Skill List > Temperature Recording: Disposable Chemical Thermometer Axilla
Clinical Alert
Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Based on Nicol: Essential Nursing Skills 4E
Adapted by: John Larkin
BSc(Hons) MSc CertEd(Nursing) RGN RCN RNT
Updated by: Tanya Middlehurst MSc BSc(Hons) RN
Last updated: August 2017
Learning Objective
After reading the skill overview, watching the video, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of recording temperature using an oral disposable chemical thermometer.

Introduction

Body temperature is one of the four main vital signs that must be monitored to ensure safe and effective patient care (McCallum & Higgins 2012). The National Institute for Health and Clinical Excellence (NICE) recommends temperature measurement as part of the initial assessment in acute illness in adults (NICE 2007). The Royal College of Nursing has collaborated with the Royal College of Physicians to produce National Early Warning Scores for acute illness in the NHS and temperature measurement is a key component of this assessment (RCP 2015).

Body temperature can be considered as the balance of heat lost from the body and gained by the body (Johnson 2007). A healthy body maintains its temperature within a narrow range using homeostatic thermoregulation mechanisms (Waugh & Grant 2014). Johnson describes the normal range of body temperature as 36–37.5°C, but says that this may vary by as much as 0.6°C according to the site used for measurement and from individual to individual (Johnson 2007). Fluctuations in body temperature occur naturally as a result of circadian rhythms, extremes of age (the young or elderly are unable to maintain an efficient equilibrium in thermoregulation), exertion or exercise, food intake, hormonal balance (e.g., ovulation), medication or alcohol, smoking, or deteriorating physiological function (e.g., shock, infection) (Johnson 2007, Evans 2009, Dougherty et al. 2015).

The following terms are used to describe abnormal temperature ranges:

  • Mild hypothermia (32–35°C).
  • Moderate hypothermia (28–32°C).
  • Severe hypothermia (below 28°C).
  • Mild pyrexia (depending on the patient’s normal baseline temperature, 37.2–38.9°C).
  • Hyperthermia (above 40.6°C).

According to Sund-Levander and Grodzinsky, assessment and evaluation of body temperature is one of the oldest known diagnostic methods and still has a huge influence on decisions about medical diagnosis, nursing care, treatment, and requesting laboratory results (Sund-Levander & Grodzinsky 2010). Body temperature is useful in monitoring health and illness as it reflects the ability of the body to manage heat loss and gain (McCallum & Higgins 2012).

There are many clinical indications for measuring body temperature, including:

  • To ascertain a baseline temperature on admission to enable comparisons in the future.
  • To enable close observation in resolving hypothermia or hyperthermia.
  • To observe and monitor the patient for changes indicating an infection.
  • To monitor the effect of treatment for antimicrobial therapy for infection.
  • Before and during a blood transfusion for signs of a reaction.

The frequency of measurement will depend upon the patient’s condition and recorded temperature (Johnson 2007). Frequency of recording may also be identified in local hospital policy (e.g., frequency of recording while receiving a blood transfusion). Nurses should also ensure that both the method of taking the temperature and the site used are consistent, and documented to accurately reflect fluctuations, while also taking into account any other factors that may cause a fluctuation. Any changes above or below the normal limits should prompt appropriate reporting and responses as set out in line with an early warning scoring system (McCallum & Higgins 2012, Royal College of Nursing First Steps 2017).

It is important that the procedure is carried out in accordance with the manufacturer’s instructions and local policies and procedures.

Chemical thermometers are contact thermometers consisting of a matrix of temperature-sensitive dots (Davie & Amoore 2010). Within each of these dots, a different combination of chemicals melts and changes colour from beige to blue at intervals of 0.1°C. The temperature is read by observing the number of dots that have changed colour (Childs 2011). These thermometers are for single use only and the manufacturer’s instructions for use must be followed to ensure accurate recordings.

Commonly used noninvasive temperature measurement sites other than the mouth include the axilla and the aural route using the tympanic membrane (Grainger 2013). Temperature is measured in the axilla by placing the thermometer in the central position and adducting the arm close to the patient’s chest wall (McCallum & Higgins 2012). In support, Sund-Levander and Grodzinsky (2010) suggest that correct placement of the thermometer to measure axilla temperature is very important and direct skin contact is essential. The measurement site should be as high as possible in the axilla with the patient’s arm pressed against their side (Davie & Amoore 2010).

The axilla site is useful for patients when the oral or tympanic site cannot be utilised, for example, following surgery or trauma (Grainger 2013). Some authors argue that axilla measurement is less desirable than other sites because of the difficulty in achieving accurate and reliable readings. The accuracy of this site is affected by ambient temperature, local blood flow, underarm sweat, inappropriate placement of the thermometer, or poor closure of the axilla cavity, and the time it takes to record the reading (Sund-Levander & Grodzinsky 2010). In comparison to oral temperature measurements, the axillary site does not have the same contact with body fluid, and, consequently, in the unwell adult patient experiencing rapid temperature changes, the axilla site is not recommended.The axilla site is not appropriate in patients where peripheral circulation is shut down, for example, patients with hypothermia. In addition, in elderly patients there may be insufficient lean body mass to ensure that the thermometer is surrounded by skin tissue (Johnson 2007).

Dougherty et al. (2015) argue that whatever site is used, it is important that this is then used consistently, as switching between sites can produce a record that is misleading and difficult to interpret. The temperature in the axilla is 0.5°C lower than oral temperature. (Nicol et al. 2012).

Preparation and safety

  • Explain the procedure to the patient to gain consent and cooperation.
  • Assess the patient regarding the suitability of the site for axillary temperature recording. The axillary site may not be suitable if the patient’s peripheral circulation is shut down (e.g., hypothermia), or if the patient has insufficient lean body mass to ensure that the thermometer is surrounded by skin tissue.
  • Ensure the patient has not recently had a hot bath or shower, ingested food or fluid, or been engaged in strenuous exercise, as these will cause a temporary rise in temperature.
  • Hands must be clean and an apron should be worn.
  • Ensure that all the necessary equipment is assembled: apron, thermometer, watch, and patient documentation.
  • Additional personal protective clothing may be necessary if indicated by the patient’s condition.

Procedure

  1. Disinfect your hands and explain the procedure to the patient.
    Rationale – To prevent cross-infection and gain the patient’s consent
  2. Check the expiry date of the thermometer and open the packaging taking care not to touch the end with the dots.
    Rationale – These dots are heat sensitive and accuracy may be affected.
  3. Ensure the patient’s privacy.
    Rationale – To respect individuality and maintain self-esteem.
  4. Help the patient into a comfortable position, either sitting or lying.
    Rationale – So that this position can be maintained for the duration of the recording.
  5. Ask or assist the patient to expose one axilla. Dry the skin of the axilla by wiping with a tissue.
    Rationale – To gain access. For an accurate reading the axilla must be dry and free from sweat.
  6. With the dots facing the chest wall, position the thermometer as high as possible in the axilla.
    Rationale – To gain an accurate temperature reading.
  7. Ask or assist the patient to keep their arm close against the chest.
    Rationale – To ensure good contact with the skin.
  8. It is vital to leave the thermometer in position for the manufacturer’s recommended length of time (usually 3 min). However, it does not affect accuracy if it is left for longer than the minimum time.
    Rationale – For accurate recording, it is vital to follow manufacturer’s instructions.
  9. Remove the thermometer, taking care not to touch the part that has been under the patient’s arm.
    Rationale – The dots are heat sensitive and accuracy may be affected.
  10. In accordance with the manufacturer’s instructions, wait a few seconds for the dots to stabilise, then read the temperature by noting the way that the dots have changed colour. 
    Rationale To ensure accuracy. Some dots may disappear before you read the thermometer; this is normal.
  11. Discard the thermometer into the clinical waste bag. 
    Rationale – The thermometer has been in contact with a body fluid and so must be discarded into the clinical waste. In hospital you can use the locker bag; this is later discarded into clinical waste.
  12. Document the temperature according to local policy and report any abnormalities. 
    Rationale – To ensure patient safety.
  13. Perform hand hygiene. 
    Rationale – To prevent cross-infection.

Ongoing care, monitoring and support

  • Ensure patient comfort, replace clothing etc. as necessary.
  • Answer any questions regarding the recording.
  • Dispose of the thermometer into the clinical waste bag.
  • If the thermometer is left in the axilla for more than 5 min, it should be discarded and a new thermometer used for the recommended length of time.
  • Document the temperature according to local policy, noting that it was measured in the axilla. See the video for an example of charting.
  • Report any abnormality. The normal range for adults is 36–37.2°C. The temperature in the axilla is 0.5°C lower than oral temperature:
    • a temperature above 37.2°C is pyrexia
    • a temperature below 35°C is hypothermia.

Documentation and reporting

  • According to the Nursing and Midwifery Council (NMC), good record keeping is an integral part of nursing and midwifery practice, and is essential to the provision of safe and effective care (Childs 2011, NMC 2015).
  • The NMC (2015) states that the nurse must keep clear and accurate records of the discussions that have taken place, the assessments undertaken, the treatment and medicines given, and how effective these have been.
  • Accurate documentation and prompt reporting of any changes in temperature are vital for patient safety. Early Warning Score (EWS) documentation is now widely used in hospitals, which gives parameters and guidance on the appropriate action to be taken if the temperature is above or below normal (Donaghue & Endacott 2010).
  • Through documentation, registered nurses communicate to other nurses and members of the multidisciplinary team their assessment about the patient’s status. Documentation and reporting must be in line with local hospital policy.
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