For older adults, temperature is one of the most recognized and frequently monitored physiologic responses to disease and illness. The first of the four traditional "vital signs," human body temperature represents a balance of heat loss and gain. Many older adults have multiple morbidities, chroniciries, and receive multiple medications. Therefore, physical changes combined with numerous predisposing drugs may contribute to temperature regulation disorders (Dharmarajan, Bullecer, & Gorich,2001).
Fever is the presenting sign for influenza-like illness. According to epidemiologists at the Centers for Disease Control and Prevention (2001), influenza-related pneumonia most often affects individuals younger than 5 and older than 64. "Influenza associated pneumonia ... can occur in over 20% of influenzainfected elderly," (p. 985). Older adults with contracted terrorist organisms and infectious diseases such as Anthrax, bubonic plague, tularemia, and small pox present with fevers. Consequently, all geriatric services, including acute, longterm, and home care; and emergency medical services, and hazardous materials units need reliable, valid, readily available body temperature assessment devices. Unfortunately, some electronic temperature devices may be unavailable, inadequate, and inappropriate for assessing older adults' temperature.
Non-electronic, metal-in-glass thermometers used and trusted by health care professionals for more than a century, may be more familiar, accessible, and affordable to older adults than electronic or digital devices. These low-tech thermometers present no power source competence concerns. With electronic devices, batteries run down, electrical power outages and blackouts occur, and devices needing on-going recharging may be left unattended. Metal-in-glass thermometers are portable, small, light, and easy to use. However, mercury-in-glass fever thermometers have become unavailable because of environmental and human safety concerns regarding mercury poisoning and contamination.
As an alternative to mercury-inglass devices, many pharmaceutical and retail corporations currently sell the slightly higher-priced Galinstanin-glass, mercury-free fever thermometers (oral/skin and rectal). Galinstan, a mixture of gallium, indium, and tin, has been identified as non-toxic to environment and humans, even if swallowed (Botzenhart, 1992). In fact, Galinstan-in-glass thermometers are considered more environmentally safe than many digital thermometers powered by batteries. Galinstan-inglass thermometers can be sterilized, and have easy-to-read simultaneous Fahrenheit and Celsius measures. However, Galinstan-in-glass thermometers need further study to identify clinical trustworthiness.
In addition to using accurate devices, caregivers for older adults also must be knowledgeable about device technique and appropriate temperature assessment sites.
One site established in children, but not in older adults is the groin temperature site - a safe, valid, and potentially acceptable alternative to oral or rectal temperature readings. This site could be implemented as a self-care strategy for older adults needing body temperature data. At the time of this study, no published research data were available regarding the use of this site in older adults, and no published research data were available on the clinical use of the Galinstan-inglass thermometer.
Left: BD mercuryin-glass; right: Geratherm Gal instan-in-glass.
The following literature review describes the importance of and the issues related to site and device selection for human body temperature measurement. Specific temperature site and device considerations for older adults are addressed.
Groin Temperature Assessments
The groin or inguinal temperature site, also called femoral site because of close proximity to the femoral artery, is a common location for temperature assessment in infants and neonates (Bliss-Holtz, 1989; Kunnel, O'Brien, Munro, & Medoff-Cooper, 1988; McKenzie & Associates, 2001). For groin temperature measurements, the thermometer is placed directly over the femoral artery and between inguinal skin folds, and heat conduction from the large femoral artery is maximized by this thermometer placement. Blood conducts heat from the body's inner core to the skin surface. This conduction is influenced by blood volume (Forth, 1994). In infants, groin temperature readings compare reliably to rectal and axillary sites (Bliss-Holtz, 1989; Kunnel et al., 1988). Although numerous authors (Erickson & Kirklin, 1993; Erickson & Meyer, 1994; Milewski, Ferguson, & Terndrup, 1991; Muma, Treloar, Wurmlinger, Peterson, & Vitae, 1991; Talo, Macknin, & Medendorp, 1991) have compared temperature sites and equipment, none have examined the validity and reliability of groin temperatures in older adults - hence, the justification for using the groin site in this study.
Rectal Temperature Assessments
The rectal temperature (Tr) site has long been considered the "gold standard" for temperature assessments. Greenes and Fleisher (2001) reported the rectal site "is an appropriate criterion standard for noninvasive clinical thermometry,"(p. 380). Rectal temperature readings have been identified as being a few tenths of a degree higher than core body temperature and, therefore, are considered by many to be the best temperature assessment site when pulmonary artery (PA) blood temperature assessment is impossible (Bliss-Holtz, 1989; Browne et al., 2000; Carlson, 1996; Cananeo et al., 2000; Eoff, Meier, & Miller, 1974; Fulbrook, 1993a, 1993b; McKenzie & Associates, 2001; Forth, 1994; Severine & McKenzie, 1997). Additionally, of the sites studied (rectal-axilla, rectal-PA blood, and PA blood-axilla), Fulbrook (1993b) found the PA blood-rectal temperature difference (R = .99) to demonstrate the highest correlation. Because of this, the rectal site was chosen for this study.
Although used for clients of all ages, rectal temperature readings may be imprecise, especially for older adults. According to Severine and McKenzie (1997), and Blainey (1974), inaccuracies of rectal temperature measurement related to common older adult variables, such as heavy lower extremity, rectal feces, improper temperature taking technique (i.e., depth and dwell time), and coliform bacterial action are possible. Rectal temperatures may create an additional inaccuracy for elderly adults because of decreased microcirculation of the rectum (e.g., decreased number of dermal blood vessels, vessels that are thinner and more fragile) (Resnick, 1997). As humans age, rectal mucosa may become more fragile and vulnerable to perforation. Patricio, Bernades, Nuno, Falcao and Silveira (1988) studied rectal circulation in 30 cadavers and reported that in individuals 50 and older, hypogastric artery blood supply was minimal, leaving circulatory blood supply to the superior rectal artery. That is, they found a generally poor rectal vascular network. Lierse (1989) concluded that as humans age, submucosal rectal circulation decreases; hence, the decision to study adults age 50 and older.
Another important consideration is that taking temperatures rectally may create client embarrassment. Additionally, older adults with limited mobility and flexibility will have a difficult time using the rectal site comfortably, safely, and correctly as a self-care routine.
Oral Temperature Assessments
Severine and McKenzie (1997) identified the oral site, the sub-lingual pocket on either side of the frenulum, as the most commonly used temperature measurement site. This non-invasive site is well accepted by older clients and caregivers. Because of this, the oral site was chosen for this study.
As with rectal and tympanic readings, oral temperature readings may be unreliable for older adults. Eating, drinking, smoking, tooth abscesses, gum chewing, or denture status may adversely affect oral temperature results (Severine & McKenzie, 1997). Readings may also be altered by thermometer misplacement, short dwell times, rapid nose breathing, mouth breathing, talking, and ambient temperatures (Zehner & Terndrup, 1991).
Ear-based Temperature Assessment Devices and Sites
Tympanic temperature readings were shown to vary from core temperatures, related to patient age (Muma et al., 1991), face fanning (Shiraki et al., 1988), ambient temperature (Cusson, Madonia, & Taekman, 1997; Zehner & Terndrup, 1991), and middle ear effusion or red-white or red tympanic membranes (Talo et al., 1991). For older adults, presence of ear cerumen (Hasel & Erickson, 1995) was a real concern. When tympanic membrane thermometers were compared with mercury glass thermometers in 102 patients, findings did not support replacement of the glass-mercury thermometer system (Ros, 1989). Modell, Katholi, Kumaramangalam, Hudson, and Graham (1998) cautioned health care professionals regarding inaccuracies and potential hazards of tympanic thermometers. Because research results (especially among older adults) have varied over use and accuracy of ear-based temperature readings, this site was not chosen for the study.
Non-electronic Metal-in-Glass Temperature Assessment Devices
The glass thermometer is traditionally and historically considered the most accurate temperature assessment device for humans (Hooker, Smith, Miles, & King, 1996). Metalin-glass thermometers are easy to use, portable, inexpensive, and widely accepted and available. Of the methods Prentice and Moreland (1999) studied (mercury-in-glass, infrared ear thermometer, electronic predictive thermometer), the mercury-in-glass thermometer was the most reliable for all patients and for each analysis. Currently, health care facilities and communities have stopped using mercury-in-glass thermometers because mercury is a potent neurotoxin and is considered a hazardous substance. Sale of mercury-filled fever thermometers has been banned or restricted in at least 13 states and many municipalities (Mercury ordinances, 2001). An alternative to mercury-in-glass devices is the slightly more expensive Galinstan- in-glass mercury-free fever thermometers (oral/skin and rectal). This pilot work was the first to assess and compare the two types of metal-in-glass devices in humans.
The purpose of this pilot study was two-fold. The first objective was to determine if a correlation existed among simultaneous within-participant readings of groin temperature (Tg), oral temperature (To), and rectal temperature (Tr) assessments in adults 50 and older. The second purpose was to ascertain if a within-participant correlation among Tg, To, and Tr temperature assessments existed between mercury-in-glass and Galinstan-in-glass thermometers.
Oral, groin, and rectal temperature assessment sites and two different metal-in-glass temperature devices - mercury and Galinstan - were used for this pilot investigation. A descriptive design determined within-participant mean differences and correlations between and among these sites and devices. Hospital and university Institutional Review Board approval was obtained. This pilot investigation took place in a rural community-based, 176 bed, Joint Commission on Accreditation of Healthcare Organizations accredited health care facility.
Study participants consisted of a convenience sample (N = 39) of willing, English-speaking, mentally competent, currently hospitalized men and women, 50 years or older. Informed consent procedures were completed prior to temperature assessments. Clients with contraindications for rectal temperature measurement (e.g., thrombosed hemorrhoids) and those without palpable femoral arterial pulses were excluded from the study. Oral temperature assessments occurred 15 minutes after oral food or fluid intake (Blainey, 1974), assessed by asking participants, "When did you last eat or drink anything?"
Three BD (Becton, Dickinson, & Company, Franklin Lakes, NJ) oral/skin and rectal mercury-inglass thermometers, and three Geratherm® (Geschwenda, Germany) oral/skin, and rectal Galinstan-in-glass thermometers with bulb ends were used for each participant. All thermometers were received as donations from their respective companies, and all thermometers were identical by type. Immersing the thermometers for 10 minutes in a swirling water bath and then checking readings against a National Bureau Standard thermometer checked accuracy of all thermometers. Thermometers with greater than a .2 °F variance were not used. This process was consistent with decisions made by previous researchers (Bliss-Holtz, 1989; Kunnel et al., 1988).
Environmental air temperature was recorded. An equal length of dwell time was used for each measurement to control time as a factor in comparisons among instruments and sites. Based on data from prior research, a 10-minute dwell time was used (BlissHoltz, 1989; Eoff, Meier, & Miller, 1974; Erickson & Meyer, 1994; Nichols & Kucha 1972; Nichols & Verhonick, 1968; Severine & McKenzie, 1997). AU temperature readings were reported in degrees Fahrenheit.
The researcher and a trained research assistant performed the temperature assessments. See the Sidebar for a timeline of temperature collection. The To, Tg (right and left readings), and Tr were taken using sheathed BD rectal or oral/skin mercury-in-glass thermometers and rectal or oral/skin Geratherm Galinstan-inglass thermometers. The To readings were simultaneous bilateral measures at the location of the sublingual artery (i.e., pocket of tissue at tongue base, above sublingual artery). Participants were instructed to keep lips closed. Thermometers measuring Tg were placed immediately after To thermometers were placed.
The Tg readings were collected simultaneously and bilaterally at the location of the femoral artery. The technique for groin temperature readings involved gentle abduction of the client's leg, location of the femoral pulse, placement of the sheathed thermometer on and lateral to the pulse site, and adducting the leg to create a seal.
Technique for Tr collection included using a water soluble lubrication and inserting two sheathed thermometers (one containing mercury and one containing Galinstan) together to a depth of 5 centimeters (Nichols & Glor, 1968; Severine & McKenzie, 1997). After insertion, the researcher's gloved thumb and forefinger held the top safety grip on the mercury thermometer and top .5 cm of the Galinstan thermometer.
All thermometers began at a reading below 96°F. Thermometer readings were documented prior to room departure. A flow sheet was used to record all data. The researcher and assistant simultaneously checked and agreed on all thermometer reading prior to documentation. A copy of these readings was given to each participant.
Description of Sample
All participants in this pilot study were hospital in-patients. Although N = 39, not all readings were possible for all participants, and some data categories had as few as 33 paired readings. One reason for this discrepancy was the calibration on the BD mercury-in-glass thermometer. These thermometers were calibrated down to 96°F. The Geratherm Galinstan-inglass thermometers were calibrated to 95.2°F. Thus, body temperature readings below 96°F on BD thermometers were recorded as missing data. Participant mean age was 71 and mean weight was 178 pounds. Of the 39 participants, 43.6% were men; 82.1% self-identified as White, and 12.8% indicated a Native-American racial heritage.
For both mercury and Galinstan thermometers, Tr was greater than To, and To was greater than Tg. That is, in each participant, rectal readings were highest, groin/femoral readings were lowest, and oral readings were lower than rectal but higher than groin. These results were as expected (Craig, Lancaster, Williamson, & Smyth, 2000; Cusson et al., 1997; Fullbrook, 1993b).
For the mercury device, mean within-participant readings were as follows:
* Oral readings: .62 °F greater than groin readings.
* Rectal readings: .84°F greater than oral readings.
* Rectal readings: 1.5°F greater than groin readings.
For the Galinstan device, withinparticipant mean readings were as follows:
* Oral readings: .46°F greater than groin readings.
* Rectal readings: 1.2°F greater than oral readings.
* Rectal readings: 1.7°F greater than groin readings.
For this sample, these two devices demonstrated some differences in readings by site. However, correlations for simultaneous sideby-side readings by device and site were statistically significant (Table 1). Table 1 represents Pearson r correlation statistics and relationships among sites and devices. The closer to 1.0 the correlation, the greater the presumed relationship. Note, however, that correlation does not mean identical readings - rather, strong correlations may simply be consistent differences.
Importantly, correlations for room temperature, participant weight, right and left random placement by thermometer type, and gender were not statistically significant with any of the recorded values or variables. Fulbrook (1993b) found no significant gender influence. These results differ from the Cusson et al. (1997) finding that environmental temperature influenced temperature readings at different sites for infants, and from Nichols and Kucha (1972) who noted different dwell times required by gender.
Within-participant mean differences (mercury versus Galinstan) by site were less than the identified 0.30F (Fallis & Christiani, 1999) and 0.20F accepted variability of devices (Bliss-Holtz, 1989; Kunnel et al., 1988; Nichols, Fielding, McKevitt, & Posner, 1969). Standard deviation scores assist with an understanding of variability among paired differences (Table 2). The Figure is a box plot representation of within-participant difference scores by site, and shows the variability between devices by site. Correlations remained strong among pairs; however, greater variability occurred among To and Tg readings. Although instruments used in the current pilot study were different, this greater variability of skin and oral sites was consistent with previous findings (Erickson & Kirklin, 1993; Erickson & Meyer, 1994).
All reported human body temperatures must be identified by site. This delineation is critical to appropriate understanding and comparison of actual core body temperature. These pilot data suggest important site differences, regardless of device used to take a temperature reading. Importantly, based on these initial data, the rectal site remains a valid temperature measurement site in older adults. The suspicion that older adults would have greater variability at rectal sites because of decreased rectal circulation was not demonstrated by the data. Also, based on these pilot data, the groin site could be an alternative to the rectal site, which is more difficult in self-care and less socially acceptable.
MEAN DIFFERENCES BY TEMPERATURE SITE
Figure. Box plot representation of within-subject difference scores by site and device. Note variability between devices is greatest at the groin site and lowest at the rectal site.
In addition to temperature assessment site, dwell times also must be reported. To assure consistent, valid temperature readings in this study, a 10-minute dwell time was used for each site. However, it is important to consider actual practice reality. Many health care providers would consider a 10-minute dwell time, especially for oral and rectal sites, excessive and burdensome. Notably, dwell times vary significantly by device and site, and it is important to follow written protocols from each device manufacturer. Skin sites, such as axillary and groin, often require longer dwell times than rectal and oral sites, depending on the device. Non-electronic devices almost always require longer dwell times.
Limitations and Further Research
Generalizability beyond these tools and participants cannot be assumed. Findings of this pilot study are limited to BD mercury-in-glass oral/skin and rectal thermometers and Geratherm Galinstan-in-glass oral/ skin and rectal thermometers. Participants, all 50 and older, consisted of a convenience sample of in-patients at one communitybased medical center. Because of the limited nature of pilot work, all results must be compared with nature, larger, more diverse samples.
Future studies should investigate:
* If differences in temperature readings exist.
* If differences in temperature readings are consistent.
* If correlations persist over time.
* If correlations are maintained with larger sample sizes and greater diversity related to age, race, geography, disease or disorder, and other key variables.
* If the results noted in the pilot study vary when different age groups, such as well elderly adults, frail "old-old" adults, and children are examined.
It is also important to determine whether the new Galinstan-in-glass thermometers are sensitive to body temperature changes over time. True core body temperature, such as would be measured from an indwelling PA catheter, was not used as a referent in this study. In the future, it will be important to examine groin, oral, and rectal temperature site readings with PA temperature data for comparison in populations older than 50.
As with most investigations, study findings lead to many additional questions. Further study must include a broader range of participant age, disease state, a larger sample, and comparisons of Galinstan and electronic temperature devices with core body temperature measures from the PA site. This is especially important when examining correlations among sites. For example, the correlation between oral mercury and groin Galinstan was .68. Though statistically significant, a larger, more diverse sample will be needed before generalized conclusions can be made.
IMPLICATIONS FOR NURSING
The Importance of Thermal Status
For older adults, many disease states are accompanied by body temperature changes. Thus, accurately measuring body temperature provides key information to the older adult's health status and treatment needs. Because body temperature is a balance between heat loss and gain, it changes based on activity level, time of day (e.g., body temperature is lower while sleeping), health status, and external temperatures.
Given these considerations, one major objective of temperature monitoring is the detection of temperature changes. For example, an elderly adult who normally awakes in the morning with a 97.2°F oral temperature reading who presents with a 99.0°F fever is demonstrating significant change and requires careful additional assessment. Though beyond the scope of this study, detection of these changes is critical. Research is needed to establish normal temperatures for healthy older adults. The "normal" thermoregulatory patterns for older adults also must include circadian differences. Health care professional need these data to appropriately interpret temperature assessments. Thus, continued diligence regarding thermal status of the clients for whom nurses care is important. It is also important for nurses to question temperature readings that contradict clinical signs and symptoms. That is, nurses always need to verify readings that "just don't seem right."
Accurate and Appropriate Devices
Diligence includes determining which devices are accurate and appropriate for elderly adults. For example, clinicians should question readings from ear-based thermometers - especially in the presence of cerumen buildup, cold ambient temperatures, compromised power sources, ear infections, and poor technique. Taking an oral temperature reading is unsafe when older patients are confused. Oral temperature readings should be questioned:
* When patients are edentulous.
* When reading are obtained in cold ambient temperatures.
* If patient has recently consumed food or fluids.
* If the patient is mouth breathing.
* If the patient is receiving inhalation therapy.
Rectal temperature readings should be questioned in the presence of stool, poor rectal circulation, rapid temperature shifts (Fulbrook, 1993a), obesity, and inactivity. Skin temperatures, such a groin and axilla, should be questioned when ambient temperatures are very warm or cold, skin surface circulation is impaired, below surface pulses are non-palpable, and skin or fatty layers are insufficient to form a seal around the imbedded thermometer.
Any time a power source is used with a temperature assessment device, a potential for power source compromise exists and those readings must be questioned. Batteries run down, electricity shuts off, and ambient temperatures can drastically change - these conditions can significantly affect device competence. One important way to eliminate battery or power source problems is to use metal-in-glass, low-tech temperature assessment devices. This pilot study was the first to examine the new and relatively inexpensive mercury-free Galinstan-in-glass thermometer and compare it with its mercury counterpart.
When working with low-tech body temperature instruments, such as those commonly found in homes, assisted living, and rural-based longterm care facilities, and when considering concerns such as power outages, battery and power source competence, technique, and toxicity, mercury-free, metal-in-glass temperature assessment devices should be given favorable consideration.
Fever as an Early Indicator of Infection
Individuals older than 50 are also more susceptible, and at risk for greater morbidity and mortality from other potentially life threatening infections, such as the West Nile mosquito-borne viral disease. Older adults infected with the West Nile virus first present with fever and head and body aches. These symptoms can rapidly progress to high fever, confusion, airway impairment, and secondary infections (Kenosha County Division of Health, 2002).
Since September 11, 2001, bioterrorism threats have been a major concern for all health care providers. In 1999, the Working Group on Civilian Biodefense, as if able to foresee the future, developed recommendations for a health care response to an intentional bioterrorist anthrax attack. The Group warned that postexposure early antibiotic therapy was essential. Unfortunately, microbiologie diagnosis may be difficult and rime consuming. Therefore, this Group recommended that anyone with fever or other disease evidence who was in a presumed anthrax environment should be immediately treated (Inglesby et al., 1999). During an anthrax epidemic in the former Soviet Union following an accidental release of anthrax spores, fever was the most frequent sign of infection (Meselson et al., 1994).
Meselson et al. (1994) reported older adults were more susceptible to mortality from anthrax infection than younger individuals. On November 16, 2001 a 94-year-old Oxford Connecticut woman was admitted to the local hospital with fever, fatigue, cough, and shortness of breath. While hospitalized, she remained febrile (maximum temperature of 101.5 ° F, 38.6° C) until her November 21 death from inhalation anthrax (Barakat et al., 2002). Thus, as the bioterrorism threat continues in the United States and abroad, the key physical indicator of body temperature becomes critically important.
To review the two study purposes, a high degree of correlation among simultaneous within-participant readings of study sites (i.e., groin, oral, rectal) and study devices (i.e., mercury-in-glass, Galinstan-in-glass) was demonstrated. Nurses understand that a correctly applied thermometer, used with the correct dwell time, is likely to yield accurate readings. Therefore, appropriate temperature assessment reporting and recording would always include the following:
* Device name and type.
* Assessment site.
* Dwell time.
* Patient response.
Moreover, body temperature, as one key indicator of morbidity, is currently and will continue to be a critical nursing assessment parameter. This is especially true during recent bioterrorism threats and the co-morbidity, immune compromised status of older adults for whom nurses care.
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MEAN DIFFERENCES BY TEMPERATURE SITE