Procedure in Taking Temperature in all methods

TEMPERATURE

Definition

•    It is the balance between the heat loss and heat production

Special Considerations

•    Stay with the patient while the thermometer is in the patient.

•    Remember that the temperature is usually taken by mouth unless otherwise ordered or contraindicated.

•     Provide individual thermometer for each patient

•     Use   only   oral   thermometer  for   taking   oral   temperature   and   rectai thermometer for rectal temp

•    When the patient has diarrhea do not take the temperature by rectum.

•    Using the axillary method, see to it that the axilla is dry and the bulb of the thermometer is with in the hallow of the axilla.

•    Remember that the rectal temperature is taken on the following conditions only:

    When there is oral obstruction, which prevents closure of the

mouth,     When the mouth is dry and inflamed     When there is oral or nasal surgery or disease,     For the very young restless, irrational and convulsive patient. "     When the patient is mouth breather

Procedure in Taking Temperature:

1.   Wash your hands.

2.   Gather all materials needed on a tray and bring it to the bedside of the client.

3.   Explain procedure to the client and provide pnvacy.

4.   Take the temperature

5   While the thermometer is in place, take the radial pulse and the cardiac rate synchronously for one full minute.

6.   After counting the cardiac rate, count the respiratory rate in  on full minute, noting the rise and fall, if there is any harsh breath sound and etc...

7.   When RR is done, take the blood pressure preferably on the left hand.

8.   After BP taking, take the thermometer and record all the results.

A. ORAL METHOD

1.   If the thermometer has been stored in a chemical solution, wipe it dry with a firm twisting motion using soft tissue or cotton balls.

2.   Wipe ones from the bulb toward the fingers with tissue or cotton.

3.   Grasp the thermometer firmly with thumb and forefinger, and with the strong wrist movements, shake the thermometer until the mercury line reaches the lowest markings.

4.   Read the thermometer by holding it horizontally at eye level and rotate it between the fingers until the mercury line can be seen clearly.

5.   Place the mercury bulb of the thermometer under the patient's tongue and instruct him to close his lips tightly.

6.   Leave the thermometer in place for a minimum of 3 minutes but preferably 7-10 minutes.

7.   Read the thermometer and wipe it once from the fingers down to the mercury bulb, using a fir twisting motion.

8.   Read the thermometer and take down the reading.

9.   Wash with soap and water and return to case.

 AXILLARY METHOD

1.   If the thermometer has been stored in a chemical solution. Wipe it dry with firm twisting motion, using clean tissue or cotton.

2.   Read and shake the thermometer for obtaining an oral temperature.

3.   Place the thermometer well into the axilla with the stem directed toward the patient's head. Bring the patient's arm down close to his body and place his forearm over his chest.

4.   Leave the thermometer and place for 10 minutes or more.

C. RECTAL TEMPERATURE

1.   Wipe then shake the thermometer for obtaining oral temperature

2.   Lubricate the mercury bulb and area approximately 2.5 cm (1 inch) above the bulb.

3.   With the patient on his side, fold back the bed linen and separate the buttocks so that the anal sphincter is seen clearly. Insert the thermometer for approximately 3.8 cm (1 1/2inch). Permit the buttocks to fall in place.

4. Leave  the Thermometer and place  for 2 to 3 minute*. Mold the thermometer in place if the patient is national or is a restless child or infant.

5.   Remove the thermometer and wipe it once from fingers to mercury bulb using a firm, twisting motion.

6.   Read and shake the thermometer and dispose the wipe in a receptacle used for contaminated items.

Rectal temperature is indicated to:

1.   Very ill

2.   Infants and young children

3.   Irrational uncooperative and unconscious.

Contraindicated to:

1.   Rectum is inflamed or operated.

2.   Impacted with fecal materials.


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