Nursing & Healthcare Programs

Axillary Temperature with Electronic Thermometer

Written by Hollie Finders, RN
Hollie Finders is a registered nurse with years of experience working in the health care field. She has degrees in both biochemistry and nursing. After working with patients of all ages, Hollie now specializes in pediatric intensive care nursing. Hollie’s LinkedIn

Procedure

Equipment needed: axillary thermometer, disposable probe cover, and gloves

  1. Perform hand hygiene and put on gloves.
  2. Explain the procedure to the patient and ask for his or her assistance in following directions.
  3. Get the thermometer from its base unit and apply a disposable cover to the probe. Be sure the probe cover is secure and locked into place. If the thermometer has multiple modes, be sure to use axillary mode.
  4. Expose the axilla (armpit) by moving the patient’s arm away from the torso.
  5. Inspect the axilla for rashes and/or open sores. If present, stop and attempt to use the opposite axilla or choose another method for obtaining the patient’s temperature. Be sure to report the found skin issues to the nurse.
  6. If needed, dry the axilla by wiping the area with a tissue.
  7. Place the tip of the covered probe into the center of the axilla and return the arm to the patient’s side. Create a tight seal around the probe by folding the patient’s arm onto his or her chest.
  8. Hold the probe in place until the thermometer signals completion (depending on the device, it may flash or beep). Read the temperature on the electronic display screen.
  9. Gently lift the arm away from the body and remove the probe.
  10. Eject the disposable probe cover into the waste bin and return the thermometer to its base unit.
  11. Remove gloves and perform hand hygiene.
  12. Record temperature, method used (axillary), date, and time in the patient’s chart.
  13. Alert the medical professional of any changes in the patient’s condition.

Important Information

Compared to other temperature measurement methods, the axillary measurement is considered the least reliable. An axillary temperature measurement typically reads 0.5 to 1 degree Fahrenheit lower than an oral temperature reading [1]. For this reason, it is recommended to use this method only when other methods are contraindicated or when taking an axillary temperature is the safest method for the patient (e.g. unconscious, confused, uncooperative, and/or disoriented patients). If a patient has an injury to the arm or shoulder, has recently had chest or breast surgery, or has a rash or an open sore in the axilla, the unaffected side should be used to perform the temperature measurement.

References

1. https://www.ncbi.nlm.nih.gov/pubmed/11198790

More Resources

Perineal Care of the Male Resident

Perineal care should be performed during a bath, after using the bedpan, and/or after incontinence. Special care should be used when performing perineal care on an uncircumcised male. Failure to retract and wash the area under the foreskin can result in infection. Failure to return the foreskin to its normal position can result in paraphimosis.

Using a Gait / Transfer Belt to Assist the Resident to Ambulate

Walking (aka, ambulating) helps residents maintain mobility and independence, and prevents complications. However, ambulation must be done safely so that the resident does not have a fall or injury. A gait or transfer belt, when properly used, can increase resident safety. Gait belts can vary between facilities, so make sure you know how to use the one in your facility.

Measuring the Respirations

Respiration is a vital sign that is measured frequently in the healthcare setting. Taking this measurement requires no equipment and relatively little time. However, it is a measurement that must be taken accurately, as a change in respiration may indicate the worsening of a patient’s condition.

Fowler’s Position

Fowler’s position is used when a patient is eating, is having difficulty breathing, or is ordered by a doctor. This position is easily recognized because the patient will be sitting “straight up.” Semi-Fowler’s is sitting “half-way up,” and is used when patients cannot be laid flat, but wish to be in a more relaxed position than Fowler’s.

Removing Personal Protective Equipment

It is important to follow the correct procedure while removing personal protective equipment to avoid contaminating your skin or clothing. The most common source of contamination in this process stems from improper removal of gloves. Gloves are often the most soiled piece of equipment. To avoid contaminating your skin or the other equipment worn, gloves should always be removed first. Then remove the goggles, gown, and mask, in that order.

Supine Position

Supine position is a natural and comfortable position for most people. For this reason, it is a highly utilized position for nursing procedures. Unfortunately, this position puts pressure on many bony prominences that can lead to discomfort and/or pressure ulcers if the pressure is not relieved every so often (typically every two hours or less).