ORAL TEMPERATURE
Measuring oral temperature is a common method to assess an individual’s body temperature.
Purpose
- To determine the body temperature of the patient
- To aid in making diagnosis
- Position the tip of the thermometer under the patient’s tongue, as far back as possible on either side of the frenulum linguae
- Placing the tip in this area promotes contact with superficial blood vessels and contributes to an accurate reading
- Instruct the patient to close his lips but to avoid biting down with his teeth
- Biting can break the thermometer, cutting the mouth or lips or causing ingestion of broken glass or mercury
- Leave a mercury thermometer in place for at least 2 minutes or a chemical dot thermometer in place for 45 seconds to register temperature, for an electronic thermometer; wait until the maximum temperature is displayed
- For a mercury thermometer, remove and discard the disposable sheath then read the temperature at eye level, noting it before shaking down the thermometer, note the temperature, and then remove and discard the probe cover
- For the chemical dot thermometer, read the temperature as the last dye dot that has changed color, or fired, then discard the thermometer and its dispenser case
Preliminary Assessment
- Determine the need of measure client’s body temperature
- Assemble equipment
- Identify the patient, greet the patient and explain the procedure
- Place the client in comfortable position, assess site most appropriate for temperature measurement
- Wait 20 to 30 minutes before measuring oral temperature if client has ingested hot or cold liquid or foods
Cutaneous thermometer: the patient has a skin sensor attached, which is a small sensor connected with the device measuring the temperature. It is usually attached to the fingers – the index finger of the right hand or to the toes. It is a reliable method of measuring temperature although it can be obscured by the patient’s movement or sweating.
The location of the cutaneous sensor is altered in regular intervals to avoid a pressure ulcer forming. The best place for the sensor is under the patient’s back, but not in the area of shoulder blades, which is a high risk area of developing pressure ulcers. This method is primary used in the overall monitoring of a patient or a patient in postoperative care
Chemical thermometers: used for a quick indicative measuring of body temperature. These are placed on a dry forehead. The measured value is displayed by a color change. The measured value is only approximate. Another form of chemical thermometer is a strip, which is inserted into the mouth, either to the right or to the left towards the buccal mucosa
Equipment
- Oral clinical thermometer
- Swab in a container
- Kidney basin or thermometer container
- Blue pen
- Watch with second hand
- Graphic TPR chart
- Paper bag
Procedure
- Hold the color coded end or system glass thermometer with finger tips
- If thermometer stored in disinfectant solution, rinse in cold water before using
- Take swab and wipe thermometer bulb end towards fingers in rotating fashion. Dispose of tissue
- Read mercury level while holding thermometer horizontally and gently rotating at eye level. If mercury is above desired level, grasp at the tip of thermometer securely and sharply flick wrist downward. Continue shaking until reading is below 35.5 degree celcius
- Ask client to open mouth and gently place thermometer under tongue in posterior sublingual, lateral to center of lower jaw
- Ask client to hold thermometer with lips closed. Caution against biting down on thermometer
- Leave thermometer in place for 2 minutes or according to agency policy
- Carefully remove thermometer and read at eye level while holding thermometer horizontally
After Care
- Wipe secretions from thermometer with soft tissue. Wipe in rotating fashion from fingers towards bulb. Dispose of tissue
- Wash thermometer in lukewarm water, rinse in cold water, dry and replace in container
- Record the temperature on the chart
- Wash hands
- Report any unusual variation to the charge nurse
Contraindications
- Injuries, inflammation and surgeries of oral cavity
- Infants, children below 6 years, and patients who cannot retain thermometer in mouth
- Unconscious, delirious, non-cooperative and mentally disturbed patients
- Patients with mouth breathing, convulsions, oxygen masks, frequent and severe cough
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