ASSESSING BODY TEMPERATURE (Axillary Temperature) ASSESSMENT: Assess: 1. Clinical Signs of fever.

Onset (Cold or Chill Stage) - Increase heart rate. - Increase respiratory rate and dept. - Shivering - Pallid and cold skin - Complaints of feeling cold - Cyanotic nail beds - gooseflesh appearance of the skin - Cessation of sweating Course - Absence of chills - Warm skin - Photosensitivity - Glassy-eyed - Increase pulse rate and respiratory rate - Increase thirst - Mild to severe dehydration - Drowsiness, restlessness, delirium or convulsion - Herpetic lesions of the mouth - Loss of appetite - Malaise, weakness and aching muscles Defervescence (Fever abatement) - Skin that appear flushed and feels warm - Sweating - Decreased shivering - Possible dehydration PLANNING: 1. Assemble equipment and supplies - Thermometer - Cotton balls with alcohol or alcohol wipes - Tissue/wipes - Watch with a second hand or indicator IMPLEMENTATION: Procedure 1. Check that all equipment is functioning properly. If necessary, shake a glass thermometer down to below 35 degree Celsius (95 degree Fahrenheit) 2. Identify the client properly. 3. Explain to the client what you are going to do, why it is necessary, and how he can cooperate. - To reduce transmission of microorganism 4. Wash hands and observe other appropriate infection control procedures. 5. Provide for client privacy. 6. Place the client in appropriate position. 7. Pat the armpit dry with tissue paper or ask the client to do it if able. 8. Wipe the thermometer from bulb to stem with alcoholized cotton ball. 9. Place the bulb of the thermometer in the center of the axilla on the clients opposite side. 10. Wait for the appropriate amount of time. 6 to 9 minutes for an axillary temperature with a glass - To maintain dignity. - To promote comfort and facilitate the taking of the vital sign. - Moisture can alter or affect axillary temperature.

2. Clinical Signs of Hypothermia. - Decreased body temperature - Severe shivering (initially) - Feeling of cold and chills - Pale, cool, waxy skin - Hypotension - Decreased urinary output - Lack of muscle coordination - Disorientation - Drowsiness progressing to coma 3. Clients readiness for the procedure. Smoking, eating, or drink a hot or cold beverages can alter the reading. In these case, the route of temperature taking must be changed or wait for 20-30 minutes before taking oral temperature. 4. Site most appropriate for measurement. 5. Factors that may alter core body temperature.

Rationale - The indicator fluid will not fall below the starting level if the clients temperature is less than that. - To be sure youre performing the procedure on the correct client. -To lessen anxiety and to promote cooperation.

- The bulb is considered less contaminated than the stem. - To facilitate the reading of body temperature and free the arm nearest to the nurse for the reading of the other vital signs. - To conserve time and energy.

temperature. 11. Remove the thermometer and wipe with a tissue if necessary. 12. Read the temperature. 13. Wipe the thermometer with alcoholized cotton ball from stem to bulb. Return to container. 14. Wash hands. 15. Document the temperature in the clients record. EVALUATION: 1. Compare the temperature measurement with the baseline data, normal range for age of client, and clients previous temperature. Analyze considering time of day and any additional influencing factors and other vital signs. 2. If reading is not within normal range, retake it to eliminate the possibility of inaccuracy. 3. Conduct appropriate follow-up such as notifying the physician, giving a medication, or altering the clients environment. This includes teaching such as increasing fluid intake, coughing and deep breathing or removing heavy coverings.