Nursing Measurements Guide
A Guide to Deep Tendon Reflexes
Taking the vital signs of your client is one of the most basic things that you should do upon assessment and temperature is the first vital sign that should be taken.
Though the process of taking the temperature of a client seems effortless, there are still nurses who get it wrong, especially when taking into consideration the different protocols for inserting the thermometer. Which is why we’ll be going into the essential information that you should keep in mind when taking your client’s temperature.
Basic knowledge: there are three routes where a thermometer can be inserted, namely:
- Axilla or the armpit
- Oral or Sublingual (under the tongue)
Currently, there are more advanced ways to take the temperature which can be through scanning the forehead or going under the ear.
Among the three routes, the rectal route is the most accurate.
Routes for Ages
When it comes to age, there are a couple of considerations that one must follow:
- Adults – orally
- Adolescents – axillary
- Pediatrics – rectally
In nursing school, you are taught to identify the different types of thermometers with their respective color-coding scheme; therefore, you should never insert a red thermometer in a client’s mouth because those are meant to be inserted in the rectum.
The average normal temperature is around 98.7 Fahrenheit. Recently, there have been new standards saying that the normal range is from 97.5 up to 99.1 Fahrenheit. At this point, it depends on the metabolic rate of your client’s body type because there are people who burn calories at a much faster rate while there are those who take time to do so.
What Affects Temperature
There are a couple of things that affect temperature; however, the primary cause is an infection. Infection, no matter where it’s located – toe, lungs, skin, and so on – will have a significant effect on a person’s temperature. Areas infected are usually warm or hot to touch, and for this reason, the client will experience fever.
Sepsis is another factor that affects temperature. If a client becomes septic due to an infection of the blood, it is immediately manifested by increased temperature. Sepsis can be due to numerous factors including:
- Urinary tract infection (UTI)
Sepsis in diabetic clients is common. For this reason, it is necessary that nurses need to watch out for signs and symptoms of sepsis, especially in older clients. If an elderly or geriatric client has sepsis, their immune system is expected to be low. Once that infection hits the bloodstream, it will travel through the entire body, affecting vital organs like the heart, brain, kidneys, etc.
Temperature with Sepsis
Clients who have sepsis are expected to have a temperature ranging from 103 up to 104 Fahrenheit; it can even go up to 105 Fahrenheit. At this point, the body will have its hypothalamus, the thermal regulator device inside the brain, to shut down due to increased heat inside the body. The moment thermal regulation ceases, there will be a drop in body temperature, which is what happens with sepsis.
The primary goal when you have a client when sepsis, is to bring down their temperature to avoid organ failure immediately. Taking the rectal temperature is advisable to get accurate data on the status of your septic client. In hospitals, there are standard core measures when handling septic workups. It is best to get acquainted as to what these core measures are.
Points to Remember
Here are a couple of things that you have to take into great consideration when getting your client’s temperature:
- You should not take the temperature of chemotherapy clients rectally. Chemotherapy shrinks down the tumor and all the while, the process also kills new cells. Therefore, those who are getting chemotherapy have thin epithelial lining especially around the rectal area, and inserting a rectal thermometer may cause complications.
- A client undergoing chemotherapy who also has sepsis should not be given a rectal thermometer to avoid bowel perforation.
- Axillary thermometers are given to clients who are unable to open their mouths like those who have neurological diseases like MS, ALS, myasthenia gravis, or those with altered level of consciousness.
- Among the three thermometer sites, the axillary temperature provides the least accurate data.
So, those are some important nursing considerations when taking the temperature. For other vital signs discussions, you can visit our SimpleNursing website.