult may reflect a fever in an older adult.
Undeveloped temperature control mechanisms in in-
fants and children can cause temperature to rise
and fall rapidly
b. Exercise
c.Hormones
d.Stress
e.Environmental temperature
f. Medications
g. Daily fluctuations