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.
