Measuring Temperature and Pulse Performance Checklist

Measuring Temperature, Pulse Respirations, Pulse Oximetry

Check care plan for direction and client needs. Perform hand hygiene. Assess the client’s status before undertaking the activity. Explain the procedure to the client. Provide for privacy.

Collect equipment:

• thermometer
• probe cover
• watch
• pulse oximeter and sensor
• tissue
• towel

Temperature:
For an oral temperature, ask the person not to eat, drink, smoke or chew gum for at least 20 minutes before.

• Position the person for an oral, axillary or tympanic temperature.
• Insert the probe or thermometer tip into disposable cover.

Oral Temperature

• Ask the client to open mouth and raise the tongue.
• Place the tip of the thermometer at the posterior of the tongue.
• Ask the client to lower the tongue and close their mouth.
• Instruct the client not to talk or bite down.
• Remove at 3 minutes or when alarm indicates it is completed. Remove and discard probe cover.
• Note temperature. Report and record temperature.

Tympanic Temperature:

• Ask the client to turn head so that the ear is in front of you.
• Pull up and back on the ear to straighten the ear canal (with children pull the ear down and forward).
• Gently insert the probe making sure the probe seals the ear canal.
• Press timer button and remove from ear when alarm sounds. Remove and dispose of probe cover.
• Note temperature. Report and record temperature.

Axillary Temperature:

• Assist the client to remove arm from the sleeve without exposing client.
• Dry the axilla with the towel.
• Place the tip of the thermometer in the center of the axilla, pointing upward.
• The tip of the probe is in contact with the client’s skin.
• Ask the client to place their arm over the chest to hold the thermometer in place or hold the thermometer in place if client cannot do it.
• Keep the thermometer in place until alarm sounds indicating it is completed.
• Remove thermometer. Remove and discard probe cover.
• Note temperature. Report and record temperature.
• Assist client to replace sleeve.

Record name and temperature on notepad noting the temperature site: A for axillary, T for tympanic, or O for oral.

Radial Pulse:

• Have the person sit or lie down.
• Locate the radial pulse using index and middle fingers.
• Note rate and rhythm.
• Count the pulse for 30 seconds. Multiply the number of beats by 2; or count the pulse for 1 minute if required by agency policy.
• Count the pulse for 1 minute if irregular.
• Record on notepad noting the strength of the pulse and if it was regular or irregular.

Respirations

• Continue to hold the client’s wrist after taking the radial pulse.
• Begin counting when the chest rises. Count each rise and fall of the chest as 1 respiration.</li.
• Count for 30 seconds noting rate, depth and regularity. Multiply number of breaths by 2.
• If respirations are abnormal or irregular, count for full minute.
• Record respiratory rate and other observations on notepad.

Pulse Oximetry

• Ensure client is not wearing nail polish.
• Check that sensor cable is connected to the oximeter and clip sensor to finger.
• Turn on the oximeter and ensure alarms are turned on.
• Compare client’s radial pulse to pulse on display, note any discrepancy and report to supervisor.
• Read the SpO2 and document according to policy.

Perform hand hygiene. Provide for safety and comfort. Tidy area.

Report and record observations, according to agency policy.