NCLIP

Measuring Body Temperature (Multiple Routes)

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Measuring Body Temperature (Multiple Routes)

Key Points

  • Route selection and correct technique directly affect temperature accuracy and safety.
  • Probe covers are required for each route and must not be touched directly.
  • Rectal temperature requires gloves, lubricant, route-specific probe use, and strict hygiene steps.

Equipment

  • Digital thermometer device
  • Route-appropriate probe covers (oral, tympanic, axillary, rectal)
  • Water-based lubricant for rectal route
  • Gloves (required for rectal route)
  • Hand hygiene supplies

Procedure Steps

  1. Complete routine pre-procedure actions: knock, identify resident, explain procedure, provide privacy, and perform hand hygiene.
  2. Apply route-specific probe cover without touching probe-contact surface.
  3. Oral route: place probe under tongue at posterior sublingual pocket, have resident close mouth, wait for signal, read and discard cover.
  4. Tympanic route: keep head still; pull pinna up/back for adults or down for children under 3, insert gently without force, wait for signal, read and discard cover.
  5. Axillary route: place probe high in dry axilla against bare skin, lower arm over probe, wait for signal, read and discard cover.
  6. Rectal route: don gloves, position resident safely, use red/rectal probe cover with lubricant, insert gently 2-3 cm or less by size, wait for signal, read, discard cover, remove gloves, and perform hand hygiene.
  7. Temporal route: remove eyeglasses if present, place sensor on forehead with continuous contact, slide to hairline near ear, and read display.
  8. Restore resident comfort, ensure bed low/locked and call light accessible.
  9. Perform hand hygiene and document route, value, time, and abnormal findings for nurse notification.

Common Errors

  • Using incorrect ear-pull direction for age during tympanic assessment → inaccurate readings or discomfort.
  • Inadequate probe contact in axillary/temporal routes → falsely low or inconsistent values.
  • Excessive insertion depth or poor lubrication in rectal route → injury risk.
  • Missing route notation in charting → unsafe trend interpretation across measurements.

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