A registered nurse (RN), licensed practical nurse (LPN), unlicensed assistive personnel (UAP), or healthcare prescriber may take temperatures. When the temperature is taken by the UAP, any variance from baseline or deviance from previous measurement is reported to the licensed caregiver.
Temperature is measured to assess the baseline status of each child within the first hour of admission and to detect change in child’s status (e.g., hypothermia, presence of infection, or other changes in the child’s condition).
Reassess temperature 30 minutes to 1 hour after an intervention to measure response to treatment regime.
Measure temperature with assessments and every 1 to 2 hours or more frequently when the child is unstable, is acutely ill, or has problems with thermoregulation.
When using a temperature-regulating device (e.g., isolette, hypothermia blanket, overhead radiant warmer, forced air warmer), assess the child’s temperature every 1 to 3 hours.
Do not use mercury-containing thermometers.
The oral route is contraindicated if the child has developmental delay, oral surgery, seizures, altered level of consciousness, or will not cooperate (e.g., children younger than 5 years).
Use the axillary route in the immediate postdelivery infant; use the rectal route only when the axillary is out of range.
The rectal route is contraindicated if the child has neutropenia, thrombocytopenia, or a bleeding disorder; is preterm birth; or has had rectal or bowel surgery.
Tympanic (infrared) measurement is not recommended for use in children younger than 3 months. Studies demonstrate that children and parents prefer tympanic thermometers over electronic and chemical dot thermometers.
Temporal artery measurements can be used for children older than 3 months.
Disposable thermometers (e.g., Tempa•DOT™) are accurate for children younger than 5 years.
Studies demonstrate conflicting findings regarding the accuracy and reliability of different measurement methods. Users must be knowledgeable as to how to accurately employ the method and operate the device being used. Use the same method and route of measurement whenever possible.
Thermometer: electronic, tympanic, temporal artery, or disposable
Disposable probe cover: necessary for electronic or tympanic thermometer
Nonsterile gloves
Water-soluble jelly
Tissues or dry cloth
Explain to child and family, in developmentally appropriate language (e.g., “I’m going to see how warm your body is.”), the reason for measuring temperature, equipment being used, and how temperature will be assessed.
Show child and family the equipment you will use.
Demonstrate on family member (or self) how the equipment is used.
PROCEDUREPreprocedural Care
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PROCEDUREMeasuring Oral Temperature in a Child Older Than 5 Years Using an Electronic Thermometer
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KidKare Letting the child hold the thermometer helps promote cooperation and involvement in self-care; remind the child to keep lips closed. Sealing lips ensures an accurate reading not altered by ambient (room) air temperature.
Dispose of the probe cover in a location where a young child may not retrieve from the trash, as probe covers present a choking hazard.
PROCEDUREMeasuring Tympanic Temperature in a Child Older Than 3 Months
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Do not leave discarded probe cover in crib or bed; dispose of probe cover in a location where child cannot retrieve from trash, as the small covers present a choking hazard.
PROCEDUREMeasuring Rectal Temperature Using an Electronic Thermometer
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If unable to insert thermometer, STOP. In an infant, this may indicate imperforate anus.
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