LWBK681-C01_p01-13.

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Skill Checklists for Taylor's Clinical Nursing Skills:

A Nursing Process Approach, 3rd edition
Name Date

Unit Position

Instructor/Evaluator: Position

Needs Practice SKILL 1-1

Assessing Body Temperature
Satisfactory
Excellent

Goal: The patient’s temperature is assessed accurately without

injury and the patient experiences only minimal discomfort. Comments

1. Check medical order or nursing care plan for frequency of

measurement and route. More frequent temperature meas-
urement may be appropriate based on nursing judgment.
Bring necessary equipment to the bedside stand or overbed
table.
2. Perform hand hygiene and put on PPE, if indicated.
3. Identify the patient.
4. Close curtains around bed and close the door to the room,
if possible. Discuss the procedure with patient and assess
the patient’s ability to assist with the procedure.
5. Ensure the electronic or digital thermometer is in working
condition.
6. Put on gloves, if appropriate or indicated.
7. Select the appropriate site based on previous assessment
data.
8. Follow the steps as outlined below for the appropriate type
of thermometer.
9. When measurement is completed, remove gloves, if worn.
Remove additional PPE, if used. Perform hand hygiene.

Measuring a Tympanic Membrane Temperature

10. If necessary, push the “on” button and wait for the
“ready” signal on the unit.
11. Slide disposable cover onto the tympanic probe.
12. Insert the probe snugly into the external ear using gentle
but firm pressure, angling the thermometer toward the
patient’s jaw line. Pull pinna up and back to straighten
the ear canal in an adult.
13. Activate the unit by pushing the trigger button. The read-
ing is immediate (usually within 2 seconds). Note the
reading.
14. Discard the probe cover in an appropriate receptacle by
pushing the probe-release button or use rim of cover to
remove from probe. Replace the thermometer in its
charger, if necessary.

Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition, by Pamela Lynn and Marilee LeBon.
LWBK681-C01_p01-13.qxd 9/3/10 5:35 PM Page 2 Aptara Inc

SKILL 1-1

Needs Practice
Assessing Body Temperature (Continued)
Satisfactory
Excellent

Comments

Assessing Oral Temperature

10. Remove the electronic unit from the charging unit, and
remove the probe from within the recording unit.
11. Cover thermometer probe with disposable probe cover and
slide it on until it snaps into place.
12. Place the probe beneath the patient’s tongue in the posterior
sublingual pocket. Ask the patient to close his or her lips
around the probe.
13. Continue to hold the probe until you hear a beep. Note the
temperature reading.
14. 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.
15. Return the thermometer probe to the storage place within
the unit. Return the electronic unit to the charging unit, if
appropriate.

Assessing Rectal Temperature

10. Adjust the bed to a comfortable working height, usually
elbow height of the care giver (VISN 8 Patient Safety
Center, 2009). Put on nonsterile gloves.
11. Assist the patient to a side-lying position. Pull back the
covers sufficiently to expose only the buttocks.
12. Remove the rectal probe from within the recording unit of
the electronic thermometer. Cover the probe with a dispos-
able probe cover and slide it into place until it snaps in
place.
13. Lubricate about 1 inch of the probe with a water-soluble
lubricant.
14. Reassure the patient. Separate the buttocks until the anal
sphincter is clearly visible.
15. Insert the thermometer probe into the anus about 1.5 inches
in an adult or 1 inch in a child.
16. Hold the probe in place until you hear a beep, then
carefully remove the probe. Note the temperature reading
on the display.
17. Dispose of the probe cover by holding the probe over
an appropriate waste receptacle and pressing the release
button.
18. Using toilet tissue, wipe the anus of any feces or excess
lubricant. Dispose of the toilet tissue. Remove gloves and
discard them.

Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition, by Pamela Lynn and Marilee LeBon.
LWBK681-C01_p01-13.qxd 9/3/10 5:35 PM Page 3 Aptara Inc

SKILL 1-1

Needs Practice
Assessing Body Temperature (Continued)

Satisfactory
Excellent

Comments

19. Cover the patient and help him or her to a position of

comfort.
20. Place the bed in the lowest position; elevate rails as needed.
21. Return the thermometer to the charging unit.

Assessing Axillary Temperature

10. Move the patient’s clothing to expose only the axilla.
11. 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.
12. Place the end of the probe in the center of the axilla.
Have the patient bring the arm down and close to the
body.
13. Hold the probe in place until you hear a beep, and then
carefully remove the probe. Note the temperature
reading.
14. Cover the patient and help him or her to a position of
comfort.
15. Dispose of the probe cover by holding the probe over
an appropriate waste receptacle and pushing the release
button.
16. Place the bed in the lowest position and elevate rails, as
needed. Leave the patient clean and comfortable.
17. Return the electronic thermometer to the charging unit.

Assessing Temporal Artery Temperature

10. Brush the patient’s hair aside if it is covering the temporal
artery area.
11. Apply a probe cover.
12. 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 instru-
ment sideways (not straight up and down), so it is not in
the patient’s face.
13. Depress the ON button. Keep the button depressed
throughout the measurement.
14. Slowly slide the probe straight across the forehead,
midline, to the hair line. The thermometer will click; fast
clicking indicates a rise to a higher temperature, slow
clicking indicates the instrument is still scanning, but not
finding any higher temperature.

Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition, by Pamela Lynn and Marilee LeBon.
LWBK681-C01_p01-13.qxd 9/3/10 5:35 PM Page 4 Aptara Inc

SKILL 1-1

Needs Practice
Assessing Body Temperature (Continued)
Satisfactory
Excellent

Comments

15. Brush hair aside if it is covering the ear, exposing the area
of the neck under the ear lobe. Lift the probe from the
forehead and touch on the neck just behind the ear lobe,
in the depression just below the mastoid.
16. Release the button and read the thermometer
measurement.
17. Hold the thermometer over a waste receptacle. Gently
push the probe cover with your thumb against the
proximal edge to dispose of probe cover.
18. Instrument will automatically turn off in 30 seconds, or
press and release the power button.

Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition, by Pamela Lynn and Marilee LeBon.