HHC Health & Home Care Clinical Policy And

HHC HEALTH & HOME CARE Section: 11-15
Pediatrics: Temperature Taking - Rectal __RN
PURPOSE:
Temperature is taken to ascertain the presence of
hypothermia, hyperthermia, or normal temperature.
CONSIDERATIONS:* A physician’s order may be
required for taking a rectal temperature, as it is an
invasive procedure.
1. There is danger of perforation of the rectum in the
young infant because it is quite short. Obtain rectal
temperature only if no other route is available.
2. The normal temperature for the child is
approximately 99.6 degrees Fahrenheit (37.5
degrees Centigrade) rectally.
3. It is difficult to determine febrile state in an infant by
touch during the first year of life.
4. There is a natural tendency by the child to expel the
thermometer. Babies usually have a bowel
movement.
5. A safe restraint method should be used to prevent
the child’s moving which might push the
thermometer further into the rectum.
6. The use of mercury filled glass thermometers
should be discouraged.
EQUIPMENT:
Rectal thermometer
Cleansing solution
Alcohol
Lubricant
Disposable thermometer sheaths
Gloves
PROCEDURE:
1. Adhere to Universal Precautions.
2. Explain procedure to caregiver and patient, if age
appropriate.
3. Shake the thermometer until the mercury is below
96 degrees Fahrenheit or 35 degree Centigrade
mark.
4. Place the thermometer sheath over the
thermometer.
5. Lubricate thermometer bulb if insufficient lubrication
from the thermometer sheath. Place child on
stomach, or on back with both legs up, or on one
side with upper leg bent.
6. The nondominant forearm should be placed firmly
across the child's hip area when child is on his/her
stomach.
7. Use the thumb and forefinger of the nondominant
hand to separate the buttocks, then the dominant
hand is free to gently insert the lubricated
thermometer.
8. Insert rectal thermometer into the rectum
approximately 1/4" or until bulb is covered.
9. Hold thermometer in place for 3 to 5 minutes.
Sometimes it is helpful to hold buttocks closed.
10. Remove, read and shake down mercury.
11. Wipe rectal area with tissues.
12. Comfort patient. Encourage caregiver to comfort
patient.
13. Remove sheath or wash thermometer with soap and
tepid water. Cleanse with alcohol and return to
thermometer container.
14. If non-mercury-in-glass thermometer is used, follow
manufacturer's guidelines for use.
15. 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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