2.0 Checking and observing the body temperature of the patient Listen

Measurement of temperature should be performed when there are objective and subjective signs where it is necessary. The purpose is to determine the normal core temperature of the person or to establish if the temperature is high or low. Additionally, one may check for various patterns of pyrexia or if the pyrexia is indicative of illness or to establish if current treatment is effective in treating an underlying condition. Thus the monitoring of the temperature is to observe for a reduction in the temperature readings.

Measuring of temperature can be made as a single assessment, regularly over time or as a continuous control. If the temperature is measured repeatedly, it is important to use the same type of measurement, method and preferably at the same time of day.

Core temperature is measured accurately in the lower part of the oesophagus, bladder or pulmonary artery. These methods however require sophisticated equipment and therefore such measurements tend be used in specialty departments, intensive care medicine and during major surgery.

Body temperature is usually measured in several places on the body and the most common methods used are: oral-, axilla- and tympanic measurement.

Benefits of axilla measurement is that it is a simple method however it is considered to be less accurate than other methods. The axilla should be dry and the thermometer must be high up in the armpit and arm tightly held to the side otherwise the thermometer can easily become dislodged. Whilst this method is considered less accurate, it is a good method when other types of measurements are excluded.

When using oral measurement it is important that the patient has not eaten, drunk or smoked in the past 10 minutes prior to measurement, because it can affect the temperature reading. During the procedure the patient must not talk, and the mouth must be kept closed. This can be difficult for certain patients, for example, patients with reduced nasal airways, cognitively impaired patients, patients with epilepsy , patients with reduced consciousness and patients receiving oxygen therapy.

A more accurate method that is commonly used in clinical practice is   temperature measurement using a tympanic thermometer. The thermometer is inserted into the ear and the core temperature is taken from the tympanic membrane.  Advantages of  using this method is that it takes a short time and is not associated with a particular patient discomfort however the method can be difficult to use in small children and in those with infections of the ear.

There are many different thermometers to measure body temperature. It is important to be aware of the purpose, advantages and disadvantages of the methods and the contra- indications for the various places where the measurement can be made.

The patient must be well informed about the measurement, where the thermometer will be and how long the process will take. The thermometer must be read correctly and the result documented accurately in the nursing documentation. The same type of measurement, time and methods should be used. If not discrepancies should be noted.

To summarise  some methods of temperature measurement are considered more reliable than others and this should be considered when choosing the method to be used , As discussed, however, the individual patient and their preferences should also be considered when selecting the method..  When conducting the measurement the aim is that values measured approximates core temperature. Whatever type of thermometer and where the body temperature is measured, the process must be carried out hygienically and safely before, during and after the procedure.


Nurses should consider:

• Is it a normal and correct finding?

• What factors may have affected the outcome?

• How do the results compare with the other temperature recordings and observations?

• What nursing actions do I need to take?