How can the nurse keep ambient air from altering a tympanic temperature measurement?

The oral site should not be used to measure body temperature for children under five years of age, and adult patients with altered consciousness, confusion, extreme breathlessness with mouth breathing, history of seizures and mouth sores, or who have had oral surgery.
Children under the age of 16 years should not be given aspirin-containing medication because of the risk of Reye’s syndrome. Advise patients to take their temperature after chills and shivering subside to obtain an accurate temperature.
Neutropenia is a reduction in the number of neutrophils (a type of white blood cells). Neutropenia can be caused by disease of bone marrow, immune system disorders, chemotherapy and some severe infections (BMJ 2017).The neutropenic patient must monitor their body temperature and seek urgent medical help if their temperature is 38°C or above and they feel unwell with shivering, chills, rigor, muscle aches, and pains. “Neutropenic sepsis should be suspected in any person with known neutropenia or any known cause for neutropenia (such as recent or ongoing chemotherapy or aplastic anaemia), who is generally unwell, or has a temperature of greater than 38°C, or meets the criteria of sepsis.” (NICE 2016). Sepsis is associated with significant morbidity and mortality if not promptly recognised and treated (Yealy et al. 2015).

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.

Based on Mosby Nursing Skills
Adapted by: Chris Brooker BSc MSc  SRN SCM RNT
Updated by: Chris Brooker BSc MSc SRN SCM RNT
Last updated: April 20

Learning Objective

After reading the skill overview, watching the animation, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of educating patients in body temperature measurement.

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.

Introduction

An elevation in body temperature sometimes is an early warning sign of serious health problems. Patients susceptible to temperature alterations (e.g., patients who are immunosuppressed) or their carers need to know how to measure temperature correctly so that they can seek urgent medical help early when alterations in temperature occur. Parents and family members need to know how to measure their child’s temperature because children can develop a seriously elevated temperature (pyrexia) very quickly; and older adults and their carers need to know the techniques for temperature measurement because older adults have impaired temperature control mechanisms. Teach patients the skills of measuring body temperature and lowering temperature when pyrexia occurs at home.

Help patients and carers to choose the most appropriate thermometer to use in the home based on the patient’s manual dexterity, vision, and financial resources. For example, a patient with poor visual acuity may need a thermometer with a large digital display.

Measuring body temperature (core and peripheral) can be made at various sites (oral, axilla, tympanic membrane, and less often the rectum) using a variety of devices. These include:

• Disposable single-use (chemical dot thermometers).
• Electronic digital devices.
• Tympanic membrane thermometers.

Note: Mercury thermometers are no longer widely used.

‘Core body temperature in health is in the range of 36.4–37.3°C ± 0.2°C'. However, body temperature is affected by:

• The individual.
• Age.
• Menstrual cycle.
• Level of activity.
• Time of day (see below).
• The site chosen to measure body temperature.

Body temperature can depart from the normal range and these abnormalities are classified as:

• Pyrexia (fever): body temperature above 37.5°C.
• Hyperthermia: body temperature above 40°C.
• Hypothermia: body temperature below 35°C.

At home the patients will generally use the oral or axillary site to measure their body temperature. Body core temperature varies throughout the day. Variations are normally within a range of 0.5–1.0°C over 24 h, with the highest point of 37.2°C at around 18.00 hours and lowest (36.7°C) around 6.00 hours. People measuring their temperature daily should therefore do so at the same time each day to avoid normal diurnal variations.

Cultural considerations

• Caring for patients from different cultural groups requires knowledge of a patient’s cultural background and beliefs, as well as, if applicable, the patient’s ability to understand instructions in English:
  • when a patient does not speak English, use professional interpreters to provide healthcare information.
• To enhance patient education in culturally diverse populations, know when and how to provide education while respecting cultural values:
  • modify teaching regarding interventions or desired behaviours to accommodate for cultural differences
  • effective educational strategies often require modification of communication.

Children and body temperature measurement

• Infants’ body temperature regulation is labile because their heat regulating mechanisms are immature.
• ‘Children also have a higher basal metabolic rate (BMR) than adults, due to increased tissue growth rates. The consequence of a higher metabolic rate is a higher mean body core temperature'.
• Stage of growth and development of the child will determine the site of measurement and type of equipment used. For example, the oral site is not used for children under the age of 5 years.
• Different types of thermometer are available for use with children (e.g., disposable single-use thermometers for oral or axillary use). Reliability of these different thermometers varies; ensure that family members know how to use the equipment correctly and how to detect the signs and symptoms of pyrexia (fever).
• Advise the family to take a child’s temperature whenever the child feels warm to the touch, even if the temperature was recently normal. Accurate assessment of a child’s temperature positively affects the child’s outcomes to a medical condition (Hockenberry & Wilson 2015).

Older people and body temperature measurement

• Older persons may have a lower mean body core temperature that is also more influenced by ambient temperature. Therefore, should an older person develop an infection, body core temperature may not rise significantly.
• Older people are more sensitive to temperature changes and tend to demonstrate symptoms of confusion, delirium, or dementia with variations of body temperature.
• Altered internal temperature regulation or fluid and electrolyte imbalances such as dehydration occur frequently in frail, debilitated patients. Temperature measurement becomes very important in early detection aimed at preventing hypothermia or hyperthermia.
• Teaching sessions need to involve active learner participation. Patients learn best when they are rested and alert. Sessions may need to be shorter in duration depending on factors such as fatigue.
• Consider common age-related sensory changes in the older person, and direct teaching strategies to compensate for any sensory changes, such as having effective lighting or the person wearing their glasses in order to read the dots on the disposable single-use thermometer.

Home care considerations

• Educate patients and carers about the environmental hazards associated with mercury in the home, in case they have an old glass mercury thermometer at home, and encourage patients to use mercury-free thermometers.
• Help the patient choose the most appropriate thermometer to use in the home based on the patient’s manual dexterity, vision, and financial resources.
• Select a setting in the home where the patient is most likely to measure their body temperature.
• Discuss common therapies for temperature reduction that are safe to perform at home, including the use of antipyretic medications, exposing the skin to air, reducing room temperature, increasing air circulation, use of a fan, applying cool moist compresses to the skin (e.g., forehead), and maintaining cool fluid intake.

Patient and family education

• Advise patients to discuss the use of aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs) and any other over-the-counter medications with their GP, nurse prescriber, or pharmacist (see British National Formulary in Additional resources).
• The rectal site can be used for measuring temperature in adults although it is not commonly used in children in the UK. It is never used in new-borns because of the risk of rectal perforation. If a non-disposable temperature probe is used, a disposable sheath is applied and discarded after use. The thermometer is cleaned according to local policy before and after use. The patient or family must be told never to force the thermometer into the rectum and never to use a rectal thermometer after rectal surgery, when the patient has a rectal disorder such as a tumour or severe haemorrhoids, or has a low platelet count (thrombocytopenia), or when it is difficult to position the patient for proper thermometer placement.

Preparation and safety

• Assess the patient’s and carer’s abilities to use and read the thermometer. Ask the patient to use their glasses, if necessary.
• Assess the patient’s knowledge of normal temperature range, signs and symptoms of pyrexia (fever) and hypothermia, and the patient’s risk for body temperature alterations.
• Assess the patient’s ability to determine the appropriate type of thermometer to be used in varying situations.
• Assess the patient’s and carer’s previous knowledge and experience in measuring temperature. Ask the patient and carer to perform a return demonstration if they indicate ability to measure temperature.
• Select a setting in the home where the patient is most likely to measure body temperature.
• Discuss and demonstrate with the patient or family member normal temperature ranges and the proper way to position the patient before thermometer insertion. Suggest that the family member remains with the patient if age or physical or mental status requires.

Procedure

1. Perform hand hygiene. Wear personal protective equipment if necessary.
2. Check the patient’s identity – using the patient’s name-band and/or verbally, according to local policy.
3. Introduce yourself and provide a brief explanation and the purpose of the procedure, to obtain the patient’s consent and cooperation.
4. Demonstrate the steps of thermometer preparation, insertion, and reading. Explain the rationale for each step to the patient or carer. Include: checking the expiry date of a disposable single-use thermometer, not touching the dots when removing the thermometer from the packaging, placing the thermometer under the tongue and closing the mouth, the recommended time to leave it in position (usually 1 min for the oral site), and disposal of the thermometer in the clinical waste or the general waste at home.
   Rationale – Demonstration is the best technique for teaching psychomotor skills. Adults learn best when they understand the purpose of the procedure. If using the axilla to measure the temperature, ensure that the axilla is dry and free from sweat. With the dots facing the chest wall, position the thermometer vertically between the arm and the chest wall. It is vital to leave the thermometer in position for the recommended length of time (usually 3 min).
5. Ask the patient or carer to perform each step with guidance from the nurse. Do not rush the patient or carer.
   Rationale – Allows for correction of errors in technique as they occur, for discussion of potential consequences of errors, and promotes the patient’s or carer’s confidence.
6. Teach the patient or carer to take the temperature at least 30 min after smoking or ingesting hot or cold liquids or foods.
   Rationale – Minimises the risk of an incorrect temperature reading.
7. Discuss common signs and symptoms of pyrexia (fever): warm, dry, flushed skin; feeling warm; feeling unwell; chills; shivering; piloerection (‘goose bumps’); aches and pains; and restlessness.
   Rationale – Respects the patient’s right to be involved in their care. Increases the patient’s or carer’s knowledge, which is especially important for patients having chemotherapy who are at risk of neutropenic sepsis.
8. Discuss common signs and symptoms of hypothermia: cool skin, uncontrolled shivering, impaired memory, and signs of poor judgement. Explain that persons with inadequate home heating, older adults, or those unaware of the potential dangers of cold conditions are at risk.
   Rationale – Respects the patient’s right to be involved in their care. Increases the patient’s or carer’s knowledge, thus minimising the risk of developing hypothermia.
9. Discuss the importance of contacting the GP when temperature elevations occur, and review common therapies for temperature reduction that are safe to use at home, including the use of antipyretics (following advice from the GP or pharmacist), exposing the skin to air, reducing room temperature, increasing air circulation, use of fan, applying cool and moist compresses to the skin (e.g., forehead), and drinking cold fluids.
   Rationale – Increases the patient’s or carer’s knowledge, thus minimising the effects of temperature elevation in a safe manner. Patients having chemotherapy are instructed to contact the hospital emergency department if their temperature is elevated. Patients are given a card with these instructions along with the contact details.
10. Teach the patient or carer about the proper storage of disposable single-use thermometers, to refer to the manufacturer’s instructions, and select a suitable storage location.
    Rationale – Ensures that disposable single-use thermometers are likely to function accurately.
11. Provide the patient with printed instructions with a written or pictorial guide, or a DVD or a website demonstrating temperature measurement and when to contact the GP or the hospital.
    Rationale – Printed and audiovisual references for the patient and carer promote confidence for independent performance.
12. Give the patient or carer a temperature chart or a logbook to record temperature and the time it was taken if the patient needs to measure temperature frequently. Ask the patient to use a written record to report temperature measurements to the practice nurse or the doctor.
    Rationale – Keeping an organised record of temperature readings empowers the patient and provides accurate information to health professionals.
13. Perform hand hygiene.
14. Document the procedure in the patient’s record.

Ongoing care, monitoring and support

• Ask the patient or carer to independently demonstrate the technique for temperature measurement, including the ability to read the thermometer correctly on three separate occasions.
  Rationale – Ensuring that the patient or carer is able to read the thermometer on three separate occasions.
• Observe the patient or carer store items of equipment.
• Ask the patient or carer to identify the normal temperature range and influence of smoking and hot and cold liquids or foods on oral readings. Discuss safety implications for temperature measurement.
• Ask the patient or carer to describe common signs and symptoms of pyrexia (fever) and hypothermia, and methods for control.
• Optional: Observe the patient or carer record temperature values and times on the chart or in the logbook. Review the patient’s chart or logbook periodically to ensure that temperatures are being recorded correctly.
  Rationale – Health professionals often make changes in patient care based on information provided by the patient. To ensure changes are made appropriately, the patient needs to record accurate information.

Documentation and reporting

Document the following in the patient’s nursing records:

• Information taught.
• Patient’s response.
• Temperature.
• Patient and family education.

What can affect a tympanic temperature reading?

What is the correct procedure that the nurse should use when taking her tympanic temperature?

What factors may influence the accuracy of a measurement using a tympanic thermometer?

What factors influence the accuracy of body temperature readings taken at different body sites?