Pediatric Corner: Don’t get a sick child’s temperature wrong

Inaccurate readings can impact care

It’s a task you may perform several times in a single day, but if you don’t take a child’s temperature correctly, the results can be devastating.

If your reading isn’t accurate, it could lead to a delay in treatment or a missed diagnosis of sepsis or meningitis, warns Susan N. Richards, RN, lead transport/trauma nurse for the pediatric ED at Virginia Commonweath University Medical Center in Richmond.

"ED nurses may do an outstanding job overall, but many don’t care for sick neonates or pediatric patients in large numbers," she says. "You may inadvertently miss a subtle sign of elevated temperature."

For example, you may attribute a child’s elevated heart rate or respiratory rate to anxiety and fussiness, when in fact the temperature is well over the charted 97.4° axillary, says Richards. "It may not be discovered until after the septic child begins to decompensate as noted by a decreased level of consciousness, bradycardia, and hypotension," she adds. "All of these are ominous signs and difficult to correct once the child enters the state of septic shock."

To ensure an accurate temperature, use these tips:

• Use the appropriate method.

Tympanic thermometers aren’t the best method to use in the ED, according to Julie Kappes, RN, CPNP, pediatric nurse practitioner at Pediatrics of Batesburg-Leesville (SC). "They are wonderful and easy to use in the proper environment, but in the ED their accuracy is limited," she explains.

This is because a tympanic thermometer only is accurate if you wait 20 minutes after a child has been lying on one ear, the ears have been covered, the ear has been exposed to extremely high or low temperatures, or the child has swam or bathed, notes Kappes.

"Waiting for 20 minutes to take a temperature on an ill child is often not acceptable in the ED, so other methods would need to be used," she says.

For infants younger than 3 months, an accurate temperature is of the utmost importance because of the ramifications it has for the treatment plan, says Kappes. "For this age group, rectal temperatures are the only accurate method," she advises.

Use a small amount of water-soluble lubricant to facilitate entrance into the rectum, says Richards. "Use a soft tissue or wipe to remove excess lubricant afterward," she advises.

However, you must obtain an axillary or tympanic temperature if the child has rectal bleeding, rectal injury or assault, is immunocompromised, or has any other contraindications, advises Richards. "If you need to use the axillary route, have the caregiver support the arm closely to the body for several minutes and take the temperature as you normally would," she recommends. "Be sure to chart that this is an axillary temperature so the practitioner will be aware of the route chosen."

• Take other vital signs first.

The temperature should be the last vital sign you take, since this procedure usually causes the greatest amount of stress for children, says Richards. "If you do it first, it could increase the heart rate and respiratory rate due to the anxiety of the child," she explains.

The first vital sign taken should be the respiratory rate while the child is at rest, followed by the heart rate, temperature, and accurate weight in kilograms, says Richards.

• Reward the child.

"Immediately offer the child a brightly colored sticker, crayon, rubber-glove chicken, book, or anything that will make up for this perceived heinous act by the nurse," recommends Richards.

• Review ways to lower elevated temperatures.

Have parents or caregivers return demonstrations on the correct way to take a child’s temperature, says Richards. "Encourage them to use other means to keep the child normothermic, such as juices and liquids, loose-fitting clothes, and a tepid bath," she adds.

• Reassess the child’s heart rate and respiratory rate.

These vital signs can be indicators of elevation in body temperature, says Richards. "The child under stress due to an elevated temperature also will have elevated heart and respiratory rate," she explains.

• Make decisions based on both reported and observed information.

If you only go by the temperature you observe, you leave out possible diagnoses, says Kappes. "We need to take history of fever seriously, especially with children under the age of 3 months," she underscores.

If you don’t consider the reported temperature when making treatment decisions, you could be harming the child, warns Kappes. "I have seen nurses discount mothers who report a fever of 105° in their infant, because they did not have a fever when the ED nurse took the temperature," she says.

Full and accurate documentation protects the patient and the nurse, she explains. "It is very dangerous to write a reported temperature in your notes, while making triage and care decisions based only on the actual temperature," adds Kappes. "If the nurse provided full and clear history of a reported fever but the physician discounts it, the nurse is covered if there are any untoward events."


For more information on temperature, contact:

  • Julie Kappes, RN, CPNP, Pediatric Nurse Practitioner, Pediatrics of Batesburg-Leesville, 120 W. Church St., Leesville, SC 29006. Telephone: (803) 532-2208. Fax: (803) 604-0207. E-mail:
  • Susan Richards, RN, Lead Transport/Trauma Nurse, Pediatric Emergency Department, Virginia Commonwealth University Medical Center, P.O. Box 980132, Richmond, VA 23298. Telephone: (804) 828-9111. Fax: (804) 828-0139. E-mail: