Monitoring temperature
Temperature monitoring is a fundamental nursing skill. When assessing a patient's temperature, it is important to place the reading in the context of the patient's presenting condition and symptoms.
Article by Barry Hill and Aby Mitchell
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Purpose
A patient's temperature should always be recorded when conducting vital signs, baseline observations or monitoring checks (Bickley, 2023). The assessment of temperature as an initial clinical examination allows health practitioners to gain a greater insight into the patient's current condition, so that more appropriate treatment and care can be given.
Temperature monitoring should also be used to measure the effectiveness of, and track the side effects arising from any intervention delivered to the patient (Bickley, 2023). This can include, for example, taking a temperature preoperatively to monitor the effects of an anaesthetic.
Several factors can affect temperature, such as:
- presenting clinical conditions
- infections
- brain function and injury
- cardiac function, including hypotension
- bleeding and haemorrhage
- older age
- body mass
- environment
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Assessment
When body temperature is in the normal range (Table 1), body tissue and cells still work efficiently and effectively (Potter et al, 2022). When a patient's temperature starts to rise or fall, this can cause serious physiological issues, and can also be a key indicator for diagnosis.
| Table 1. Temperature values corresponding with various conditions | |
| Hypothermia | <35.0°C |
| Pyrexia | >38.0°C |
| Normal range in accordance with definitions | 35.1°−37.9°C |
| Optimal range for homeostasis | 36.5°−37.5°C |
| From: White et al (2011) | |
For example, prolonged hypothermia causes vasoconstriction and bradycardia (slow heart rate), which preserves body temperature. Such changes will affect the delivery of energy and oxygen to cells (Dutton and Finch, 2018) and will result in slowed breathing, lack of co-ordination, irritability, confusion and sleepy behaviour.
Thermometer choice
When taking a patient's temperature, it is important to consider a number of factors, such as the appropriate choice of thermometer (Table 2) (Perry
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Procedure
The nurse should ensure they gain consent before taking a temperature by any method, by explaining the nature of the procedure and why it is being undertaken to the patient. Nurses should undertake hand hygiene prior to taking a blood pressure to minimise the risk of transmitting infection.
The patient should be rested and comfortable and the nurse should attend to any privacy and dignity issues associated with the procedure. The nurse should observe the patient for any signs that they may be hot or cold, such as sweating, facial colour, shivering, as these may add validity to, or raise questions about the temperature as indicated by the thermometer.
See taking temperature for a step-by-step procedure on monitoring temperature using various types of measurements.
Surgical patients
The National Institute for Health and Care Excellence (NICE, 2016) has produced guidelines on the most effective ways to prevent, manage and
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Risks and complications
A raised temperature is recognised as a key indicator in diagnosing sepsis, and ongoing temperature monitoring will indicate the progression of the infection (Mai et al, 2018).
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Next steps
Temperature monitoring is a fundamental skill used by nurses in clinical practice. It is a vital sign that is significant and must be acknowledged as such. Using the right equipment and the correct route of measurement, is important for obtaining an accurate reading.
Ensure that the patient has given consent for the procedure, that infection control policy has been followed, and the relevant documentation is accurate and legible. Escalate any concerns you may have, and always advocate for the patient.
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NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 1: Procedures for assessing people’s needs for person-centred care
1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages:
1.2 physical health and wellbeing
1.2.1 symptoms and signs of physical ill health
2.1 take, record and interpret vital signs manually and via technological devices
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Resources
Bickley L. Bates' guide to physical examination and history taking. 13th edn. Philadelphia (PA): Wolters Kluwer Publishers; 2023
Dutton H, Finch J (eds). Acute and critical care nursing at a glance. 1st edn. Chichester: Wiley Blackwell; 2018
Gates D, Horner V, Bradley L et al. Temperature measurements: comparison of different thermometer types for patients with cancer. Clin J Oncol Nurs. 2018;22(6):611–617. https://doi.org/10.1188/18.CJON.611-617
Hart SR, Bordes B, Hart J et al. Unintended perioperative hypothermia. Ochsner J. 2011; 11(3):259–270
Levin RF, Wright F, Pecoraro K et al. Maintaining perioperative normothermia: sustaining an evidence-based practice improvement project. AORN J. 2016; 103(2):213.e1–213.e13. https://doi.org/10.1016/j.aorn.2015.12.020
Mai SHC, Sharma N, Kwong AC et al. Body temperature and mouse scoring systems as surrogate markers of death in cecal ligation and puncture sepsis. Intensive Care Med Exp. 2018; 6(1):20. https://doi.org/10.1186/s40635-018-0184-3
National Institute for Clinical Excellence. Hypothermia: prevention and management in adults having surgery. 2016 . https://www.nice.org.uk/guidance/Cg65 (accessed 27 October
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