Based on Nicol: Essential Nursing Skills 4E Show Heat pockets in the oral cavity. (Adapted from Jamieson E M, Whyte L A, McCall J M (eds) 2007 Clinical Nursing Practices, 5th edn. Churchill Livingstone, Edinburgh.) Thermometer reading (Adapted from Nicol M, Bavin C, Cronin P, et al. 2012 Essential Nursing Skills, 4th edn. Mosby Elsevier, Edinburgh) Learning Objective The purpose of this learning material is to provide you with a resource to: • Facilitate the development of new knowledge • Build on existing knowledge • Test knowledge • Assess the skill in practice IntroductionBody temperature is one of the four main vital signs that must be monitored to ensure safe and effective patient care (McCallum & Higgins 2012). The National Institute for Health and Clinical Excellence (NICE) recommends temperature measurement as part of the initial assessment in acute illness in adults (NICE 2020). The Royal College of Nursing has collaborated with the Royal College of Physicians (RCP) to produce National Early Warning Scores for acute illness in the NHS and temperature measurement is a key component of this assessment (RCP 2015). Body temperature can be considered as the balance of heat lost from the body and gained by the body (Walsh 2019). A healthy body maintains its temperature within a narrow range using homeostatic thermoregulation mechanisms (Waugh & Grant 2014). Walsh (2019) describes the normal range of body temperature as 36–37.5°C, but says that this may vary by as much as 0.6°C according to the site used for measurement and from individual to individual. Fluctuations in body temperature occur naturally as a result of circadian rhythms, extremes of age (the young or elderly are unable to maintain an efficient equilibrium in thermoregulation), exertion or exercise, food intake, hormonal balance (e.g. ovulation), medication or alcohol, smoking, or deteriorating physiological function (e.g. shock, infection) (Dougherty et al. 2015, Evans 2009, Geneva et al. 2019, Walsh 2019). The following terms are used to describe abnormal temperature ranges:
(Smith et al. 2019). According to Sund-Levander and Grodzinsky (2010), assessment and evaluation of body temperature is one of the oldest known diagnostic methods and still has a huge influence on decisions about medical diagnosis, nursing care, treatment, and requesting laboratory results. Body temperature is useful in monitoring health and illness as it reflects the ability of the body to manage heat loss and gain (McCallum & Higgins 2012). There are many clinical indications for measuring body temperature, including:
The frequency of measurement will depend upon the patient’s condition and recorded temperature (Walsh 2019). Frequency of recording may also be identified in local hospital policy (e.g. frequency of recording while receiving a blood transfusion). Nurses should also ensure that both the method of taking the temperature and the site used are consistent, and documented to accurately reflect fluctuations, while also taking into account any other factors that may cause a fluctuation. Note: chemical disposable thermometers should be avoided in suspected cases of hypothermia, as under those circumstances, they lack sufficient clinical accuracy (McCallum & Higgins 2012). Any changes above or below the normal limits should prompt appropriate reporting and responses as set out in line with an early warning scoring system (McCallum & Higgins 2012, Royal College of Nursing First Steps 2017). Most clinical areas in the UK use the National Early Warning Score (NEWS) system, as designed by the Royal College of Physicians (RCP 2017). It is important that the procedure is carried out in accordance with the manufacturer’s instructions and local policies and procedures. To accurately measure the oral temperature the thermometer is placed in the posterior sublingual pocket of tissue at the base of the tongue (Figure 1). It is vital that the thermometer is placed in this region and not in the area in front of the tongue, as there may be a temperature difference of up to 1.7°C between these sites. Neff and colleagues' 1989 research (cited by Dougherty et al. 2015) found that this variance in temperature is due to sublingual pockets being protected from the air currents that cool the frontal areas. Chemical thermometers are contact thermometers consisting of a matrix of temperature-sensitive dots (Davie & Amoore 2010). Within each of these dots, a different combination of chemicals reacts and changes colour, for example, in the case of Tempadots from beige to blue, at intervals of 0.1°C. The temperature is read by observing the number of dots that have changed colour and correlating them on the scale marked on the thermometer (Childs 2011; Figure 2). These thermometers are for single use only and the manufacturer’s instructions for use must be followed to ensure accurate recordings. Preparation and safety
Procedure
Ongoing care, monitoring and support
Documentation and reporting
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