1 Name____________________________________________________ Unit _____________________________________________________ Instructor/Evaluator: _________________________________________ Date______________________________ Position ____________________________ Position____________________________

Needs Practice

PROCEDURE 17-1

Satisfactory

Excellent

Assessing Body Temperature

Goal: Obtain baseline temperature ata !or comparin" !uture measurements# screen !or alterations in temperature# evaluate temperature response to t$erapies% 1% Per!orm $an $&"iene% '% I enti!& t$e patient% (% Close oor or be curtains) an e*plain t$e proce ure to t$e patient% Assessing Oral Temperature Wit an Electronic T ermometer +% Remove electronic t$ermometer !rom t$e batter& pac,) an remove t$e temperature probe !rom t$e recor in" unit) notin" a i"ital ispla& o! temperature on t$e screen -usuall& (+.C /0+.123% 4% Place t$e isposable cover over t$e temperature probe an attac$ securel&% 5rasp t$e base o! t$e probe% 6% Insert t$e probe belo7 t$e patient8s ton"ue an into t$e posterior sublin"ual poc,et o! t$e mout$% 9s, t$e patient to close $is or $er lips aroun t$e probe% :ol t$e probe) supportin" it in place% 7% ;ait !or a beep -usuall& 1< to '< secon s3) 7$ic$ in icates t$e estimate temperature% ;atc$ to see i! temperature continues to rise% ;$en t$e temperature rea in" stops risin") note t$e temperature ispla&e on t$e unit an remove t$e probe !rom t$e patient8s mout$% =% :ol t$e probe over a 7aste container) an isplace t$e probe cover b& pressin" t$e probe release button% 0% Return t$e probe to t$e stora"e place 7it$in t$e unit) an return t$e t$ermometer to t$e batter& pac,% Cleanse accor in" to a"enc& polic&% 1<% Recor temperature on vital si"n ocumentation recor ) in icatin" >O? !or oral site% Discuss !in in"s 7it$ patient i! appropriate% Assessing !ectal Temperature Wit an Electronic T ermometer +% 9ssist patient to @ims8 position 7it$ upper le" !le*e % E*pose onl& anal area% 4% Remove rectal -re 3 electronic t$ermometer !rom batter& pac,) an e*ten t$e temperature probe !rom t$e unit) notin" a i"ital ispla& o! temperature on t$e screen% 6% @ecurel& attac$ t$e isposable cover over t$e temperature probe%

Comments

Cop&ri"$t A '<1( b& ;olters Blu7er :ealt$ C Dippincott ;illiams E ;il,ins% Procedure Checklist for Fundamentals of Nursing: Human Health and Function) 7t$ e ition) b& Rut$ 1% Craven) Constance F% :irnle) E @$aron Fensen%

2 Name____________________________________________________ Unit _____________________________________________________ Instructor/Evaluator: _________________________________________ Date______________________________ Position ____________________________ Position____________________________

Needs Practice

PROCEDURE 17-1

Satisfactory

Excellent

Assessing Body Temperature (Continued)

Comments Assessing !ectal Temperature Wit an Electronic T ermometer (Continued) 7% 9ppl& 7ater-soluble lubricant liberall& to t$ermometer probe tip% =% @eparate patient8s buttoc,s 7it$ one "love $an until t$e anal sp$incter is visible% 0% 9s, patient to ta,e a eep) slo7 breat$% Insert t$ermometer into anus in irection o! umbilicus) 1 inc$ -'%4 cm3 !or a c$il an 1%4 inc$es -+ cm3 !or an a ult% Do not !orce% 1<% :ol t$e probe in place until mac$ine emits a beep% Obtain rea in"% 11% 1ollo7 steps 7 t$rou"$ 0 in 9ssessin" Oral Gemperature ;it$ an Electronic G$ermometer% Document >R? !or rectal site% Assessing Temperature "sing a Tympanic #em$rane T ermometer +% Remove t&mpanic t$ermometer !rom rec$ar"in" base) an c$ec, t$at t$e lens is clean% 9ttac$ t&mpanic probe cover to sensor unit% 4% Insert probe into ear canal) ma,in" sure t$e probe !its snu"l&% 9voi !orcin" t$e probe too eepl& into t$e ear% Pullin" t$e pinna bac,) up) an out in an a ult 7ill strai"$ten t$e ear canal% @ome manu!acturers recommen movin" t$e t$ermometer in a !i"ure ei"$t pattern% Rotate t$e probe $an le to7ar t$e Ha7line% 6% 9ctivate t$e t$ermometer) an note t$e temperature rea out) 7$ic$ is usuall& ispla&e 7it$in ' secon s% 7% EHect sensor probe cover irectl& into 7aste container) cleanse accor in" to a"enc& polic&) an return t&mpanic t$ermometer to base !or stora"e or rec$ar"in"% @tore a7a& !rom temperature e*tremes% =% Recor temperature on vital si"n ocumentation recor % Document >GI? !or t&mpanic membrane site% Discuss !in in"s 7it$ patient i! appropriate% Assessing Temperature "sing a Temporal Artery T ermometer +% Remove t$ermometer !rom stora"e base% I! lo7 batter& in icator s$o7s) replace batter&% 4% Inspect t$e t$ermometer lens% I! not s$in&) clean b& !irst 7ipin" 7it$ alco$ol) t$en rinsin" 7it$ 7ater- ampene s7abs% 9llo7 to air r&% Dens s$oul be cleane ail&%

Cop&ri"$t A '<1( b& ;olters Blu7er :ealt$ C Dippincott ;illiams E ;il,ins% Procedure Checklist for Fundamentals of Nursing: Human Health and Function) 7t$ e ition) b& Rut$ 1% Craven) Constance F% :irnle) E @$aron Fensen%

3 Name____________________________________________________ Unit _____________________________________________________ Instructor/Evaluator: _________________________________________ Date______________________________ Position ____________________________ Position____________________________

Needs Practice

PROCEDURE 17-1

Satisfactory

Excellent

Assessing Body Temperature (Continued)

Comments Assessing Temperature "sing a Temporal Artery T ermometer (Continued) 6% 9ttac$ isposable cover% 7% Iove $air to e*pose !ore$ea an $airline% Ieasure onl& e*pose si e o! !ore$ea % I! patient is l&in" on si e) measure >up? si e onl&% I! patient is perspirin" $eavil& - iap$oretic3) consi er alternate met$o -e%"%) oral3% =% Place probe !lus$ a"ainst t$e center o! t$e !ore$ea an epress button% @lo7l& sli e probe strai"$t across !ore$ea to $airline% Beepin" button epresse ) li!t t$e probe !rom t$e !ore$ea an touc$ it brie!l& a"ainst t$e nec, Hust be$in t$e earlobe% 0% Release t$e button an rea t$e recor e temperature 7it$in 14 secon s% I! repeate measurements are necessar&) 7ait at least (< secon s% 1<% EHect probe cover irectl& into 7aste container or ,eep at be si e to use a"ain on t$e same patient) cleanse accor in" to a"enc& polic&) an return temporal t$ermometer to stora"e base% @tore a7a& !rom temperature e*tremes% 11% Recor temperature on vital si"n ocumentation recor ) in icatin" >G9? !or temporal arter& site% Discuss !in in"s 7it$ patient i! appropriate% Assessing Axillary Temperature Wit an Electronic T ermometer 7% 9ssist patient to com!ortable position) an remove clot$in" to e*pose a*illa% =% Place t$ermometer a"ainst mi le o! a*illa# !ol patient8s arm o7n an place across c$est) enclosin" t$ermometer in a*illar& area% 0% ;ait !or a beep t$at in icates t$e estimate temperature% ;atc$ to see i! temperature continues to rise% ;$en it stops) note t$e temperature ispla&e on t$e unit an remove t$e probe !rom t$e patient8s a*illa% 1<% 1ollo7 steps = an 0 in 9ssessin" Oral Gemperature ;it$ an Electronic G$ermometer% Document >9? !or a*illar& site%

Cop&ri"$t A '<1( b& ;olters Blu7er :ealt$ C Dippincott ;illiams E ;il,ins% Procedure Checklist for Fundamentals of Nursing: Human Health and Function) 7t$ e ition) b& Rut$ 1% Craven) Constance F% :irnle) E @$aron Fensen%