Taking Axillary Temperature

Assessment:

            Although the Doctor’s order is not needed for routine temperature, pulse, respiration and blood pressure, check the policy of the facility and then prepare the client. Ascertain which method of taking the temperature is appropriate for the client and determine number of times temperature needs to be taken.

Planning:

Wash your hands. Prepare all necessary materials. Rinse thermometer in cold water if kept in chemical solution and wipe dry with tissue.

Implementation:

            Bring to bedside and explain the procedure to patient. Provide privacy. Grasp the thermometer with thumb and forefinger and shake vigorously by flicking wrist in downward motion to below 35ºC (95ºF). Expose client’s axilla and pot it dry with a towel or tissue. Assist the client to place the arm tightly across the chest to keep the thermometer in place. Leave the thermometer in place for 9 minutes or according to agency protocol. For infants and children, leave the thermometer in place for 5 minutes. Remain with the client, and hold the thermometer in place if the clients is irrational or very young. Remove the thermometer. Remove the plastic sheath, or wipe the thermometer with a tissue. Wipe in a rotating manner toward the bulb. Discard the tissue in a receptacle used for contaminated items. Read the temperature. Hold the thermometer at eye level, and rotate it until the mercury column is clearly visible. Clean and shake down thermometer. Wash the thermometer in cold water, dry it, and store it dry. Shake down the thermometer, and return it to its container or discard it. If the thermometer is to be disinfected before storage, use recommended agency disinfectant. Return an electronic thermometer to the battery base for recharging. Document the temperature. Record the temperature to the nearest indicated tenth (for example, 98.4 F, 37.1 C) on a flow sheet or in a notebook.

Taking Oral Temperature

Assessment:

Although the Doctor’s order is not needed for routine temperature, pulse, respiration and blood pressure, check the policy of the facility and then prepare the client. Ascertain which method of taking the temperature is appropriate for the client and determine number of times temperature needs to be taken.

Planning:

Wash your hands and gather equipments you will need. Temperature type of thermometer and pulse and respirations; watch with second hand. Bring pocket notebook and ballpen and tissues or paper towels (if available), also cotton balls with alcohol or antiseptic wipes.

 Implementation:

Identify patient and explain what you are going to do. Inquire previous activity or intake. Be sure lightning is adequate. Assist patient to a comfortable position as well as provide privacy. And then proceed with the following:

Determine the time the client last took hot or cold food or fluids or smoked. Remove the thermometer from its package, and check the temperature reading on the thermometer. If thermometer has been stored in a chemical solution, rinse well in cold water. Wipe it dry with firm twisting motion from bulb end to fingers. Bring to patients bedside and explain the procedure to patient-gain cooperation. Place patient on a comfortable position. Shake down the mercury (if necessary) by holding the thermometer between the thumb and forefinger at the end farthest from the bulb. Snap the wrist downward. Repeat until the mercury is below 35ºC (95ºF). Place the thermometer or probe at the base of the tongue to the right or left of the frenulum, the posterior sublingual pocket. Ask the client to close the lips, not the teeth, around the thermometer, and breathe through the nose. Leave the thermometer in place a sufficient time for the temperature to register or for the length of time recommended by the agency. The recommended time is generally either 2 minutes. If an electronic oral thermometer is use, the client holds the thermometer under the tongue 10 to 20 second or until it completes registering. Remove the thermometer and wipe with tissue from the nurses finger from the nurses fingers (stem) down to the bulb using a firm twisting motion. Discard tissue. Read the thermometer at eye level and rotate it until the mercury comes into view. Clean and shake down the thermometer and replace in container. Record patient’s temperature according to hospital procedure.

Hand Washing

Assessment:
Determine the need for hand washing.

Planning:
State the purpose and preparation for hand washing procedure and then check that nails are filed short, also check hands for breaks in the skin, such as hangnails or cuts. Remove all jewelry.

Implementation:
Stand in front of the sink, keeping hands and uniform away from sink surface. Turn on water and adjust the flow. Adjust the flow so that the water is warm. Hold the hands lower than the elbows so that the water flows from the arms to the fingertips. If soap is liquid; apply 2-4 ml ( 1 tsp.). If it is bar soap, rub it firmly between the hands to remove its outer layer. Lather hands and arms well. Wash hands and arms up to your elbow then drop bar soap without touching the sink or the soap dish. Thoroughly wash and rinse the hands. Use firm, rubbing and circular movements to wash the palm, back and wrist of each hand. Interlacing the fingers and thumbs cleans the interdigital spaces. Rinse the hands thoroughly starting from elbow and move down to the arms.

Wash hands for a minimum of 10 seconds. For a more thorough washing, extend the time for wetting, and rinsing. Turn off water flow using foot or knee pedals. Use clean, dry paper towel to turn off hand faucet. Avoid touching with hands. Thoroughly dry the hands from fingers to forearm by blotting paper towel on the skin. Apply lotion to the hands if the skin appears dry. Tidy the sink area and wipe excess water with a paper towel. Discard the paper towel in the appropriate container.

Evaluation:
Indications of Effective Hand Washing: Strict application of medical asepsis and Hand washing procedure performed at recommended time duration.