Temperature management : rectal temperature (PCCU)

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Objectives

Temperature measurement is a commonly used assessment parameter when caring for acutely and critically ill children. In the critically ill child an abnormal temperature may reflect changes in their physiological status. Therefore, temperature measurement and temperature trends must be accurate and consistent, as decisions about therapeutic intervention may be based upon it. 

Pulmonary artery temperature measurement was considered to be the ‘gold standard’ for measuring core body temperature. However, in practice this is too invasive and not a practical method of thermometry. Instead, body temperature is usually measured from a site, or ‘shell’ sites that are thought to reflect the core temperature.  The site and measuring device chosen is based upon a number of factors including age, clinical condition, degree of accuracy required, safety and ease of use. It is responsibility of the nurse to determine the best method for monitoring patient temperature and to use the temperature monitoring device correctly. Whichever site/equipment chosen, the nurse must be aware of the benefits and limitations of each. 

This nursing procedural guideline is intended as a resource for nursing staff involved in caring for children in the Paediatric Critical Care Unit that require monitoring and measurement of body temperature. The guideline has been constructed after literature search and review of sourced textbooks, Medline and CINAHL, and external nurse expert peer review and opinion.

See also recommendations and further information at end of this guideline.

Scope

This nursing procedural guideline is intended to be followed by nurses involved in caring for the highly dependent or critically ill infant or child requiring body temperature monitoring within the Paediatric Critical Care Unit at the Royal Hospital for Children, Glasgow.

Audience

All nursing staff involved in the measuring and monitoring of temperature in the Paediatric Critical Care unit should be familiar with this nursing procedural guideline.

Equipment
  • Disposable indwelling latex free temperature probe (compatible with Paediatric Critical Care Phillips monitoring system) E.g. Henleys - REF4491H or GE Disposable probe 400 series (fig 1)



    Fig 1
  • Sachet of Optilube™ or similar water-based lubricant            
  • Disposable apron
  • Adhesive tape/dressing or Clinfix® – to secure probe in position
  • Disposable gloves

     

Procedure

PROCEDURE: 

RATIONALE

Provide age appropriate explanation to child (where applicable) and/or parents

To ensure the child (and parent) understand need for and consent to indwelling rectal probe use.

Before inserting probe wash hands thoroughly with appropriate antibacterial skin cleanser and don disposable apron and gloves

To minimise the risk of cross infection.

Check disposable temperature measurement probe packaging is sealed and does not appear ‘used’ or opened.

Check expiry date on probe packaging prior to use (fig 1).

To ensure that the probe is sterile, unused, not broken, suitable for use and to minimise the risk of cross infection.

Temperature probe may no longer be sterile if out of date.

The disposable single-patient use probe (lubricated) should be placed 2-3cm past the sphincter into the rectum (depending upon child or infant’s age or size).

 

Once in correct position the probe should be secured to the infant or child’s leg with non-irritant tape or Clinfix®. (fig 2)


Fig 2.

To ensure the probe is the best position to obtain a more accurate rectal temperature.

There may be an increased risk of rectal ulceration and perforation in infants if the probe is in too far.

Securing the probe will help ensure it does not slip further in or out of the rectum thus affecting the temperature measurement and trend.

The rectal temperature will be displayed continuously via the monitor and will automatically be recorded on the hour.

Each hour the nurse should check and validate (if accurate) the child’s temperature

The Clinical Information System will record whatever temperature is being monitored. It will not take account of other factors which may lead to an inaccurate recording. 

For example, if the probe has slipped out. It is vital that the nurse checks the temperature ‘recorded’ and adds comments or events where applicable.

Recommendations & precautions

The rectal site for temperature measurement has been routinely used in clinical practice for temperature assessment in infants and very young children where it has not been possible to use a pulmonary artery catheter. It can be a favourable estimate of core temperature when body temperature does not fluctuate greatly and is a commonly used site in scientific research.  Rectal thermometry (with a disposable indwelling probe) is widely used in paediatric and neonatal intensive care units despite its limitations, as it provides a continuous temperature reading or trend without being influenced greatly by changes in ambient temperature. The use of a disposable probe rather than mercury or digital thermometer also helps reduce the risk of cross infection. However, the nurse must be aware of the limitations of rectal thermometry if choosing this method of temperature monitoring. 

There are documented risks when using rectal thermometry and these include discomfort, rectal perforation in neonates (rarely) and dissemination of rectal pathogens. With this in mind the nurse should consider whether rectal thermometry is appropriate for specific critically ill infants/children. For example, those children who are immunocompromised, coagulopathic or have had rectal trauma/surgery.

Rectal temperature also varies depending upon the site in the rectum where the measurement is taken and the accuracy can be affected by the presence of faeces in the rectum. Rectal thermometry readings can be unreliable where there are extremes of temperature. In shock states where there is poor perfusion to the rectum or in the presence of fever, a ‘lag’ in rectal temperature reading compared to other temperature sites, including pulmonary artery, has been reported.

If the nurse finds any abnormal temperature measurements using a rectal temperature monitoring probe, then this must be redone as a check and also consider another method & site of thermometry.

References
  1. Bahorski, J Repasky, T Ranner, D Fields, A Jackson, M Moultry, L Pierce, K Sandell (2012) Temperature measurement in pediatrics: A comparison of the rectal method versus he temporal artery method. Journal of Pediatric Nursing, Vol. 27, pp. 243-247.

  2. Bernardo, LM  Henker, R O’Connor, J (1999) Temperature measurement in pediatric trauma patients: A comparison of thermometry and measurement routes. Journal of Emergency Nursing, Vol. 25 (4), pp 327-329

  3. Brennan, DF Falk, JL Rothrock, SG Kerr, RB (1995) Reliability of infrared tympanic thermometry in the detection of rectal fever in childrenAnnals of Emergency Medicine, Vol. 25 (1), pp 21-30. 

  4. Christensen, RD Pysher, TJ Christensen, SS (2007) Case report: perianal necrotizing fasciitis in a near-term neonate. Journal of Perinatology, Vol. 27, pp 390-391.

  5. Community Paediatrics Committee, Canadian Paediatric Society (2015) Position statement: Temperature measurement in paediatrics

  6. El-Radhi, AS Barry, W (2006) Thermometry in paediatric practice. Archives of Diseases in Childhood, Vol. 91, pp 351-356.

  7. Fallis, W Brunsdon-Clark, B Andries, A Gilbert, E (2005) A parents’ response prompts a search for current trends in taking the temperature of pediatric ED patients. Journal of Emergency Nursing, Vol. 31 (5), pp 462-464.

  8. Greenes, DS Fleisher, GR (2004) When body temperature changes, does rectal temperature lag? The Journal of Pediatrics, Vol. 144 (6), pp 824-826.

  9. Hebbar, K Fortenberry, JD Rogers, K Merritt, R Easley, K (2005) Comparison of temporal artery thermometer to standard temperature measurements in pediatric intensive care units. Pediatric Critical Care Medicine, Vol. 6 (5), pp 557-561.

  10. Hoffman, RJ Etwaru, K Dreisinger, N Khokhar, A Husk, G (2013) Comparison of temporal artyery thermometry and rectal thermometry in febrile pediatric Emergency Department patients. Pediatric Emergency Care, Vol. 29 (3), pp. 301304.

  11. Holzhauer, JK Reith, V Sawin, KJ Yen, K (2009) Evaluation of temporal artery thermometry in children 3-36 months old. Journal for Specialists in Pediatric Nursing, Vol. 14 94), pp. 239-244.

  12. Hutton, S Probst, E Kenyon, C Morse, D Friedman,B Arnold, K Helsley, L (2009) Accuracy of different temperature devices in the post partum population. Journal of Obstetrics, Gynecolgic and Neonatal Nursing, Vol. 38 91), pp.42-49.

  13. Kai, J (1993) Parents’ perceptions of taking babies’ rectal temperature. British Medical Journal, Vol. 307 (6905), pp 660-662.

  14. Lefrant, JY Muller, L Emmanuel Coussaye, J Benbabaali, M Lebris, C Zeitoun, N Mari, C Saissi, G Ripart, J Eledjam, JJ (2003) Temperature measurement in intensive care patients: comparison of urinary bladder, oesophageal, rectal, axillary and inguinal methods versus pulmonary artery core method. Intensive Care Medicine, Vol. 29, pp. 414-418.

  15. Loveys, AA Dutko-Fioravanti, I Eberly, SW Powell, KR (1999) Comparison of ear to rectal temperature measurements in infants and toddlers. Clinical Pediatrics, Vol. 38, pp 463-466.

  16. Luginbuehl, L Bissonnette, B (2008) Chapter 25 - Thermal regulation. In: A Practice of Anesthesia for Infants and Children. 4th Edition. Saunders Elsevier.

  17. Martin, S Kline, A (2004) Can there be a standard for temperature measurement in the pediatric intensive care unit? Advanced Practice in Acute Critical Care: Clinical Issues, Vol. 15 (2), pp 254-266.

  18. Maxton, FJC Justin, L Gillies, D (2004) Estimating core temperature in infants and children after cardiac surgery: a comparison of six methods. Journal of Advanced Nursing, Vol. 45 (2), pp 214-222.

  19. McCallum, L Higgins, D (2012) Measuring body temperature. Nursing Times, Vol. 108 (45), pp. 20-22.

  20. Mogensen, CB  Wittenhoff, L  Fruerhøj, G  Hansen, S (2018) Forehead or ear temperature measurement cannot replace rectal measurements, except for screening purposes. BioMedicalCentral Pediatrics, Vol. 18: 15.

  21. Moran, DS Mendal, L (2002) Core temperature measurement: Methods and current insights. Sports Medicine, Vol. 32 (14), pp 879-885.

  22. NHS Greater Glasgow Prevention and Control of Infection Manual (2011)  Decontamination of Equipment and the Environment; Standard Precautions. NHS Greater Glasgow Control of Infection Committee Policy. NHSGG.

  23. Nimah, MM Bshesh, K Callahan, JD Jacobs, BR (2006) Infrared tympanic thermometry in comparision with other temperature measurement techniques in febrile children. Pediatric Critical Care Medicine, Vol. 7 (1), pp 48-55.

  24. Robinson, JL Seal, RF Spady, DW Joffres, MR (1998) Comparison of esophageal, rectal, axillary, bladder, tympanic and pulmonary artery temperatures in children. The Journal of Pediatrics, Vol. 133 (4), pp 553-556.

  25. Schuh, S Komar, L Stephens, D Chu, L Read, S Allen, U (2004) Comparison of the temporal artery and rectal thermometry in children in the emergency department. Pediatric Emergency Care, Vol. 20 (11), pp736-741.

  26. Sessler DI (2008) Temperature monitoring and perioperative thermoregulation. Anesthesiology, Vol. 109 (2), pp 318-338.

  27. Siberry, GK Diener-West, M Schappell, E Karron, RA (2002) Comparison of temple temperatures with rectal temperatures in children under two years of age. Clinical Pediatrics, Vol. 41 (6), pp. 405-414. 

  28. Sund-Levander, M Grodzinsky, E (2009) Time for a change to assess and evaluate body temperature in clinical practice. International Journal of Nursing Practice, Vol. 15, pp. 241-249.

Editorial Information

Last reviewed: 31 December 2018

Next review: 31 December 2021

Author(s): Jeanette Grady

Approved By: PICU Guideline Group