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Oral Temperature Measurement with an Electronic Monitor

Written by Amanda R. McDaniel, MS, BSN, RN
Amanda is a BSN/RN with a MS in Physiology and a BA in English. She worked as a medical writer in the pharmaceutical industry for 11 years before pursuing a career in nursing. She now works as a nurse on a NeuroTelemetry unit and continues to write and edit on a freelance basis. Amanda’s LinkedIn

Body temperature is one of the vital signs frequently measured in healthcare settings. Changes in a body temperature can indicate improvement or worsening of a patient’s condition, so accurate measurement is important. Oral (also known as sublingual) temperature measurement using an electronic monitor is a convenient and accurate method of assessment. It is quick, typically 20 to 30 seconds, and does not require the patient to change position. Oral temperatures are appropriate for most patients; however, patients who cannot breathe through their nose or cannot hold their mouth closed for the duration of the assessment for any reason should have their temperature taken via another route (axillary, tympanic, rectal, etc.).

Obtaining Oral Temperature with an Electronic Monitor

  1. Gather your supplies. These include:
    • Gloves
    • Thermometer
    • Thermometer probe covers
  2. Perform hand hygiene and don gloves (per institutional policy).
  3. Ask the patient if they have had anything to drink or eat in the past 15 minutes or whether they have smoked in the last 2 minutes (food, drink, and smoking can alter the temperature of the oral cavity).
  4. Turn the thermometer on and slide a disposable probe cover over the probe stem until the cover äóìclicksäó into place.
    • Check that you are using the correct probe. Typically, blue indicates that the probe is for oral and/or axillary temperatures while red indicates that the probe is used for rectal temperatures.
  5. Ask the patient to open his mouth and gently place the tip of the probe under the tongue in the posterior portion of the mouth. If needed, press the äóìStartäó button on the thermometer.
  6. Ask the patient to close his mouth around the probe and keep the tip of the probe under his tongue.
  7. The probe should stay in place until the monitor audibly signals (beeps) that the measurement has completed and the final measurement is shown on the display.
  8. Gently remove the probe from the patient’s mouth, then press the ejection button on the probe to remove the probe cover. Discard the probe cover and place probe back in storage position.
  9. Remove gloves and perform hand hygiene.
  10. Document the temperature in the patient’s record and inform the nurse of any significant change from previous temperature per institutional or unit protocol.
  11. Disinfect the thermometer and return it to the storage or charging location per institutional or unit protocol.

Amanda R. McDaniel, MS, BSN, RN

References

Fetzer, S. J. (2014). Vital signs and physical assessment. In A. G. Perry, P. A. Potter, and W. R. Ostendorf (Eds), Clinical nursing skills & techniques (8th ed., pp. 67-72). St. Louis, MO: Mosby Elsevier.

General Survey, measurement, vital signs. (2012). In C. Jarvis (Ed.), Physical examination & health assessment (6th ed., pp. 132-133). St. Louis, MO: Elsevier Saunders.

More Resources

Making an Occupied Bed

If a patient is bedridden or on bedrest, the bed linens will need to be changed while the patient is in the bed. For safety reasons, the nurse’s aid should avoid making an occupied bed if the patient is able to get out of bed. Bed linens should be changed according to the facility’s policy or anytime they are wet or soiled.

Measuring the Apical Pulse

The apical pulse rate is the most accurate non-invasive measurement of heart rate because it is measured directly over the apex of the heart. Apical pulse is preferred in cases when the radial pulse is difficult to palpate, when the pulse is irregular, greater than 100 beats per minute, or less than 60 beats per minute when measured by other means (electronic, radial, etc.).

Dressing and Undressing a Patient

Patients who have suffered a stroke or have weakness or injury to one side of their body may struggle with dressing and undressing. In order to help these patients regain their strength and independence, it is important that the nurse’s aide only assist them as needed. The nurse’s aide may need to teach patients how to dress and undress safely with their limitations.

Measuring Blood Pressure

Many factors can interfere with obtaining an accurate blood pressure. The most common mistakes that lead to inaccurate blood pressures are a result of improper technique, including: not supporting the patient’s arm, using the wrong sized cuff, positioning the cuff too low on the patient’s arm, improper positioning of the cuff’s artery marker, and attempting to measure blood pressure through clothing.

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).

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