Temperature Assessment for Student Nurses
Learn how to measure body temperature accurately, recognise important changes and understand how temperature contributes to the assessment of infection, illness and patient deterioration.
What does body temperature tell us?
Body temperature reflects the balance between heat production and heat loss. Changes may occur with infection, inflammation, environmental exposure, medication, neurological disturbance and other clinical conditions.
Adult temperature
This is a commonly used teaching range, although normal temperature varies between individuals and measurement sites.
Pyrexia / fever
A raised temperature may occur with infection or inflammation, but the clinical context and other observations remain essential.
Hypothermia
A core temperature below 35°C is commonly used to define hypothermia and requires appropriate clinical assessment.
How to measure temperature safely
Accurate technique is essential because different devices and measurement sites can produce different readings.
Assess the patient first
Look for shivering, sweating, flushing, altered behaviour, confusion or other signs that the patient may be unwell.
Select the correct device
Use equipment approved for the clinical area and follow the manufacturer's instructions and local procedure.
Use the correct site
Follow local guidance for oral, tympanic, axillary or other temperature measurement methods.
Use good infection prevention practice
Clean equipment and use disposable covers or probes where required by local policy.
Record accurately
Document the temperature promptly and include the measurement site where required by local documentation.
Interpret the result
Compare with previous readings, NEWS2 and the patient's symptoms and overall clinical presentation.
Unexpected reading?
If the temperature does not fit the patient's condition, consider whether technique, device position or equipment may have affected the result. Recheck where appropriate without delaying escalation when the patient appears unwell.
Raised and low temperatures
Both high and low temperatures can be clinically significant. The direction of change and the patient's other observations are often as important as the absolute value.
| Finding | What it may indicate | What else should you assess? |
|---|---|---|
| Raised temperature | May occur with infection, inflammation, environmental heat or other physiological causes. | Pulse, respiratory rate, blood pressure, oxygen saturation, symptoms, hydration and overall appearance. |
| Low temperature | May occur with environmental exposure, severe illness or other physiological disturbance. | Consciousness, circulation, blood pressure, pulse, respiratory rate and evidence of systemic deterioration. |
| Rising trend | A gradual rise may be clinically important even before a dramatic temperature is reached. | Compare with previous observations and review for developing signs of infection or deterioration. |
| Falling temperature in an unwell patient | A low or falling temperature can also occur in serious illness. | Do not assume absence of fever means absence of significant infection or deterioration. |
Sepsis does not always mean fever
A patient with serious infection may have a high temperature, a normal temperature or a low temperature. Always assess the whole patient and look for other signs of deterioration.
Changes that should get your attention
- A significant rise or fall compared with the patient's previous temperature.
- Fever combined with tachycardia or an increasing respiratory rate.
- Low temperature in a patient who appears acutely unwell.
- New confusion, drowsiness or reduced responsiveness.
- Rigors, marked shivering or sweating.
- Changes in blood pressure or signs of poor perfusion.
- New symptoms suggesting infection.
- Several NEWS2 parameters becoming abnormal at the same time.
Think trend, not snapshot
A temperature changing from 36.8°C to 37.4°C to 38.1°C over several observations tells a different story from one isolated reading. Always review previous observations where available.
Putting the observations together
Example
Earlier in the shift, your patient's temperature was 36.7°C. Several hours later it has risen to 38.3°C.
Their pulse is now faster, respiratory rate has increased and they appear flushed and more tired than before.
The key issue is not simply the temperature of 38.3°C. There is a developing pattern of physiological change.
As a student nurse, record the observations accurately, recognise the change and promptly communicate your findings to the appropriate registered practitioner.
Temperature assessment errors to avoid
- Assuming every raised temperature means infection. Consider the full clinical context.
- Assuming no fever means no infection. Serious illness can occur without a high temperature.
- Ignoring the measurement method. Different sites and devices can produce different readings.
- Recording without reviewing the trend. Compare with previous temperatures whenever possible.
- Looking at temperature alone. Review respiratory rate, pulse, blood pressure, oxygen saturation and consciousness.
- Delaying escalation while repeatedly checking the temperature. If the patient looks unwell, seek appropriate help.
Recognise → assess → communicate → escalate
Notice the change
Identify a rising or falling temperature, new symptoms or a change in the patient's general condition.
Build the picture
Confirm the temperature and review pulse, respiration, blood pressure, oxygenation, consciousness and symptoms.
Report clearly
Communicate abnormal findings, trends and clinical concern and follow local escalation procedures.
Further learning: Royal College of Physicians — National Early Warning Score (NEWS2) .
Level of Consciousness and AVPU for Student Nurses
Learn how to assess level of consciousness using AVPU, recognise new confusion or reduced responsiveness and understand why neurological change can be a critical sign of deterioration.
Continue to AVPU Assessment →