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Glass or electronic and disposable protective sheath;
Disposable (chemical)
Two pairs of non-sterile gloves
Lubricant (rectal, glass thermometer)
1. Review medical record for baseline
data and factors that influence vital
2. Explain to the client that vital signs
will be assessed. Encourage client to
remain still and refrain from drinking,
eating, or smoking.
3. Assess clients toileting needs and
proceed as appropriate.
4. Gather equipment as indicated above.
5. Provide for privacy.
6. Wash hands and don gloves.

1. Establishes parameters for clients
normal measurements, provides
direction in device selection, and
determines site to use for measurement.
2. Encourages participation, allays
anxiety, and ensures accurate
measurements. Cold or hot liquids and
smoking alter circulation and body
3. Prevents interruptions during
measurements, communicates caring,
and promotes client comfort.
4. Facilitates organized assessment and
5. Decreases embarrassment.
6. Hands are washed before and after
every contact with a client. Gloves are
worn to avoid contact with all bodily
secretions and to reduce transmission of
7. Promotes comfort and site access for
all measurements.
Activity and movement can elevate
heart and respiratory rates.

7. Position the client in a sitting or lying

position with the head of the bed
elevated 45 to 60 for measurement of
all vital signs except those designated
8. Oral Temperature: Glass Thermometer
a. Select correct color tip of
a. Identifies correct device; a blue color
thermometer from clients bedside
tip usually denotes an oral thermometer.
b. Cleansing removes disinfectant that
b. Remove thermometer from storage
can cause irritation to oral mucosa. Cool
container and cleanse under cool water.
water prevents expansion of the
c. Wipe thermometer dry with a tissue
from bulbs end toward fingertips.

c. Wipe from area of least contamination

to most contaminated area.

d. Read thermometer by locating

mercury level.
It should read 35.5C (96F).

d. Thermometer must be below normal

body temperature to ensure an accurate

e. If thermometer is not below a normal

body temperature reading, grasp
thermometer with thumb and forefinger

e. Shaking briskly lowers level of

mercury in the column. Because glass
thermometers break easily, make sure

and shake vigorously by snapping the

wrist in a downward motion to move
mercury to a level below normal.
f. Place thermometer in mouth under the
tongue and along the gum line to the
posterior sublingual pocket. Instruct
client to hold lips closed.

g. Leave in place as specified by agency

policy, usually 35 minutes.
h. Remove thermometer and wipe with a
tissue away from fingers toward the
bulbs end.

that nothing in the environment comes

in contact with the thermometer when
shaking it.

f. Ensures contact with large blood

vessels under the tongue. Prevents
environmental air from coming in
contact with the bulb.

g. Thermometer must stay in place long

enough to ensure an accurate reading.
h. Mucus on thermometer may interfere
with disinfectant solutions effectiveness.
Wipe from area of least contamination to
most contaminated area.

i. Read at eye level and rotate slowly

until mercury level is visualized.

i. Ensure an accurate reading.

j. Shake thermometer down, and cleanse

glass thermometer with soapy water,
rinse under cold water, and return to
storage container.

j. Mechanical cleansing removes

secretions that promote growth of
microorganisms. Hot water may cause
coagulation of secretions and cause
expansion of mercury in thermometer.

k. Remove and dispose of gloves in

Wash hands.

k. Reduces transmission of

l. Record reading and indicate site as

l. Accurate documentation by site allows
for comparison of data.
9. Oral Temperature: Electronic Thermometer
a. Place disposable protective sheath
a. Prevents transmission of
over probe.
b. Grasp top of the probes stem. Avoid
placing pressure on the ejection button.

b. Pressure on the ejection button

releases the sheath from the probe.

c. Place tip of thermometer under the

clients tongue and along the gum line to
the posterior sublingual pocket lateral to
center of lower jaw.

c. Sublingual pocket contains superficial

blood vessels.

d. Instruct client to keep the mouth

closed around thermometer.

d. Maintains thermometer in proper

place and decreases amount of time for
an accurate reading.

e. Thermometer will signal (beep) when

a constant temperature registers.

e. Signal indicates temperature reading.

f. Read measurement on digital display

of electronic thermometer. Push ejection

f. Reduces transmission of

button to discard disposable sheath into

receptacle and return probe to storage

Ensures that the electronic system is

ready for next use.

g. Inform client of temperature reading.

g. Promotes clients participation in care.

h. Remove gloves and wash hands.

h. Reduces transmission of

i. Record reading and indicate site OT.

i. Accurate documentation by site allows
for comparison of data.
j. Return electronic thermometer unit to
charging base.

j. Ensures charging base is plugged into

electrical outlet and ready for next use.

10. Rectal Temperature

a. Place client in the Sims position with
upper knee flexed. Adjust sheet to
expose only anal area.

a. Proper positioning ensures

visualization of anus. Flexing knee
relaxes muscles for ease of insertion.

b. Place tissues in easy reach. Don


b. Tissue is needed to wipe anus after

device is removed.

c. Prepare the thermometer (refer to

steps 8b and 8c).
d. Lubricate tip of rectal thermometer or
(a rectal thermometer usually has a red
e. With dominant hand, grasp
With non-dominant hand, separate
buttocks to expose anus.
f. Instruct client to take a deep breath.
Insert thermometer or probe gently into
anus: infant, 1.2 cm (0.5 in.); adult, 3.5
cm (1.5 in.). If resistance is felt, do not
force insertion.
g. Length of time (refer to step 8g).

d. Promotes ease of insertion of

thermometer or probe.
e. Aids in visualization of anus.

f. Relaxes anal sphincter. Gentle

insertion decreases discomfort to client
and prevents trauma to mucous

h. Removes secretions and fecal

material for visualization of mercury
level. Prevents transmission of

h. Wipe secretions off glass

thermometer with a tissue. Dispose of
tissue in a receptacle.

i. Encourages client participation.

i. Read measurement and inform client

of temperature reading.

j. Prevents contamination of clean

objects with soiled thermometer,
decreases skin irritation, and promotes
client comfort. Prevents embarrassment.

j. While holding glass thermometer in

one hand, wipe anal area with tissue to

remove lubricant or feces with other

hand and dispose of soiled tissue. Cover
k. Cleanse thermometer (refer to step

l. Decreases transmission of

m. Accurate documentation by site

allows for comparison of data.

l. Remove and dispose of gloves in

Wash hands.
m. Record reading and indicate site as
11. Axillary Temperature
a. Remove clients arm and shoulder
from one sleeve of gown. Avoid exposing
b. Make sure axillary skin is dry; if
necessary, pat dry.
c. Prepare thermometer (refer to steps
8b and 8c).
d. Place thermometer or probe into
center of
axilla. Fold clients upper arm straight
down and place arm across clients
e. Leave glass thermometer in place as
specified by agency policy (usually 68
minutes). Leave an electronic
thermometer in place until signal is
f. Remove and read thermometer.
g. Inform client of temperature reading.
h. Cleanse glass thermometer (refer to
steps 8h and 8j) and return to storage

a. Exposes axillary area.

b. Removes moisture and prevents a

false low reading.

d. Puts device in contact with axillary

blood supply.
Maintains the device in proper position.

e. Device must stay in place long

enough to ensure an accurate reading.
Signal indicates temperature reading.

g. Encourages client participation.

h. Prevents transmission of
microorganisms and breakage of glass
i. Promotes comfort.
j. Promotes accurate documentation for
data comparison.

i. Assist client with replacing gown.

j. Record reading and indicate site as
12. Disposable (Chemical Strip) Thermometer
a. Apply tape to appropriate skin area,
a. Tape must be in direct contact with
usually forehead.
the clients skin.
b. Observe tape for color changes.

b. Color reflects temperature reading

(refer to the manufacturers

c. Record reading and indicate method.
c. Promotes accurate documentation for
data comparison.
13.Tympanic Temperature: Infrared Thermometer
a. Position client in Sims position.
a. Promotes access to ear.
b. Remove probe from container and
attach probe cover to tympanic
thermometer unit.
c. Turn clients head to one side. For an
adult, pull pinna upward and back; for a
child, pull down and back. Gently insert
probe with firm pressure into ear canal.
d. Remove probe after the reading is
displayed on digital unit (usually 2
e. Remove probe cover and replace in
storage container.
f. Return tympanic thermometer to
storage unit.
g. Record reading and indicate site as

b. Prevents contamination.

c. Provides access to ear canal. Gentle

insertion prevents trauma to external
canal. Firm pressure is needed to ensure
probe contact against tympanic
d. Reading is displayed within seconds.

e. Protects damage to the reusable


f. Recharges batteries of unit.

g. Promotes accurate documentation for
data comparison.

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