Problem 2 - Clinical Nursing Skills and Techniques

Question

After checking the tympanic temperature two consecutive times in an 82 -year- old patient, the nurse finds the reading to be several degrees lower than expected. What is the most appropriate nursing action at this time? 1 Obtain a different thermometer 2 Observe for the presence of cerumen 3 Document the temperature assessed 4 Record the average between the two readings

Step-by-Step Solution

Answer

Option 2: Observe for the presence of cerumen.

Step 1: Understand the Problem

We need to determine the most appropriate nursing action after getting unexpected tympanic (ear) temperature readings that are low. Tympanic temperatures can be lowered by factors such as cerumen (earwax) in the ear canal.

Step 2: Evaluate the Options

We have four options: 1) obtaining a different thermometer, 2) observing for the presence of cerumen, 3) documenting the temperature assessed, and 4) recording the average between the two readings.

Step 3: Analyze the Relevance of Each Option

Option 1 involves using a different thermometer. This might help if there is a thermometer malfunction but does not address potential interference with ear temperature readings. Option 2 involves checking for cerumen, which is a common cause for lowered tympanic readings and should be addressed before taking further action. Option 3 involves simply documenting the readings without investigating the cause. Option 4 involves averaging readings, which does not resolve the inconsistency of lowered temperatures.

Step 4: Identify the Best Action

Considering that the presence of cerumen is a frequent reason for lower tympanic readings and can be fixed, evaluating for cerumen should be the priority. Once this is checked, we can decide on further actions if needed.

Step 5: Conclusion

The most appropriate action based on the analysis is Option 2: "Observe for the presence of cerumen". It is important to first verify that the low reading isn't due to a simple, correctable factor before using a different thermometer or documenting erroneous information.

Key Concepts

Tympanic Temperature Assessment

Checking the tympanic temperature is a common and non-invasive method to quickly assess a person's body temperature. This type of assessment takes the temperature in the ear canal, reflecting the body's core temperature. It's a preferred method for many because it's fast and usually comfortable. However, it's important to ensure the tip of the thermometer is properly aligned with the eardrum for accurate readings.

• Key Points: The positioning of the thermometer is crucial.
• Ensure the ear is pulled back and up in adults for a clear pathway to the eardrum.
• Ensure the thermometer is compatible with tympanic assessment.

Cerumen Interference

Cerumen, commonly known as earwax, can sometimes interfere with tympanic temperature assessments. It creates a barrier, potentially obstructing the clear passage needed for accurate readings. If a patient presents an unexpectedly low temperature, assessing for cerumen is crucial.

• Examine the ear canal for any visible blockage.
• If cerumen is present, consider removal to ensure an accurate reading.
• Cerumen can affect the accuracy of the readings significantly.

Checking and correcting for cerumen can mean the difference between diagnosing a fever accurately or missing it altogether.

Thermometer Accuracy

The accuracy of the thermometer being used is another factor to consider when diagnosing unusual temperature readings. Although technology generally ensures reliability, malfunction can occur, leading to incorrect readings. Different models might also vary slightly, which can contribute to inconsistencies in results.

• Ensure regular maintenance and calibration of the thermometers.
• Follow manufacturer's guidelines for proper use and care.
• Consider testing a different thermometer only after ruling out other causes of inaccuracy, such as cerumen.

While switching the thermometer might seem like an immediate solution, neglecting other sources of error could lead to continued incorrect assessments.

Geriatric Nursing Care

Nursing care for elderly patients often requires special considerations. The tympanic temperature assessment must be adapted to the physiological changes that occur with aging. With older adults, factors like ear shape changes, increased cerumen production, and even decreased thermal regulation can affect body temperature readings.

• Understand the normal temperature range that might be slightly different in elderly patients.
• Account for anatomical changes that might affect temperature measurement techniques.
• Ensure thorough observations and gentle handling to not disrupt or distress the patient.

Understanding these unique factors can improve care and accuracy in health assessments for the geriatric population.