Quality of Life
• Knock before entering the person's room.
• Address the person by name.
• Introduce yourself by name and title.
• Explain the procedure before starting and during the procedure.
• Protect the person's rights during the procedure.
• Handle the person gently during the procedure.
Pre-Procedure
1 Follow Delegation Guidelines: Taking
Temperatures, p. 508. See Promoting Safety and Comfort:
a Thermometer Types, p. 506 b Taking Temperatures, p. 508
2 For an oral temperature, ask the person not to eat, drink, smoke, or chew gum for at least 15 to 20 minutes before the measurement or as required by agency policy.
3 Practice hand hygiene.
4 Collect the following.
• Oral or rectal thermometer and holder
• Tissues
• Plastic covers if used
• Gloves
• Toilet paper (rectal temperature)
• Water-soluble lubricant (rectal temperature)
• Towel (axillary temperature) 510
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5 Practice hand hygiene.
6 Identify the person. Check the ID bracelet against the assignment sheet. Use 2 identifiers (Chapter 13). Also call the person by name.
7 Provide for privacy.
Procedure
8 Put on the gloves.
9 Rinse the thermometer under cold running water if it was soaking in a disinfectant. Do not use hot water. The substance can expand and break the thermometer. Dry it from the stem to the tip with tissues.
10 Check for breaks, cracks, or chips. Discard it following agency policy if it is broken, cracked, or chipped.
11 Shake down the thermometer below the lowest number. Hold the device by the stem. Stand away from walls, tables, and other hard surfaces. Flex and snap your wrist until the substance is below 94ºF or 34ºC (Fig. 33-6, p.
512).
FIGURE 33-6 The wrist is snapped to shake down the thermometer.
This moves the substance down in the tube.
12 Insert it into a plastic cover if used (Fig. 33-7, p.
512).
FIGURE 33-7 The thermometer is inserted into a plastic cover.
13 For an oral temperature:
a Have the person moisten the lips.
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b Place the tip of the thermometer under the tongue and to 1 side (see Fig. 33-2).
c Have the person lower the tongue and close the lips around the thermometer to hold it in place.
d Ask the person not to talk or bite down on the thermometer.
e Leave it in place for 2 to 3 minutes or as required by agency policy.
14 For a rectal temperature:
a Position the person in the Sims' position.
b Put a small amount of lubricant on toilet paper. Lubricant is used for easy
insertion and to prevent injury.
c Lubricate the tip of the thermometer.
d Fold back top linens to expose the anal area.
e Raise the upper bu ock to expose the anus (see Fig. 33-3).
f Insert the thermometer 1 inch into the rectum. Do not force the thermometer.
g Hold the thermometer in place for 2 minutes or as required by agency policy.
Continue to hold it while it is in the rectum.
15 For an axillary temperature:
a Help the person remove an arm from the gown. Do not expose the person.
b Dry the axilla with the towel.
c Place the tip of the thermometer in the center of the axilla.
d Have the person place the arm over the chest to hold the thermometer in place (see Fig. 33-4). Hold it and the arm in place if he or she cannot help.
e Leave the thermometer in place for 5 to 10 minutes or as required by agency policy.
16 Remove the thermometer.
17 After an oral or axillary temperature:
a Use a tissue to remove the plastic cover.
b Wipe the thermometer with a tissue if no cover was used. Wipe from the stem to the tip.
c Discard the tissue and cover (if used).
d Read the thermometer (p. 512).
e Help the person put the gown back on (axillary temperature).
18 After a rectal temperature:
a Use toilet paper to remove the plastic cover.
b Wipe the thermometer with toilet paper if no cover was used. Wipe from the stem to the tip.
c Place used toilet paper on several
thicknesses of clean toilet paper. Discard the cover (if used).
d Read the thermometer (p. 512).
e Place the thermometer on clean toilet paper.
f Wipe the anal area with toilet paper to remove lubricant and any feces (stools).
Set the used toilet paper on several thicknesses of clean toilet paper.
g Cover the person.
h Dispose of toilet paper in the toilet.
i Remove and discard the gloves. Practice hand hygiene.
19 Note the person's name, temperature, and temperature site on your note pad or assignment sheet.
20 Shake down the thermometer.
21 Clean the thermometer following agency policy.
(Wear gloves.) Agency policy may require that you:a Wipe the thermometer with tissues or
toilet paper to remove mucus, feces (stools), or sweat. Wipe from the stem to the tip.
b Rinse the thermometer under cold running water. Do not use hot water. Hot water causes the substance to expand and break the thermometer.
22 Store the thermometer in a holder or a container with a disinfectant solution. Follow agency policy.
23 Remove and discard the gloves. Practice hand hygiene.
Post-Procedure
24 Provide for comfort. (See the inside of the back cover.)
25 Place the call light and other needed items within reach.
26 Unscreen the person.
27 Complete a safety check of the room. (See the inside of the back cover.)
28 Practice hand hygiene.
29 Report and record the temperature. Note the temperature site. Report an abnormal temperature at once.
Reading a Glass Thermometer.
To read a glass thermometer:
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• Hold it at the stem. Bring it to eye level (Fig. 33-8).
FIGURE 33-8 The thermometer is held at the stem. It is read at eye level.
• Turn it until you can see the numbers and the long and short lines.
• Turn it back and forth slowly until you can see the silver or red line.
• Read from the tip toward the stem.
• Read the nearest degree (long line) to the left of the silver or red line.
• Read the nearest tenth of a degree (short line)—an even number on a Fahrenheit thermometer.
See Focus on Math: Reading a Glass Thermometer.