RECTAL TEMPERATURE

RECTAL TEMPERATURE

Rectal temperature measurement is a technique used to measure body temperature by placing a thermometer in the rectum. Measuring rectal temperature is a common method, especially for infants and young children, as it is considered one of the most accurate ways to assess core body temperature.

Purpose

• To determine body temperature mainly for infants, young children, adult unconscious patients and postoperative patients
• To aid in making diagnosis

Indication

• Unconscious patients
• Neonates
• Malignant – hyperthermia

General Instructions

• Position the patient on his side with his top leg flexed and drape him to provide privacy. Then fold back the bed linens to expose the anus
• Squeeze the lubricant onto a facial tissue to prevent contamination of the lubricant supply
• Lubricate about half inches of the thermometer tip for an infant, one inch for a child or about for an adult. Lubrication reduces friction and thus eases insertion. This step may be unnecessary when using disposable rectal sheaths because they reprelubricated
• Lift the patient’s upper buttock, and insert the thermometer about 1.3 cm for an infant 3.8 cm for an adult. Gently direct the thermometer along the rectal wall towards the umbilicus. This will avoid perforating the anus or rectum or breaking the thermometer. It will also help ensure an accurate reading because the thermometer will register hemorrhoid artery temperature instead of fecal temperature.
• Hold the mercury thermometer in place for 2 to 3 minutes or the electronic thermometer until the maximum temperature is displayed. Holding the thermometer prevents damage to rectal tissues caused by displacement or loss of the thermometer, wiping it as necessary. Then wipe the patient’s anal area to remove any lubricant or feces.

Preliminary Assessment

• Determine the need to 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 indigested hot or cold liquid or foods
• Hold the color coded end or system glass thermometer with fingertips
• 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 off 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 Celsius.

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

• Draw curtain around client’s bed or close room door. Assist client to sims position with upper leg flexed. Move aside bed linen to expose only anal area
• Squeeze liberal portion of lubricant on tissue. Dip thermometer’s bulb end into lubricant, covering 2.5 to 3.5 cm (1 to 1.5 inches) for adult or 1.2 to 2.5 cm (0.5 to 1.5 inch) for infant
• With non-dominant hand, separate client’s buttocks to expose anus. Ask client to breathe slowly and relax
• Gently insert thermometer into anus in direction of umbilicus. Insert 1.2 cm (0.5 inch) for infant and 3.5 cm (1.5 inches) for adult. Do not force thermometer
• If resistance is felt during insertion withdraw thermometer immediately
• Hold thermometer in place for 2 minutes or according to agency policy
• Carefully remove thermometer and wipe off secretions with tissue. Wipe in rotating fashion from fingers towards bulb. Dispose the tissue
• Read thermometer at eye level rotate until scale appears
• Wipe client’s anal area to remove lubricant or feces and discard tissue. Help client return to comfortable position

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

Contraindication

• Injury, inflammation and surgeries of rectum
• Fecal impaction
• Chronic diarrhea
• Patients requiring bowel wash/enema