Nursing Equipments:- Thermometer: glass; electronic and disposable protective sheath; disposable (chemical); tympanic.
- Lubricant (rectal, glass thermometer)
- Two pairs of nonsterile gloves
- Tissues
Nursing Action:
- Review medical record for baseline data and factors that influence vital signs
- Explain to the patient that vital signs will be assessed and encourage them to remain still and refrain from drinking, eating, or smoking
- Assess patient’s toileting needs and proceed as appropriate
- Obtain equipment as indicated
- Provide privacy
- Wash hands and don gloves
- Keep the patient in a sitting or lying position with the head of the bed is elevated 45 – 60 degrees to measure all vital signs except those designated otherwise
- Follow next nursing action for body temperature measurement with oral temperature (glass and electronic thermometer), rectal temperature, axillary temperature, disposable (chemical strip) thermometer, and tympanic temperature (infrared thermometer)
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