Skill List > Body Temperature Measurement: Axillary (Child)
Clinical Alert
Inaccurate temperature measurement can result in serious errors in diagnosis and treatment. In a hypothermic child, measurement of axillary temperature may be inaccurate and cause a delay in accurate temperature measurement because multiple attempts may be necessary and the reading may be slower to register (Barringer et al. 2011)

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 Mosby Nursing Skills
Adapted by: Karen Jeffery MSc CertEd(FE) RN RSCN RNT RCNT
Updated by: Janet Kelsey: BSc(Hons) MSc PGCEA AdvDipEd RSCN RN RNT
Last updated: October 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 axillary temperature measurement in children and infants.

Introduction

Temperature measurement is an important assessment and monitoring tool for critically ill infants and children. Normal body temperature represents the balance between heat production (primarily from metabolism and environmental factors) and heat loss (primarily from environmental factors) (Marieb & Hoehn 2010). Humans are homoeothermic, dependent on a normal core temperature despite variable external environmental temperatures (Mains et al. 2008).  Core body temperature is maintained constantly, with only minor deviations from the normal range, which is 36.6–37.8ºC (Aylott 2008).

Body temperature is influenced by factors such as age, circadian rhythms, exercise, and hormones (Dougherty & Lister 2011). The hypothalamus functions as the body’s thermostat, initiating physiological mechanisms to balance heat loss and heat production (Mains et al. 2008). Heat-producing processes of the body include metabolism, disease processes, exercise, shivering, unconscious tensing of muscles, and increased thyroid activity. To offset excessive heat production and restore normothermia, the body uses these four processes:

  • Convection: heat transfer by air movement or liquid carrying heat away from an object. This transfer is dependent on air velocity, temperature, and exposed surface area. Convection losses increase with shivering and wind conditions.
  • Radiation: an energy transfer via electromagnetic waves to surrounding cooler surfaces without direct contact. The degree of heat loss by radiation is directly related to core and ambient temperature and the exposed body surface area. The large head size in proportion to body size of infants and children also predisposes them to hypothermia. Most losses emanate from the unprotected head, which accounts for the majority of heat loss in the operating room.
  • Conduction: the transfer of heat to surrounding objects through direct physical contact. Conduction heat loss increases five times if the child is wet and up to thirty times with cold water immersion (Lange Varga 2008).
  • Evaporation: occurs primarily through perspiration, which is removed from the skin as transdermal water loss by changing from a liquid into a vapour. Evaporation can also occur from the respiratory tract and open body cavities.

Infants maintain body temperature through a chemical non-shivering thermogenesis that begins with the secretion of norepinephrine and results in the breakdown of brown fat to create heat (Altimier 2012).  Body surface area in children and infants is proportionally greater compared with that of adults (James et al. 2014); thus, more heat is lost to the environment through evaoparation, conduction, and convection (Freer & Lyon 2012). Thermoregulation in children can be affected by illness, and environmental and maturational factors (MacGregor 2008).

The mechanisms for temperature regulation are so efficient in health that a departure from normal body temperature has become a cardinal sign of illness. 

A vigilant and accurate assessment of thermal balance is vital in the recognition of the seriously ill infant, child or young person (Department of Health 2004). Critically ill infants and children are at risk for ineffective thermoregulation from environmental and maturational factors (Jones at al. 2003).

The selection of site and device to be used in measuring temperature needs to be considered depending on the age of the child. Infants under the age of 4 weeks should have their temperature measured with an electronic thermometer in the axilla (Macqueen et al. 2012). In children aged 4 weeks to 5 years body temperature should be measured by one of the following methods:

  • Electronic thermometer in the axilla.
  • Chemical dot thermometer in the axilla.
  • Infrared tympanic thermometer (National Institute for Health & Excellence (NICE) 2017, Royal College of Nursing (RCN) 2017).

Rectal thermometers should not be routinely used with children aged 0–5 years (NICE 2017); however, their use may be indicated within the intensive or high dependency care setting, where clear guidance for health professionals should be available (RCN 2017).

No single method of measurement in children provides an exact core temperature measurement. In paediatrics, the goal is to obtain the most accurate temperature measurement in the least invasive manner. Specific information about temperature monitoring devices is available from each manufacturer and must be understood by the nurse before the equipment is used.

Axillary temperature measurement is frequently used to assess a child’s temperature, although for critically ill children, intermittent or continuous core temperature monitoring may be necessary (Barringer et al. 2011). Oral routes should not be used to measure temperature in children aged 0–5 years. In children under 4 weeks of age the axilla route is recommended using an electronic thermometer (NICE 2017).

The difference between axillary and rectal temperatures has been found to be inconsistent and variable based on factors such as febrile state, age of patient, and time of day. The inconsistency in the mean differences indicates that axillary temperatures may not be an acceptable substitution for rectal temperatures (Stine 2012). However, rectal thermometry is not routinely advocated due to its invasive nature (NICE 2017, RCN 2017) and there is evidence that suggests that measurement of axillary temperature can be considered reliable (Klein & De Witt 2010).

To perform the procedure, the nurse must have:

  • Knowledge of the metabolic and environmental factors that cause heat gain and heat loss in paediatric patients.
  • An understanding of the physiological mechanisms that balance heat loss and heat production.
  • An understanding of the differences among temperature measuring devices and temperature measuring sites (RCN 2017).

The following additional knowledge is required:

  • Child development as it relates to body temperature and changes in body temperature.
  • Specific information about temperature monitoring devices.
  • The need for regularly scheduled calibration and battery changes to decrease the possibility of inaccurate results with electronic and infrared devices.

Patient and family education

  • Provide individualised, developmentally appropriate education to the family and the child based on desire for knowledge, readiness to learn, and overall neurological and psychosocial state.
  • Explain the procedure for monitoring temperature, including the reason for monitoring, the site selected, the device to be used, and the frequency of monitoring.
  • Explain the risks related to the procedure, including infection.
  • Explain how the child can assist with the procedure by remaining still.
  • Determine the child’s and family’s understanding of the mode selected.
  • Explain normal body temperature ranges, indications for obtaining measurements, and deviations from the baseline that may be pertinent for the child.
  • Explain interventions that may be needed to assist with the child’s body temperature regulation.
  • Encourage and answer questions as they arise and gain consent.

Preparation and safety

  • Assess the child’s developmental level and ability to interact.
  • Assess risk factors, medical history, and cause of the child’s underlying condition.
  • Review current medication therapy.
  • Assess the child’s and family members’ understanding of the reasons for and risks and benefits of the procedure.
  • Assess the environment. Ensure all equipment and supplies have been collected and are working properly.

Procedure

  1. Perform hand hygiene and put on an apron. Wear personal protective equipment where necessary. Verify the correct patient according to local policy and obtain consent.
  2. Verify the correct patient according to local policy and obtain consent. Explain the procedure to the child in developmentally appropriate language. Rationale – The child knows what to expect.
  3. Some thermometers have a memory feature built in that can recall previous temperature measurements.
  4. Take the child’s temperature with the same method at intervals as designated in local policy. Temperature should be monitored regularly until it is stable. Rationale – Vital signs should be taken as often as necessary considering the child’s current condition and status. Temperature monitoring should not be delayed in infants, children, and young people with worrying symptoms.
  5. Check that the thermometer is in good working order. To decrease the possibility of inaccuracy, electronic and infrared devices should be regularly checked or calibrated and batteries replaced according to the manufacturer’s instructions. Rationale – Question the accuracy of any temperature reading that does not correlate with the child’s present state. The temperature should be checked with an alternative device or site. Inaccurate temperature measurement can result in serious errors in diagnosis and treatment.
  6. Apply the cover to the temperature probe according to manufacturer’s instructions.
  7. Place the tip of the thermometer under the armpit, ensuring contact between the skin of the arm and skin of the chest.
    Rationale – Ensures accurate probe placement; prevents ambient air from affecting reading.
  8. Hold the arm next to the side of the chest, keeping the thermometer under the arm for the recommended time period. The digital device displays a reading or produces an audible sound when the measurement is completed (Davie & Amoore 2010).
    Rationale – Keeping the arm in close proximity to the chest decreases the effect of environmental temperature on the measurement.
    For safety, never leave the child alone when taking a temperature measurement. Keep one hand on the thermometer at all times while it is in place.
  9. Remove the thermometer.
  10. Obtain the measured value from the device readout.
    If the temperature reading does not correlate with the child’s present state, double check with an alternate device or site.
  11. Dispose of the probe cover, remove apron, and perform hand hygiene.
  12. Document the temperature including mode, time, and date on the child’s observation chart and if required in the child’s notes. Rationale – Establishes temperature measurement and complets the assessment.

Ongoing care, monitoring and support

  • Perform physical assessment of all body systems every 1–2 h. Rationale – Alterations in temperature can affect all body systems.
    Reportable condition: significant changes in assessment findings.
  • Monitor body temperature according to local policy. If temperature falls outside of the normal range it should be taken more frequently until stable (Macqueen et al. 2012). Take vital signs, including temperature, as often as necessary given the child’s condition and status. Do not delay temperature monitoring if a deleterious trend is suspected to be developing.
    Reportable conditions: hypothermia, hyperthermia.
  • Confirm the accuracy of the temperature measurement by comparing the value with the child’s other signs and symptoms. Using an alternative site or mode, or selecting a continuous mode of monitoring may help confirm accuracy. Rationale – Falsely high or low temperature readings may trigger unnecessary therapy.
    Reportable condition: variation in temperature from child’s baseline.
  • Assess, treat, and reassess pain according to institution standard.
    Reportable condition: unrelieved discomfort.
  • Initiate nursing actions for hypothermia or hyperthermia as indicated by the child’s condition.
    Reportable condition: unrelieved temperature imbalance.

Documentation and reporting

  • Child’s temperature, site used, and time and date of assessment.
  • Deviation from the child’s baseline temperature.
  • Comfort assessment.
  • Child and family education.
  • Unexpected outcomes and related treatment.
  • Education of parents regarding monitoring temperature and keeping a temperature diary at home where appropriate.
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