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48 august 14 :: vol 27 no 50 :: 2013 NURSING STANDARD / RCN PUBLISHING

Learning zone
CONTINUING PROFESSIONAL DEVELOPMENT
Principles of temperature monitoring
NS706 Grainger A (2013) Principles of temperature monitoring.
Nursing Standard. 27, 50, 48-55. Date of submission: October 1 2012; date of acceptance: March 11 2013.
Abstract
Maintaining optimum body temperature is essential to life, and taking and
recording a patients temperature is a fundamental nursing skill. Deviation
from the normal range of body temperature can be an important clinical
indicator of altered physiological status requiring further investigation.
Correct technique and careful recording are important for accuracy
because clinicians rely on clinical observations to make diagnoses and
decide on treatment. Nurses need to be able to interpret single stand-alone
temperature recordings as well as sequential pattern recordings in the
context of safe and acceptable physiological boundaries.
Author
Angela Grainger
Assistant director of nursing, Education & Research Lead,
Kings College Hospital NHS Foundation Trust, London.
Correspondence to: angela.grainger@nhs.net
Keywords
Body temperature, clinical observations, hyperpyrexia, hyperthermia,
hypothermia, pyrexia, thermal recording equipment, thermometers
Review
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4
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Temperature monitoring
multiple choice
questionnaire
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Guidelines on
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Aims and intended learning outcomes
This article aims to explain the physiological
mechanisms for maintaining a normal or
optimum body temperature, and the factors
that can positively or adversely affect this. The
article discusses why measuring and recording
the body temperature of patients is important
to nursing care, and presents methods of
doing this. After reading this article and
completing the time out activities you
should be able to:
4Describe the factors involved in maintaining
body temperature.
4Discuss the importance of monitoring
a patients temperature accurately.
4Evaluate the different ways of monitoring
a patients temperature in relation to
evidence-based practice.
4Identify patients who are at risk of
developing hypothermia or hyperpyrexia,
and the actions that can be taken to
minimise the risk of these two conditions.
4Outline the nursing interventions that
can be used to make patients who have
an altered body temperature feel more
comfortable.
4Discuss the link between professional
accountability and the accurate recording
of clinical observations.
Introduction
Normal human body temperature is between
36C and 37.5C (Silverthorn 2010). Body
temperature is the result of continuous
physiological mechanisms that balance heat
production, heat gain and heat loss. As the
body metabolises nutrients, heat is produced.
The circulation of warmed blood is the means
by which heat is transported to all parts of the
body (Seeley et al 2006, Silverthorn 2010).
According to Flouris and Cheung (2009),
metabolic activity in the liver is high, making
it one of the bodys major heat producers
and reservoirs. Heat is also generated by
musculoskeletal activity, in particular
by physical exertion or exercise (Krustrup
et al 2001, Mora-Rodriguez 2012).
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NURSING STANDARD / RCN PUBLISHING august 14 :: vol 27 no 50 :: 2013 49
While a sensation of feeling warmer in a hot
environment and colder in a cold environment
is commonly experienced, people in good
health are able to maintain a constant body
temperature despite environmental variation.
This is because internal physiological feedback
mechanisms balance heat loss and heat gain
to achieve homeostasis (Seeley et al 2006,
Silverthorn 2010). Nurses routinely take
and record patients temperatures, and this
is a fundamental nursing skill because it can
provide important information about the
patients clinical status.
In a nursing context, body temperature is
measured at or near a body surface, for example
the forehead, armpit or underside of the tongue,
or in the ear or a more insulated body cavity
such as the rectum. The rectum generally gives
an adequate indication of the bodys deeper
(core) temperature (Randle et al 2009), which
will usually be slightly higher than the surface
temperature (Dougherty and Lister 2011).
Complete time out activity 1
Maintenance of body temperature
The hypothalamus in the brain controls body
temperature by functioning as a thermostat,
reacting to the heat of arterial blood ow
and to signals received from sensory neurons
known as thermoreceptors located peripherally
in the skin. If body temperature is below the
hypothalamuss thermostatic control threshold,
efferent impulses are sent from the central
to the peripheral nervous system to constrict
peripheral blood vessels, thereby reducing the
amount of heat lost from the body by blood
circulating close to the skin (Seeley et al 2006,
Flouris and Cheung 2009, Silverthorn 2010).
When heat needs to be generated, skeletal
muscles will sometimes be involuntarily
activated by messages from the central nervous
system to cause shivering which, being intense
physiological work, produces heat rapidly
(Endacott et al 2009, Silverthorn 2010).
Conversely, if the arterial blood temperature
is higher than the hypothalamuss threshold,
efferent impulses are activated and the blood
vessels in the skin dilate and allow increased
blood ow through the peripheral circulation so
that heat radiation through the skin increases. In
addition, to lower the bodys temperature, sweat
glands are activated to secrete perspiration on to
the surface of the skin, thus enabling heat loss
by evaporation (Dougherty and Lister 2011).
Temperature regulation can be disrupted
by bacterial infections, for example tonsillitis,
and by viral infections, for example inuenza.
Proteins called pyrogens (a type of cytokine)
are released when the white blood cells attempt
to overcome the infecting microorganisms.
The hypothalamus responds to the presence of
pyrogens in the blood by causing an elevation
of body temperature (Silverthorn 2010).
There are many other types of cytokines
that perform other specic functions in the
body, for example the regulation and mediation
of cellular immunity, and the formation
of blood cells (haematopoiesis) (Taichman
2005, Silverthorn 2010). McInnes (2004)
explained that cytokines can also be part of an
inammatory but non-infectious autoimmune
response mechanism. The bodys temperature
can therefore be raised as a result of an
inammatory process, for example in the acute
phase of rheumatoid arthritis, or during repair
of tissue following injury or surgery.
Complete time out activity 2
Pyrexia and hyperpyrexia
The body requires maintenance of a normal
body temperature so that biochemical and
enzyme reactions necessary for cellular
functioning can occur (Seeley et al 2006,
Silverthorn 2010). If body temperature is not
maintained within the normal range, bodily
systems will fail or malfunction.
A body temperature of between 37.5C and
40C constitutes pyrexia (Weller 2009). Patients
with pyrexia often complain of feeling hot. The
skin can look pinkish or ushed, the patient
may be especially thirsty and the pulse rate will
be slightly raised. A body temperature above
40C indicates hyperpyrexia (Weller 2009).
When a patient is hyperpyrexial, the skin may
range in colour and appearance, from a pinkish
ush to a orid ruddy complexion, and there
may be visible sweating. The pulse rate will be
raised and might feel full and bounding when
being palpated. In hyperpyrexia, the patient
may appear to be shivering severely and may
even complain of being cold despite the contrary
being the case.
This seemingly paradoxical manifestation
is a state known as rigor and is the result of
the hypothalamus responding to pyrogens by
triggering the release of specic prostaglandins
which re-set the hypothalamic thermostat to
a higher level, thereby inducing mechanisms
to increase and conserve body heat.
Vasoconstriction of the peripheral blood
vessels can cause the central nervous system
to interpret the skin temperature as cold.
1 Conduct a
literature review to nd
out how temperature is
controlled and how the
human body attempts
to control heat loss to
maintain homeostasis
for normothermia.

2 Explain the terms
hyperpyrexia, pyrexia,
and hypothermia, and
describe the presenting
features of each.
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50 august 14 :: vol 27 no 50 :: 2013 NURSING STANDARD / RCN PUBLISHING
Learning zone patient monitoring
Feedback of this cold sensation to the central
nervous system triggers shivering, which the
body permits in this case only because the
hypothalamic thermostat has been set to a
higher than normal target temperature by the
detection of pyrogenic cytokines (Dougherty
and Lister 2011). The distinction between
rigor and shivering is clinically important
because although they look the same when
observed, rigor indicates an excessively raised
body temperature and shivering an excessively
low one. This highlights the importance of
accurate assessment in determining the correct
treatment to pursue.
Neill and Bowden (2004) and Thalange
et al (2006) noted that infants and pre-school
children can have a febrile convulsion when
body temperature reaches 38.5C. Infants
and pre-school children are prone to febrile
convulsions when their body temperatures
are raised. This is because physiologically
the hypothalamus is still in development and
triggers are particularly sensitive to changes in
arterial blood temperature (Neill and Bowden
2004, Thalange et al 2006). It can be alarming
for parents to witness their child convulsing,
but the nurse can reassure them that it is the
bodys natural way of responding to a raised
temperature.
It is important that the cause of any
infection, such as middle ear infection (otitis
media) or throat, chest or urine infection, is
identied and treated. The pyrexia is usually
treated with antipyretic medications such as
paracetamol, and the baby is nursed in a nappy,
or pre-school children in light loose clothing, in
an appropriate environmental temperature.
In adults, a temperature of 40C or above
(hyperpyrexia) can cause disruptions to
neural activity (Seeley et al 2006), resulting
in a convulsion.
Nursing care of patients who are pyrexial
or hyperpyrexial
The nurse should help the patient to feel cool
and fresh by changing the bed linen at least
once daily and more often if the patient is
sweating profusely. Turning the patients pillow
over to present the cooler underside in between
bed linen changes is also advised. Providing
frequent cool drinks, as long as the patient
is not on restricted uids because of renal
impairment, and changing the patients water
jug frequently to ensure water remains fresh
and cool, can also help. If the patients mouth
is dry or does not feel fresh, this can be relieved
by offering mouthwashes of water.
Observation of the patients urine output and
uid intake is an important aspect of nursing
care. Recording temperature, pulse, respiration
rate and blood pressure (BP) at least every four
hours is advised. Careful inspection of the
observation chart is required to see whether
the temperature is rising or subsiding. The
frequency of clinical observations should be
increased if the patients temperature continues
to rise or if he or she appears to be experiencing
delirium. If antibiotics are prescribed for the
underlying cause of the pyrexia, the nurse
must ensure that they are administered at the
prescribed times so that the patient sustains
the necessary therapeutic blood levels of the
antibiotics to ensure their effectiveness.
It is no longer acceptable practice to perform
tepid sponging on babies or young children
(Thalange et al 2006, National Institute for
Health and Clinical Excellence (NICE) 2007)
because there is a risk of lowering the core
body temperature too quickly, necessitating
resuscitative measures. Tepid sponging refers
to sponging of the patients arms, legs and
chest with a cloth and lukewarm water. For
older children and adults, tepid sponging can
also cool the body too quickly, causing further
distress (Kelsey and McEwing 2009).
Patients at risk of heat stroke
In extremely hot conditions, the bodys
heat-loss mechanisms may become
overwhelmed and fail because of the external
environment alone. When the atmospheric
temperature is higher than the body
temperature, it becomes impossible for the body
to lose heat by normal physiological methods
(Silverthorn 2010). The resultant excessive
sweating may be so severe that it causes critical
loss of body uid and sodium. A patient
experiencing heat exhaustion will be sweating,
but have pale, cold, clammy skin. He or she will
become progressively weak, faint, disorientated
and agitated, with a rapid and weak pulse
(Wyatt et al 2006). If this continues, a severe
headache may develop and the patient may
complain of limb and/or abdominal cramps.
When the patients condition becomes so
severe that he or she can no longer produce
sweat, the skin becomes red and dry. This
potentially life-threatening condition is known
as heat stroke (Wyatt et al 2006, Silverthorn
2010). It is most often seen in people who
are working in extremely hot and humid
environments, especially if the person is not
acclimatised to this setting. People travelling
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NURSING STANDARD / RCN PUBLISHING august 14 :: vol 27 no 50 :: 2013 51
in particularly hot countries who become
unwell with diarrhoea and vomiting will
be especially prone to heat stroke. This is
because although eliminations from the body
remove heat, repeated severe episodes reduce
the amount of uid available to the bodys
cooling mechanisms such as sweating. Wyatt
et al (2006) advised that the patient must be
moved to a cool environment and the uid and
electrolyte imbalance corrected by the use of an
intravenous infusion, if necessary.
Hypothermia
A body temperature below 35C indicates
hypothermia and is incompatible with life
(Weller 2009), unless medically induced and
maintained under strict safety procedures to
treat certain head injuries, or when performing
certain cardiac operations. Patients who are
hypothermic as a result of a pathological
condition (as distinct from patients having
medically-induced hypothermia) are very pale,
semi-comatose, with confused speech, or may
appear apathetic, be unconscious or lapse into
unconsciousness. The patients skin will be cold
to touch and the pulse will be slow and sluggish.
Patients at risk of hypothermia and
required nursing responses
Older people
A slightly lower than average body temperature
is not unusual for many older people because
neurological feedback and response may
become slower or less efcient in old age
(Timaris 2009). Consequently, older people are
more dependent on metabolic heat production,
and special consideration must be given to
ensuring that their food and uid intake is
sufcient and appropriate (Timaris 2009).
For the same reasons, frail older people are
especially reliant on conserving body heat by
means of clothing, bedding and indoor heating.
Since it is through the skin that most heat loss
occurs (Seeley et al 2006, Silverthorn 2010),
it is essential that nurses ensure that frail older
people wear suitable clothing and that the
temperature of their immediate surroundings
is appropriate (Timaris 2009, Department of
Health (DH) 2010).
Lowered body temperature leads to
drowsiness and further lowering of body
temperature because the patient or those
attending the person are unable or unaware of
the need to increase the temperature in the
room, cover the patient with extra blankets,
and provide a hot drink. If hypothermia
is left untreated and the patient appears
unresponsive, he or she might die (Wyatt et al
2006). By slowly re-warming the patients body
in a space blanket (a specially insulated thermal
blanket that is placed under and over the
patient), his or her temperature should be gently
raised to 36C and full consciousness regained.
It is important not to raise the body
temperature too quickly as this can cause
physiological shock, requiring resuscitative
measures (Weller 2009).
Frequent monitoring of clinical
observations is important for a patient who
has hypothermia. In addition, it is dangerous
to put hot water bottles next to the patients
skin because this can lead to skin damage; the
patients neurological status while hypothermic
may prevent instinctive recoil from any extreme
heat applied locally, and burns may result.
It is important that older patients who have
hypothermia are nursed on a pressure-relieving
mattress and turned every two hours to avoid
capillary pressure over bony prominences of
their bodies and to prevent the formation of
pressure ulcers (Timaris 2009). They also need
nourishing meals containing sufcient amounts
of protein and carbohydrate, and a high uid
intake (Timaris 2009, DH 2010). It is essential
that a uid balance chart and a food intake
chart are used (Endacott et al 2009) because
frail, older hypothermic patients often do not
exhibit an interest in eating or drinking and
can easily become malnourished. If the patient
is unconscious, intravenous uids will be
prescribed and it is important to ensure the drip
ow rate is running according to the prescribed
regimen. Because of vasoconstriction of the
peripheral veins caused by hypothermia, there
is an increased risk that intravenous uids may
extravasate and lter into the nearby tissue,
causing local tissue damage. A new intravenous
cannula will be re-sited if the doctor considers
this to be clinically necessary (McCallum and
Higgins 2012). Should an intravenous cannula
need to be re-sited, it is important that this is
done urgently to avoid depriving the patient of
required uids for an optimum uid balance in
which cellular function can occur.
Vigilance is required to prevent hypothermia
in susceptible patients who are being nursed
in hospital for other clinical reasons or in a
residential care setting. Endacott et al (2009)
explained that the nurse has a duty to check
the discharge arrangements for older patients
who have had hypothermia to ensure the risk
of recurrence is reduced or eliminated.
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52 august 14 :: vol 27 no 50 :: 2013 NURSING STANDARD / RCN PUBLISHING
Learning zone patient monitoring
Infants
In terms of physical proportions, infants have
a larger surface-to-volume ratio compared
to older children and adults. As previously
explained, most body heat is generated and
stored in deep tissues and organs, and is lost
through surface areas. Therefore, in relative
terms, infants have too little deep interior
and too much surface in which to conserve
heat. Consequently, they are at increased
risk of becoming hypothermic. This is the
main reason why premature or very low
birth-weight babies are nursed in incubators
where the environmental temperature can be
controlled, thereby reducing thermal stress
in the neonate and facilitating the proper
functioning of physiological processes (Kelsey
and McEwing 2009).
Others at risk of hypothermia and
associated conditions
There is a risk of hypothermia occurring in
frail older people who might also have a
degree of dementia, which may result in
them wandering away from their normal
surroundings with insufcient outdoor
clothing. Young people who have decided
to leave home and who have not taken
suitable outdoor clothing with them and/or
the means to purchase hot food and drink
are also at risk of developing hypothermia.
Wyatt et al (2006) explained that those who
have been immersed in cold water for any
length of time are at increased risk of
becoming hypothermic. People who are
homeless and sleep outdoors in all weather
conditions, as well as those who remain
outdoors for a long period in freezing and
windy conditions, may develop frostbite
(Wyatt et al 2006). In frostbite, the tissues of
the extremities freeze, and if this is not treated
early, it can progress to permanent tissue
damage and possibly gangrene necessitating
amputation (Wyatt et al 2006).
Complete time out activity 3
Patients at risk of signifcant changes
in body temperature
Patients at risk of signicant changes in
body temperature include those whose basal
metabolic rate is affected by certain conditions
such as disorders of the thyroid gland.
Hypothyroidism results from an inadequate
secretion of hormone from the thyroid gland
and as a consequence, physical and basal
metabolic activity is slowed.
Hyperthyroidism is excessive activity
of the thyroid gland accompanied by an
increase in metabolism. Patients with
hyperthyroidism complain of feeling
the heat even when the environmental
temperature is low. A sudden burst of
thyroid hormone can lead to hyperpyrexia
(Cisneros and Goins 2009).
In rare circumstances, a patients
temperature can rise dangerously high
during general anaesthesia and this is often
linked to a rare autosomal dominant genetic
condition called malignant hyperthermia
(Silverthorn 2010). Malignant hyperthermia
is related to the use of suxamethonium,
a short-term muscle relaxant, or halothane,
an inhalational gas, both of which are
commonly used in general anaesthesia
(Wyatt et al 2006).
Surgical patients can also be at risk of
a lowered body temperature and even
hypothermia. Patients having lengthy surgical
interventions involving large wound incisions
with the consequent exposure of organs,
will have a lowered body temperature
(Dougherty and Lister 2011). The use of
anaesthetic drugs can reduce vasoconstrictor
processes, lowering body temperature. For
these reasons, anaesthetists and theatre
staff need to monitor the temperature of
anaesthetised patients regularly.
Post-operative patients require regular
temperature monitoring (Dougherty and Lister
2011) as a persistently elevated temperature
could indicate the presence of infection.
Immunosuppressed patients who have a
low white cell count, and those undergoing
radiotherapy or chemotherapy, or who are on
long-term, high-dose corticosteroids, are prone
to contracting infections.
Bacteraemia can lead to septicaemia
and, if untreated, septic shock. Severely
immunosuppressed patients are not always
pyrexial, and therefore it is important to be
watchful for other signs and symptoms of
infection. In other patients, septic shock is
characterised by a rising temperature, rising
pulse rate, lowered BP and reduced urine
output (oliguria).
This requires urgent medical attention.
Dougherty and Lister (2011) and Randle et al
(2009) explained that patients receiving a
transfusion of blood or blood products
require temperature monitoring throughout
the procedure since a raised temperature
can indicate incompatible blood reactions.
Complete time out activity 4
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NURSING STANDARD / RCN PUBLISHING august 14 :: vol 27 no 50 :: 2013 53
Taking and recording temperature
A variety of thermometers are used to measure
a patients body temperature and researchers
have investigated the accuracy of the different
types, the most suitable body area to place the
thermometer and the optimum length of time
to leave it in position (Sund-Levander et al
2002, Randle et al 2009). Taking a patients
temperature depends on the clinical status
of the patient and whether an immediate
temperature measurement is clinically required,
and subsequently on the wards schedule for the
taking and recording of clinical observations.
The rst temperature recording taken is the
baseline recording. This, in conjunction with
the patients overall clinical condition, is used
to make a clinical judgement about the need for
and frequency of any subsequent temperature
monitoring. If the patient is pyrexial,
temperature monitoring and recording is
usually undertaken every four hours. If the
patient is hyperpyrexial or hypothermic,
temperature monitoring and recording at
one or two-hour intervals may be required,
depending on the overall clinical stability of
the patient. The aim of the frequency of clinical
observations monitoring is to detect any
deterioration in the patients condition so
that medical intervention can commence
as soon as possible.
The traditional sites for recording a patients
temperature with a thermometer are under the
tongue, in the axilla with the patients arm
positioned to keep the thermometer in place,
and in the groin with the patients leg positioned
to keep the thermometer in place (Randle
et al 2009, Dougherty and Lister 2011). The
axilla (Figure 1) and the groin can be used in
patients for whom it is hazardous to place the
thermometer in the mouth. These include
unconscious patients or those who are confused.
The temperature can also be taken rectally.
Glass oral thermometers containing mercury
are no longer extensively used because it
has been found that they are slow to detect
temperature changes and do not detect
temperatures lower than 34.5C or higher than
40.5C (Sund-Levander et al 2002). If the patient
has consumed a hot or cold drink before the
use of an oral thermometer, the measurement
is affected by residual warmth or coldness
remaining in the oral tissues (Sund-Levander
et al 2002, Randle et al 2009). In addition,
mercury is a hazardous substance (Control
of Substances Hazardous to Health 2002).
Breakage of such a thermometer creates a toxic
environment and requires special techniques
to avoid contamination (North East London
NHS Foundation Trust 2009). While not
recommended for use professionally, mercury
thermometers are not banned by legislation, and
nurses can still nd them in practice.
Should a nurse be using a glass thermometer
containing mercury, a skilled and dexterous
manual technique is required to shake down
the column of mercury to below the mark
for 34C immediately before use. Mercury
thermometers are not designed for single,
disposable use, therefore the hospitals infection
control department should be consulted on
effective prevention of cross-infection and
decontamination procedures.
Oral electronic thermometers are now often
used. These have a single-use disposable cover
and the thermometer is placed sublingually and
left for three minutes (Randle et al 2009). On
removal, the temperature is read by looking at
the point shown on the electronic scale and the
nurse records this temperature reading on to
the patients clinical observation chart.
Kelsey and McEwing (2009) described
the use of an aural tympanic thermometer
(Figure 2). These thermometers detect body
temperature in the ear by means of an infrared
sensor. They are easy to use and do not cause
patient discomfort, although young children
may not like procedures that involve having
something placed in their ears. In this case,
a liquid crystal or chemical dot thermal
recording strip can be used (Figure 3).
A liquid crystal or chemical dot thermometer
is a exible strip or patch that is placed on the
childs forehead or held against his or her axilla
while a liquid crystal or chemical substance
responds to the temperature by contact. The
temperature is displayed on the panels thermal
recording strip. In the case of a young child,
it is often desirable to ask his or her parent to
hold the non-recording edges of the thermal
recording strip in place, with the nurses
guidance, to lessen the childs anxiety.
3 Explain why
patients receiving
general anaesthesia
pre-operatively are
at risk of a signicant
change in body
temperature.

4 What factors should
the nurse take into
account when selecting
the type of thermometer
to use to ensure that the
monitoring of a patients
temperature is evidence
based?
FIGURE 1
Placing a mercury thermometer in the axilla
S
P
L
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54 august 14 :: vol 27 no 50 :: 2013 NURSING STANDARD / RCN PUBLISHING
Learning zone patient monitoring
Each aural tympanic thermometer has a cap
on the end of the probe that can be disposed
of after single use. Therefore, each patient has
a fresh, clean probe-cap in accordance with
good infection control practice. As with any
piece of equipment, the nurse must follow the
manufacturers instructions for accurate results.
The nurse should inspect the ear canal for
any wax or rashes. Otitis externa is a painful
condition in which the outer ear is encrusted
with an infectious rash and the patient cannot
tolerate any stimulation in this area. If otitis
externa is present, a liquid crystal or chemical
dot thermal recording strip should be used.
If inserting an aural tympanic thermometer,
the nurse should check for the presence of
hearing aids. If the patient has a hearing aid
in one ear only, the other ear can be used for
taking the temperature. If the patient has
bilateral hearing aids, it is important to ask the
patient which is the preferred ear to use. The
hearing aid should be returned to the patient or
replaced when the temperature has been taken.
It is best not to insert a tympanic thermometer
into the ear on the same side as that on which
the patient has just been lying against a pillow
or other surface, because heat will have built
up in and around that ear (Grainger 2009,
Randle et al 2009). The other ear should be
used, or if this is not acceptable to the patient
for some reason, the nurse should wait
20 minutes before proceeding. For infection
control purposes, the nurse should ensure that
the lens located on the thermometers probe
is clean and must attach a new disposable
cover to the probe before use on each patient.
The used probe cover must be placed in the
appropriate labelled clinical waste disposal
bag. The methods described are for taking the
peripheral or surface temperature of the body.
Rectal temperature taking is considered
most accurate for determining core body
temperature, but the procedure can detract
from a patients sense of dignity (Randle et al
2009, Dougherty and Lister 2011).
A special rectal thermometer with a wider
end-bulb has to be inserted 4cm into the adult
rectum. The presence of a thermometer in
the rectum sometimes stimulates a bowel
movement, especially in pre-term infants
(Kelsey and McEwing 2009), and this is
obviously associated with a loss of uid. It is
for this reason, and the associated dangers of
rectal ulceration and perforation, that rectal
temperature taking is no longer performed on
infants. In addition, rectal temperature taking
should be avoided for patients who have had
rectal surgery or who have haemorrhoids, and
because of the risk of vagal stimuli, the method
is contraindicated in those who have cardiac
disease (Randle et al 2009).
As a general principle, greater accuracy
in monitoring the patients temperature and
in record keeping is achieved if the nurse
consistently uses the same type of thermometer.
Complete time out activity 5
Professional accountability
Nurses have a duty of care to patients
(Nursing and Midwifery Council 2008, NHS
Institute for Innovation and Improvement
2012). It is not enough merely to record the
patients temperature, and nurses should use
their knowledge to make a clinical judgement
about whether the temperature recorded is
within an acceptable range given the patients
overall clinical condition, and if frequent
temperature monitoring needs to take place.
Medical interventions need to be implemented
FIGURE 2
Aural tympanic thermometer
FIGURE 3
Liquid crystal or chemical dot thermometer
5 Reect on the clinical
circumstances of a
patient you have nursed
who had either a low or
high temperature. What
factors were taken into
account in the selection
of the thermometer?
What care did the
patient receive and
why, in relation to either
raising or lowering body
temperature? Consider
the patients experience
of the practical nursing
interventions. What do
you think helped to make
the patient feel better?
G
E
T
T
Y
G
E
T
T
Y
G
E
T
T
Y
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NURSING STANDARD / RCN PUBLISHING august 14 :: vol 27 no 50 :: 2013 55
in a timely manner to prevent, where possible,
any further deterioration of the patients
clinical condition.
Nurses often delegate the task of taking
and recording patients clinical observations
to healthcare assistants (HCAs). In doing so,
nurses still have a duty of care to the patient in
ensuring that required aspects of care are acted
on. The nurse needs to oversee the patients
temperature chart and interpret the ndings
in relation to the individuals pulse rate, BP,
respiratory rate and overall clinical status. The
nurse needs to work with the HCA to ensure
he or she understands the normal parameters
of temperature, pulse, respiratory rate and BP
readings, and that the HCA has a competent
technique when taking and recording these
observations. Nurses are advised to check
patients observational recordings as part of
their routine therapeutic and social interactions
with patients. In hospitals, the hourly
intentional quality assurance ward rounds aim
to ensure that routine nursing procedures do
not become so routine that they are a mere
tick-box exercise, resulting in patients needs
being overlooked (DH 2012).
Conclusion
Temperature monitoring is a routine but
essential nursing task that provides important
information about the patients clinical
condition. Monitoring a patients temperature
alongside other clinical observations such
as respiratory rate, pulse rate, BP, oxygen
saturation, blood glucose levels and level
of consciousness can aid medical staff in
making a diagnosis and in detecting the
early deterioration of a patient NS
Complete time out activity 6
6 Now that you have
completed the article,
you might like to write
a practice prole.
Guidelines to help you
are on page 58.
References
Cisneros AB, Goins BL (Eds) (2009)
Body Temperature Regulation. Nova
Science Publishers, New York NY.
Control of Substances Hazardous
to Health (2002) The Control of
Substances Hazardous to Health
Regulations 2002. S.I. 2002/2677.
The Stationery Ofce, London.
Department of Health (2010)
Essence of Care 2010: Benchmarks
for the Fundamental Aspects of
Care. The Stationery Ofce, London.
Department of Health (2012)
PM Announces New Focus on
Quality and Nursing Care.
tinyurl.com/my5jq7w
(Last accessed: July 24 2013.)
Dougherty L, Lister S (Eds) (2011)
The Royal Marsden Hospital Manual
of Clinical Nursing Procedures.
Eighth edition. Wiley-Blackwell,
Oxford.
Endacott R, Jevon P, Cooper S (Eds)
(2009) Clinical Nursing Skills. Core
and Advanced. Oxford University
Press, Oxford.
Flouris AD, Cheung SS (2009)
Reviewing the functional architecture
of the human thermoregulatory
system. In Cisneros AB, Goins BL
(Eds) Body Temperature Regulation.
Nova Science Publishers, New York
NY, 25-64.
Grainger A (2009) The importance
of clinical observations. In Grainger A
(Ed) Essential Practice for Healthcare
Assistants. Quay Books, Dinton,
33-47.
Kelsey J, McEwing G (Eds) (2009)
Clinical Skills in Child Health
Practice. Elsevier, London.
Krustrup P, Gonzlez-Alonso J,
Quistorff B, Bangsbo J (2001)
Muscle heat production and
anaerobic energy turnover during
repeated intense dynamic exercise
in humans. Journal of Physiology.
536, 3, 947-956.
McCallum L, Higgins D (2012)
Care of peripheral venous cannula
sites. Nursing Times. 108, 34/35,
12-15.
McInnes IB (2004) Cytokines.
In Harris E, Budd R, Firestein G
et al (Eds) Kellys Textbook of
Rheumatology. Elsevier, London,
325-340.
Mora-Rodriguez R (2012)
Inuence of aerobic tness on
thermoregulation during exercise
in the heat. Exercise and Sport
Sciences Review. 40, 2, 79-87.
National Institute for Health and
Clinical Excellence (2007) Feverish
Illness in Children: Assessment and
Initial Management in Children
Younger Than 5 Years. Clinical
guideline No. 47. NICE, London.
Neill S, Bowden L (2004) Central
nervous system development. In
Neill S, Knowles H (Eds) The Biology of
Child Health: A Reader in Development
and Assessment. Palgrave Macmillan,
Basingstoke, 54-86.
NHS Institute for Innovation and
Improvement (2012) Energise for
Excellence: A Call to Action for
Nurses and Midwives. NHS Institute
for Innovation and Improvement,
Coventry.
North East London NHS Foundation
Trust (2009) Control of Substances
Hazardous to Health (COSHH) Policy
and Mercury Spillage Procedure.
North East London NHS Foundation
Trust, London.
Nursing and Midwifery Council
(2008) The Code: Standards of
Conduct, Performance and Ethics
for Nurses and Midwives. NMC,
London.
Randle J, Coffey F, Bradbury M
(2009) Oxford Handbook of Clinical
Skills in Adult Nursing. Oxford
University Press, Oxford.
Seeley RR, Stephens TD, Tate P
(2006) Anatomy and Physiology.
Seventh edition. McGraw Hill,
Boston MA.
Silverthorn DU (2010) Human
Physiology. An Integrated Approach.
Fifth edition. Pearson Benjamin
Cummings, New York NY.
Sund-Levander M, Forsberg C,
Wahren LK (2002) Normal oral,
rectal, tympanic and axillary body
temperature in adult men and
women: a systematic literature
review. Scandinavian Journal of
Caring Sciences. 16, 2, 122-128.
Taichman RS (2005) Blood and
bone: two tissues whose fates
are intertwined to create the
hematopoietic stem-cell niche.
Blood. 105, 7, 2631-2639.
Thalange N, Holmes P, Beach R,
Kinnaird T (2006) Pocket Essentials
of Paediatrics. Saunders Elsevier,
Philadelphia PA.
Timaris PS (Ed) (2009)
Physiological Basis of Aging and
Geriatrics. Third edition. Sage,
New York NY.
Weller BF (Ed) (2009) Baillie `res
Nurses Dictionary. 25th edition.
Bailliere Tindall, London.
Wyatt JP, Illingworth RN,
Graham CA, Clancy MJ,
Robertson CE (2006) Oxford
Handbook of Emergency Medicine.
Third edition. Oxford University
Press, Oxford.
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