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Nursing - Procedure and Recording of Temperature | 11th Nursing : Chapter 5 : Nursing - Health Assessment and Physical Examination

Chapter: 11th Nursing : Chapter 5 : Nursing - Health Assessment and Physical Examination

Procedure and Recording of Temperature

Body temperature is its degree of heat. Normally the degree at which balance between heat production and heat loss is maintained is called the “Normal Body Temperature”.

Procedure and Recording of Temperature

Body temperature is its degree of heat. Normally the degree at which balance between heat production and heat loss is maintained is called the “Normal Body Temperature”. It is also called as “Normothermia or Euthermia”.


Factors affecting body temperature

1) Age, 2) Exercise, 3) Hormone level, circadian rhythm 5) Stress, 6) Environment, 7) Temperature attraction, ever, 9) Hyperpyrexia, 10) Heat stroke, Hypothermia

1.        Age: Temperature regulation is unstable until children reach puberty. Older adults are sensitive to temperature extremes because of deterioration in control mechanisms, reduced sweat gland activity, reduced amounts of subcutaneous fat and reduced metabolism

2.        Exercise: Muscle activity causes increased metabolism by increasing carbohydrate and fat breakdown. Any form of exercise can increase heat production and the body temperature because of increased metabolism.

3.        Hormone level: Women generally experience greater fluctuations in body temperature than men. Hormonal variations during menstrual cycles cause body temperature fluctuation.

Temperature changes occur in women during menopause (cessation of menstruation).

4.        Circadianrhythm:Bodytemperature normally changes from 0.5º to 1ºC during 24 hours period. The temperature is usually lowest between 1.00 AM and 4.00 AM

5.        Stress: Physical and emotional stress increases body temperature through hormonal and neural stimulation. Those physiological changes increase metabolism, which increases heat production.

6.        Environment:Environmentinfluences body temperature because of extensive radiant and conductive heat loss.

7.        Temperature attraction: Changes in body temperature can be related to excess heat loss, minimal heat production, minimal heat loss or any combination of these.

8.        Fever: Hyperpyrexia or fever occurs because heat loss mechanisms are unable to keep pace with excess heat. Production, resulting in an abnormal rise in body temperature.

9.        Hyperpyrexia:  An  elevated  body temperature related to the body’s inability to promote heat loss or reduce heat production is hyperthermia. Any disease or trauma to the hypothalamus can impair heat loss mechanisms.

10.   Heat stroke: Prolonged exposure to the sum or high environmental temperature can overwhelm the body’s heat loss mechanisms. Heat also depresses hypothalamic function. These conditions cause heat stroke, a dangerous emergency condition with a high mortality rate. Patients at risk for heat stroke are the very young, very old, cardio vascular condition, diabetes and alcoholics.

11.   Hypothermia: Heat loss during prolonged exposure to cold overwhelms the body ability to produce heat causing hypothermia. Hypothermia is classified as follows:


Sites for assessing temperature:

1)       Oral

2)       Rectal

3)       Auxiliary

4)       Groin

5)       Ear (Tymphanic membrance)

The Mouth (oral Temperature)

This is a convenient, reliable and commonly used method, but should not be used if the patient is;

a)       A child under 6 years of age

b)       Unconscious, mentally confused or very nervous condition

c)        Very weak, so that the mouth may full open

d)       Having breathing difficulty or frequent cough

e)        Having an injured of inflammed mouth.

Contra Indications

1)       Oral temperature: Temperature should also not be taken by mouth soon after a hot drink (or) hot bath

2)       Rectal: Rectal temperature is used for very ill patients, for infants and children. The reading is a little higher than oral when the temperature is taken by rectum

3)       The Axilla: This is convenient when the temperature cannot be taken by mouth. It is less accurate and the reading will be a little lower than when taking by mouth. The axilla must be dried and the thermometer is placed. So that the bulb is in contact with both skin surfaces the arm should be held close to the chest.

4)       Groin: This is a convenient site in children. The groin must be wiped dry and the thigh well flexed over the abdomen and held there.

5)       Ear: It is also a convinient site for mentally disturbed patients. For assessment, digital thermometers are used.


Types of Thermometers

1)       Mercury thermometers (Clinical thermometer)

2)       Electronic thermometer

3)       Temporal artery thermometer

4)       Disposable thermometer

1.        Mercury thermometers (Clinical thermometer):Clinicalthermometers are meant for clinical purposes. It is developed for measuring the human body temperature. It is a long narrow glass tube with a bulb containing mercury at the end.

The normal human body temperature is 37ºC. It can fluctuate between the ranges 35ºC. The level of mercury tells our body temperature in ºC. Since mercury is toxic element has been eliminated from health care facilities because of the environmental hazards of mercury. When you find a mercury – in – glass thermometer in the home

Teach the patient about safer temperature devices and encourage the disposal of mercury products at appropriate neighbourhood hazardous disposal locations.

2.        Electronic thermometer: The electronic thermometer consists of a rechargable battery – powered display unit, a thin wire cord and a temperature – processing probe covered by a disposable probe cover. Separate unbreakable probes are available

For oral and rectal use. You can also use the oral probe for auxiliary temperature measurement. Electronic thermometers provide two modes of operation; a 4-second predictive temperature and a 3-minute standard temperature. A sound signals, and a … Readings appears on the display unit when the Peak temperature readings has been measured.

3.        Temporal artery thermometer: Measures the temperature of the superficial temporal artery. A handheld scanner with an infrared sensor tip defects the temperature of Cetaceous blood flow by sweeping the sensor across the forehead and just behind the ear. After scanning is complete, a reading appears on the display unit. Temporal artery temperature is reliable non-invasive measure of core temperature.

4.        Disposable thermometer: Single use (or) reusable chemical dot thermometers are thin strips of plastic with dots on the surface that have been impregnated with temperature – sensitive chemicals. The strips are sticker on the armpit and prevent slippage.

The dots change colour at different temperatures (within 60 seconds) as the chemicals in them respond to body heat. In the Celsius version there are 50 dots, each representing a temperature increment of 0.1ºC, over a range of 35.5 – 40.4ºC.

The Fahrenheit version has 45 dots with increments of 0.2ºF and range of 96-104.8ºF. Disposable thermometers are usually for oral temperatures. You also use them at auxiliary with a placement time of minutes. Chemical dot thermometers are useful for screening temperatures, especially in infants and young children and patients who are incubated.

Purpose of Taking Temperature

1)       To aid in diagnosis or the patient’s condition

2)       To find out the progress of the patient.


Taking Temperature By Mouth

General Instructions

1)       Oral temperature should not be taken immediately after the patient has had a hot or a cold drink or food.

2)       Oral temperature should not be taken for the following patients.

1.        Children below the age of five years

2.        Patients receiving oxygen

3.        Patients with nasal obstruction, dyspnoea or sore throat

4.        Patient who are delirious, unconscious and not cooperating, hysterical

5.        Restless or mentally ill

6.        Patients with oral surgeries.

Recording temperature – oral Equipment

Tray Containing

1)       3 or 4 test tubes or bottles with antiseptic lotions (Savlon 2%) and a little cotton underneath

2)       A glass tumbler with clean water and little cotton underneath

3)       A bowl containing a bit soapy white wipers

4)       A small piece of clean cloth

5)       A Kidney tray

6)       A Paper bag

7)       Watch with second hand

8)       Red lead pen


1)       Explain the procedure and take the patients cooperation

2)       Let the patient be sitting or lying down

3)       Remove thermometer from the lotion, wash with clean water and dry with clean piece of cloth form the bulb upwards to prevent bacteria from setting down on the lower part which goes into the mouth of the patient.

4)       Shake down the mercury by 95ºF. Place the bulb of the thermometer under the tongue and tell the patient not to bite the thermometer but to hold it with his lips.

5)       Leave the thermometer in the mouth for 2 minutes (during this time take his pulse and respiration)

6)       Remove the thermometer, note the temperature clean with the soapy wiper from above downwards towards the bulb(to prevent bacteria from spreading all over the thermometer)

7)       Collect the dirty soapy water in the kidney tray and place the dirty wiper in the paper bag.

8)       Replace thermometer in the test tube of bottle with the lotion

9)       Record the temperature in the chart

After care of the equipment

1)       Clean all the articles used

2)       Wash the thermometer with soap and cold water

3)       Keepthethermometerintheantiseptic lotion for 2 to minutes

4)       Reset the tray and keep it ready for the next use.

Conversion of Scales

To convert centigrade to Fahrenheit, multiply by 9, divide by 5 and add 32.

To convert Fahrenheit to centigrade, deduct 32, multiply by 5 and divide by 9

C = (F−32) x 5/9

F = 9/5×C+32

Abnormal temperature

1)       Subnormal-35oto36.1oC(95oto97oF)

2)       Collapse – below 35oC (95oF)

3)       Fever or pyrexia

Low pyrexia – 37.2oto 38.3oC (99oto 101oF)

Moderate Pyrexia – 38.3oto 39.4oC (101oto 103oF)

High Pyrexia – 39.5o to 40.5oC (103oto 105oF)

Hyper Pyrexia – 40.5oC (105oF) and above


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