St. Michael’s College
College of Nursing
Iligan City
Name: ______________________________________________
Clinical Instructor: _____________________________________
Group: ______________
Date: _______________
Assessing a Temperature
Concept:____________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Purpose:
:___________________________________________________________________________________________________
____________________________________________________________________________________________________
_____________________________________________________________________________________________
Equipments:______________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Procedure
Written Rationale
Oral
Rationale
Yes
1. Assessment:
 Clinical signs of fever
 Clinical signs of hypothermia
 Site most appropriate for
measurement
 Factors that may alter core body
temperature
 Physician’s order or nursing care
plan for frequency and route.
 Identify patient.
2. Planning:
Gather all the necessary equipment
needed for the procedure.
 ________________________
 ________________________
 ________________________
 ________________________
 ________________________
No
Performed
Done
Not
Done
3.
Implementation:
 Explain procedure to patient
 Make sure the electronic or digital
thermometer is in operating
condition
 Perform hand hygiene and don
gloves if appropriate or indicated.
 Select appropriate site.
 Follow steps as outlined below
for the appropriate type of
thermometer
Assessing Tympanic Membrane
Temperature:
 If necessary, push the “On”
button and wait for the “ Ready”
signal on unit.
 Attach tympanic probe cover.
 Using gentle but firm pressure,
insert probe snugly into external
ear, angling thermometer toward
patient’s jaw line. Pull pinna up
and back to straighten the ear
canal in an adult.
 Activate unit by pushing trigger
button. The reading is immediate,
usually within 2 seconds. Note
temperature reading
 Discard probe cover in
appropriate receptacle by
pushing the probe release button
and replace thermometer in its
charger or holder.
Assessing Oral Temperature with
an Electronic or Digital
Thermometer
 Release the electronic unit from
the charging unit; remove probe
from within recording unit
 Cover thermometer probe with
disposable probe cover; slide it
until it snaps into place
 Place probe beneath patient’s
tongue in the posterior sublingual



pocket. Ask the patient to close
his lips around the probe.
Continue to hold probe until you
hear a beep to let you know the
reading is completed. Note the
temperature reading
Remove the probe from the
patient mouth and dispose of
probe cover by holding probe
over appropriate receptacle and
pressing probe release button
Return the thermometer probe to
the storage place within the unit;
return electronic unit to charging
unit to make sure it is fully
charged
Assessing Rectal Temperature
with an Electronic or Digital
Thermometer
 Provide privacy for the patient by
closing door or curtain
 Place the bed at an appropriate
working height to reduce back
strain during the procedure
 Assist the patient into side lying
position. Pull back covers enough
to expose only the buttocks
 Remove the probe from within
the recording unit of the
electronic thermometer. Cover
the probe with a disposable
probe cover and slide it until it
snaps into place.
 Lubricate about 1 inch of the
probe with the water soluble
lubricant
 Reassure patient. Separate the
buttocks until anal sphincter is
clearly visible.
 Insert thermometer probe into the
anus about 1 ½ inch in an adult
or 1 inch in a child.
 Hold the probe in place until you
hear a beep. Carefully remove
the probe. Note the temperature
reading on the display.




Dispose of the probe cover by
holding probe over appropriate
waste receptacle and pressing
release button.
Using toilet tissue, wipe the anus
of any feces or excess lubricant.
Dispose of the toilet tissue
Remove gloves and discard.
Perform hand hygiene
Cover the patient and help him to
a position of comfort. Place bed
in lowest position; elevate rails as
needed.
Assessing Axillary Temperature
with an Electronic or Digital
Thermometer
 Ensure privacy by closing door or
curtains
 Place bed at an appropriate
working height to reduce back
strain during the skill
 Move patient’s clothing to expose
axilla
 Remove probe from recording
unit of the electronic
thermometer. Slide on a
disposable probe cover and snap
it securely into place
 Place the end of the probe in the
center of the axilla. Have patient
bring his or her arm down and
close to the body
 Hold the probe in place until you
hear a beep, and then carefully
remove probe. Note the
temperature reading
 Dispose of the probe cover by
holding probe over appropriate
waste receptacle and pushing
release button
 Place the bed in the lowest
position and elevate rails as
needed. Leave the patient clean
and comfortable.
 Return the electronic
thermometer to the charging unit.
4. Evaluation:
 Document patient’s body
temperature. Record temperature
on paper, flow sheet, or
computerized record.
 Report abnormal findings to the
appropriate person.
 Note the area and type of
assessment of temperature.