Measurement of body temperature may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

• Digital or electronic thermometer, appropriate for site to be used
• Disposable probe covers
• Water-soluble lubricant for rectal temperature measurement
• Nonsterile gloves, if appropriate
• Additional personal protective equipment (PPE), as indicated
• Toilet tissue, if needed
• Electronic record or pen and paper or flow sheet

Note baseline or previous temperature measurements. Assess the patient for the presence of the following:

Cognitive functioning: When selecting the oral site, the patient must be able to close their mouth around the probe. Therefore, this site is not suitable for use in children younger than 6 years old, in some children with developmental delay, in patients who are unable to follow directions, with patients with changes in or inflammation of the oral mucosa, or for confused and comatose patients (Jensen, 2019; Mason et al., 2017; Opersteny et al., 2017).

Consumption of food or drink: If a patient has had either hot or cold food or fluids or has been smoking or chewing gum, the general recommendation is to wait 15 to 30 minutes before measurement of an oral temperature to allow the oral tissues to return to normal temperature.

Presence of mouth breathing, diseases of oral cavity, facial surgery, seizures: Mouth breathing can influence the results of an oral temperature measurement (Jensen, 2019). Oral temperatures should not be taken in people with diseases of the oral cavity, in those who have had surgery of the nose or mouth, or when there is a risk of seizures (Sund-Levander & Grodzinsky, 2013).

Delivery of oxygen by mask: Oral temperatures should not be assessed in patients receiving oxygen by mask, because the time it takes to assess a reading is likely to result in a serious drop in the patient's blood oxygen level.

Ear pain or ache: If a patient has an earache, do not use the affected ear to take a tympanic temperature. The movement of the tragus may cause severe discomfort.

Presence of ear drainage, ear infection or a scarred tympanic membrane: These conditions can contribute to inaccurate measurement of tympanic temperature (Jensen, 2019).

Presence of cerumen (earwax): Tympanic temperature readings may be negatively impacted by the presence of cerumen (Oguz et al., 2018; Robertson & Hill, 2019).

Patient positioning: If the patient has been sleeping or lying with the head turned to one side, take a tympanic temperature in the other ear. Measure only the side of the head exposed to the environment when using a temporal artery thermometer. Heat may be increased on the side that was against the pillow, especially if it is a plastic-covered pillow.

Presence of head coverings: Anything covering the area, such as a hat, hair, wigs, or bandages will insulate the area, resulting in falsely high temporal artery temperature readings.

Presence of scars, open lesions, or abrasions: Do not measure temporal artery temperature over scar tissue, open lesions, or abrasions.

Presence of diaphoresis or sweat: Temporal temperature readings may be negatively impacted in the presence of diaphoresis or sweat (Jensen, 2019).

Patient's ability to hold arm tightly against the body: Axillary readings are affected by ambient temperature, local blood flow, appropriate placement of the probe, and closure of the axillary cavity (Oguz et al., 2018; Sund-Levander & Grodzinsky, 2013).

Recent rectal, anal, vaginal, or prostate surgery: The rectal site should not be used in patients who have undergone recent rectal, anal, vaginal, or prostate surgeries or have a disease of the rectum to avoid trauma and injury (Jensen, 2019; Weber & Kelley, 2018).

Presence of heart disease or recent cardiac surgery: Because the insertion of the thermometer into the rectum can slow the heart rate by stimulating the vagus nerve, assessing a rectal temperature for patients with heart disease or after cardiac surgery should be avoided (Jensen, 2019).

Presence of neutropenia: Assessing a rectal temperature is contraindicated in patients who are neutropenic (have low white blood cell counts, such as in leukemia) due to the increased risk of infection (Jensen, 2019).

Presence of thrombocytopenia: Do not insert a rectal thermometer into a patient who has thrombocytopenia (low platelet count). The rectum is very vascular, and a thermometer could cause rectal bleeding.

Implementation

Action	Rationale
1. Check the prescribed interventions or plan of care for frequency of measurement and route. More frequent temperature measurement may be appropriate based on nursing judgment.	Assessment and measurement of vital signs at appropriate intervals provide important data about the patient's health status.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures that the right patient receives the intervention and helps prevent errors.
4. Close the curtains around the bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient's ability to assist with the procedure.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates cooperation. Dialogue encourages patient participation and allows for individualized nursing care.
5. Assemble equipment on the overbed table within reach.	Organization facilitates task performance.
6. Ensure that the electronic or digital thermometer is in working condition.	Improperly functioning thermometer may not give an accurate reading.
7. Put on gloves, if indicated.	Gloves prevent contact with blood and body fluids. Gloves are usually not required for an oral, axillary, or tympanic temperature measurement, unless contact with blood or body fluids is anticipated. Gloves should be worn for rectal temperature measurement.
8. Select the appropriate site based on assessment data.	This ensures safety and accuracy of measurement.
9. Follow the steps as outlined below for the appropriate type of thermometer.
10. When measurement is completed, remove gloves, if worn. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
Measuring an Oral Temperature
11. Remove the electronic unit from the charging unit and remove the probe from within the recording unit.	The electronic unit must be taken into the patient's room to assess the patient's temperature. On some models, the machine is turned on when the probe is removed.
12. Cover thermometer probe with disposable probe cover, sliding it on until it snaps into place (Figure 2).	Using a cover prevents contamination of the thermometer probe.
13. Place the probe beneath the patient's tongue in the posterior sublingual pocket (Figure 3). Ask the patient to close their lips around the probe.	When the probe rests deep in the posterior sublingual pocket, it is in contact with blood vessels lying close to the surface.
14. Continue to hold the probe until you hear a beep (Figure 4). Note the temperature reading.	If left unsupported, the weight of the probe tends to pull it away from the correct location. The probe must remain in the sublingual pocket for the full period of measurement to ensure accurate measurement. The signal indicates that the measurement is completed. The electronic thermometer provides a digital display of the measured temperature.
15. Remove the probe from the patient's mouth. Dispose of the probe cover by holding the probe over an appropriate receptacle and pressing the probe-release button (Figure 5).	Disposing of the probe cover ensures that it will not be reused accidentally on another patient. Proper disposal prevents spread of microorganisms.
16. Return the thermometer probe to the storage place within the unit. Return the electronic unit to the charging unit, if appropriate.	The thermometer needs to be recharged for future use. If necessary, the thermometer should stay on the charger so that it is ready to use at all times.
Measuring a Tympanic Membrane Temperature
17. If necessary, push the “ON” button and wait for the “ready” signal on the unit.	For proper function, the thermometer must be turned on and warmed up.
18. Attach the disposable cover onto the tympanic probe (Figure 6).	Use of a disposable cover deters the spread of microorganisms.
19. Insert the probe snugly into the external ear using gentle but firm pressure, angling the thermometer toward the patient's jaw line. Pull the pinna up and back to straighten the ear canal in an adult (Figure 7).	If the probe is not inserted correctly, the patient's temperature may be noted as lower than normal.
20. Activate the unit by pushing the trigger button. The reading is immediate (usually within 2 seconds). Note the reading.	The digital thermometer must be activated to record the temperature.
21. Discard the probe cover in an appropriate receptacle by pushing the probe-release button or use the rim of cover to remove it from the probe (Figure 8). Replace the thermometer in its charger, if necessary.	Discarding the probe cover ensures that it will not be reused accidentally on another patient. Proper disposal prevents the spread of microorganisms. If necessary, the thermometer should stay on the charger so that it is always ready to use.
Measuring Temporal Artery Temperature	If the temporal artery and behind the ear locations are not accessible, the femoral artery, lateral thoracic artery, and axillary sites may be used to assess body temperature using a temporal artery thermometer (Exergen, n.d.b). Refer to the Skill Variation on page 55.
22. Brush the patient's hair aside if it is covering the temporal artery area.	Anything covering the area—such as a hat, hair, wigs, or bandages—would insulate the area, resulting in falsely high readings. Measure only the side of the head exposed to the environment.
23. Apply a probe cover.	Using a cover prevents contamination of the thermometer probe.
24. Hold the thermometer like a remote control device, with your thumb on the red “ON” button. Place the probe flush on the center of the forehead, with the body of the instrument sideways (not straight up and down) so that it is not in the patient's face (Figure 9).	This allows for easy use of the device and reading of the display. Holding the instrument straight up and down could be intimidating for the patient, particularly young patients and/or those with alterations in mental status.
25. Depress the “ON” button. Keep the button depressed throughout the measurement.
26. Slowly slide the probe straight across the forehead, midline, to the hairline, maintaining contact with the skin (Figure 10). Do not move the probe down the side of the face.	Midline on the forehead, the temporal artery is ;2 mm below the skin, whereas at the side of the face, the temporal artery is much deeper. Measuring there would result in falsely low readings. Slow movement and continuous contact with the skin are necessary to ensure accurate results.
27. If required, based on specific thermometer in use, brush hair aside if it is covering the ear, exposing the area of the neck under the ear lobe. Keeping the button depressed, lift the probe from the forehead and touch on the neck just behind the ear lobe, in the depression just below the mastoid (Figure 11).	Sweat causes evaporative cooling of the skin on the forehead, possibly leading to a falsely low reading. During diaphoresis, the area on the head behind the ear lobe exhibits high blood flow necessary for the arterial measurement; it is a double check for the thermometer (Exergen, n.d.a).
28. Release the button and read the thermometer measurement.
29. Hold the thermometer over a waste receptacle. Gently push the probe cover with your thumb against the proximal edge to dispose of the probe cover.	Discarding the probe cover ensures that it will not be reused accidentally on another patient.
30. The instrument will automatically turn off in 30 seconds, or press and release the power button.	This turns the thermometer off.
Measuring Axillary Temperature
31. Remove the probe from the recording unit of the electronic thermometer. Place a disposable probe cover on by sliding it on and snapping it securely.	Using a cover prevents contamination of the thermometer probe.
32. Move the patient's clothing to expose only the axilla (Figure 12).	The axilla must be exposed for placement of the thermometer. Exposing only the axilla keeps the patient warm and maintains their dignity.
33. Place the end of the probe in the center of the axilla (Figure 13). Have the patient bring the arm down and close to the body. Hold the patient's arm by the patient's side until the measurement is complete.	The deepest area of the axilla provides the most accurate measurement; surrounding the bulb with skin surface provides a more reliable measurement.
34. Hold the probe in place until you hear a beep, and then carefully remove the probe. Note the temperature reading.	Axillary thermometers must be held in place to obtain an accurate temperature.
35. Cover the patient and help them to a position of comfort.	This ensures patient comfort.
36. Dispose of the probe cover by holding the probe over an appropriate waste receptacle and pushing the release button.	Discarding the probe cover ensures that it will not be reused accidentally on another patient.
37. Place the bed in the lowest position and elevate rails, as needed. Leave the patient clean and comfortable.	A low bed position and elevated side rails provide for patient safety.
38. Return the electronic thermometer to the charging unit.	The thermometer needs to be recharged for future use.
Measuring Rectal Temperature
39. Adjust the bed to a comfortable working height (VHACEOSH, 2016). Put on nonsterile gloves.	Having the bed at the proper height prevents back and muscle strain. Gloves prevent contact with contaminants and body fluids.
40. Assist the patient to a side-lying position. Pull back the covers sufficiently to expose only the buttocks. Position a young infant supine with legs flexed (Kyle & Carmen, 2021).	The side-lying position allows the nurse to see the buttocks. Exposing only the buttocks keeps the patient warm and maintains their dignity. Rectal temperatures are not normally taken in newborns, infants, and young children (Jensen, 2019; Silbert-Flagg & Pillitteri, 2018) but may be indicated. Refer to the Special Considerations section at the end of the skill.
41. Remove the rectal probe from within the recording unit of the electronic thermometer. Cover the probe with a disposable probe cover, sliding it on until it snaps in place (Figure 14).	Using a cover prevents contamination of the thermometer.
42. Lubricate about 1 inch of the probe with a water-soluble lubricant (Figure 15).	Lubrication reduces friction and facilitates insertion, minimizing the risk of irritation or injury to the rectal mucous membranes.
43. Reassure the patient. Separate the buttocks until the anal sphincter is clearly visible.	If not placed directly into the anal opening, the thermometer probe may injure adjacent tissue or cause discomfort.
44. Insert the thermometer probe into the anus about 1.5 inches in an adult or no more than 1 inch in children (Figure 16) (Kyle & Carmen, 2021).	The depth of insertion must be adjusted based on the patient's age. Rectal temperatures are not normally taken in newborns, infants, and young children (Jensen, 2019; Silbert-Flagg & Pillitteri, 2018) but may be indicated. Refer to the Special Considerations section at the end of the skill.
45. Hold the probe in place until you hear a beep, then carefully remove the probe. Note the temperature reading on the display.	If left unsupported, movement of the probe in the rectum could cause injury and/or discomfort. The signal indicates that the measurement is completed. The electronic thermometer provides a digital display of the measured temperature.
46. Dispose of the probe cover by holding the probe over an appropriate waste receptacle and pressing the release button.	Proper probe cover disposal reduces risk of microorganism transmission.
47. Using toilet tissue, wipe the anus of any feces or excess lubricant. Dispose of the toilet tissue. Remove gloves and discard them. Perform hand hygiene.	Wiping promotes cleanliness. Disposing of the toilet tissue avoids transmission of microorganisms.
48. Cover the patient and help them a position of comfort.	This ensures patient comfort.
49. Place the bed in the lowest position; elevate rails as needed.	These actions provide for the patient's safety.
50. Perform hand hygiene.	Hand hygiene prevents the spread of microorganisms.
51. Return the thermometer to the charging unit.	The thermometer needs to be recharged for future use.