HHC Health & Home Care Clinical Policy And

HHC HEALTH & HOME CARE Section: 11-14
Pediatrics: Temperature Taking - Axillary Or Oral __RN
PURPOSE:
Temperature is taken to ascertain the presence of
hypothermia, hyperthermia, or normal temperature.
CONSIDERATIONS:
1. The normal temperature for the child is
approximately 98.6 degrees Fahrenheit (37 degrees
Centigrade) orally.
2. Oral temperatures are not usually taken on children
under five years of age. Axillary temperatures are
usually recommended for the child under one year,
when unable to cooperate with oral route.
3. The time needed to achieve accurate temperature is
generally reduced with an electronic thermometer.
4. If possible use disposable or electronic
thermometer. The use of glass thermometers with
mercury is discouraged.
EQUIPMENT:
Thermometer
Disposable thermometer sheaths
Cleansing solution
Alcohol
PROCEDURE:
1. Adhere to Universal Precautions.
2. Explain procedure to caregiver and patient, in age
appropriate manner.
3. Place the thermometer sheath over the
thermometer.
4. Shake the thermometer until the mercury is below
96 degrees Fahrenheit or 35 degree Centigrade
mark if glass thermometer is being used. Turn
thermometer on if it is electronic.
a. Axillary Option:
(1) Place bulb under arm, well up into armpit,
with arm pressed close to body.
(2) Leave in place for 3-5 minutes, or until
electronic thermometer beeps.
(3) If necessary, hold child's arm close to body.
b. Oral Option:
(1) Place the bulb under the side of the child's
tongue. Have child close mouth while
instructing child not to bite the
thermometer.
(2) Leave the thermometer under the tongue
for 3-5 minutes, or until electronic
thermometer beeps.
5. Remove and read thermometer.
6. Remove sheath or wash thermometer with soap and
tepid water, rinse with alcohol and return to
thermometer container.
7. If non-mercury-in-glass thermometer is used, follow
manufacturer's guidelines for use.
8. Discard soiled supplies in appropriate containers.
AFTER CARE:
1. Document in patient's record:
a. Temperature reading, including method.
b. Associated symptoms if temperature is
elevated.
c. Notification of physician, if indicated.
d. Instructions given to caregiver.
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