Obtaining Pulse Oximetry

Nursing Procedure 6.15

Obtaining Pulse Oximetry

Provides a noninvasive method for monitoring the oxygen saturation of arterial blood

Pulse oximeter
Sensor (permanent or disposable)
Alcohol wipe(s)
Nail polish remover, if indicated
Pen

Assessment should focus on the following:

Signs and symptoms of hypoxemia (restlessness; confusion; dusky skin, nail beds, or mucous membranes)
Quality of pulse and capillary refill proximal to potential sensor application site
Respiratory rate and character
Previous pulse oximetry readings
Amount and type of oxygen administration, if applicable
Arterial blood gases, if available

Nursing diagnoses may include the following:

Impaired gas exchange related to excessive secretions
Ineffective tissue perfusion related to hypoxemia

Outcome Identification and Planning

Desired Outcomes

Sample desired outcomes include the following:

Client's arterial oxygen saturation (SaO₂) remains between 95% and 100%.
Client exhibits signs of adequate gas exchange evidenced by respirations 18 to 20 breaths/min, nail beds pink, capillary refill less than 3 s.
Client demonstrates knowledge of factors affecting pulse oximeter readings.

Special Considerations in Planning and Implementation

Pediatric

For children, choose an appropriate-sized sensor.

Geriatric

Be sensitive to probe placement in elderly clients: Avoid tension on the probe site, and be careful when applying tape to dry, thin skin.

Home Health

Pulse oximetry monitoring has mostly replaced home arterial blood gas measurement.

Transcultural

Keloids may be present on the earlobes of clients of African descent and may not allow accurate SaO₂ readings. These ropelike scars result from an exaggerated wound-healing process after ear piercing.

Delegation

Pulse oximetry measurement can be performed by unlicensed assistive personnel.

[Outline]

Desired Outcomes
Special Considerations in Planning and Implementation

Action		Rationale
1	Perform hand hygiene and organize equipment.	Reduces microorganism transfer; promotes efficiency
2	Explain procedure to client (if conscious).	Reduces anxiety; promotes cooperation
3	Plug in oximeter and choose sensor. Sensor types may vary according to the client’s weight and site considerations. If using a disposable sensor, attach sensor to cable.	Enhances accuracy of results
4	Prepare site. Use alcohol wipe to cleanse site gently. Remove nail polish or acrylic nails, if needed, if a finger is being used as the monitoring site.	Ensures site is clean and dry; nail polish and acrylic nails can interfere with pulse oximetry readings
5	Check capillary refill and pulse proximal to the chosen site.	Reduces risk of inaccurate readings due to compromised peripheral circulation caused by a probe that is applied too tightly or by poor circulation due to medications or other conditions
6	Assess the alignment of the light-emitting diodes (LEDs) and the photo detector (light-receiving sensor). These sensors should be directly opposite each other (Fig. 6.25).	Ensures proper alignment of sensors to yield an accurate SaO₂ reading
7	Turn the pulse oximeter to the ON position. DISPOSABLE SENSORS NEED TO BE ATTACHED TO THE CLIENT CABLE BEFORE TURNING THE PULSE OXIMETER ON.	Allows LEDs to transmit red and infrared light through the tissue so that the receiving sensor (photodetector) will measure the amount of oxygenated hemoglobin (which absorbs more infrared light) and deoxygenated hemoglobin (which absorbs more red light); the pulse oximeter will compute the SaO₂ using these data
8	Listen for a beep and note waveform or bar of light on front of pulse oximeter.	Indicates that the pulse oximeter has detected a pulse (beep) and displays the strength of the pulse (light or waveform changes); a weak pulse may not yield an accurate SaO₂ reading.
9	Check alarm limits. Reset if necessary. Make sure that both high and low alarms are on before leaving the client’s room. Alarm limits for both high and low SaO₂ and high and low pulse rates are preset by the manufacturer but can be easily reset in response to doctor’s orders.	Identifies the need for possible intervention
10	Tell the client that common position changes may trigger the alarm, such as bending the elbow or gripping the side rails or other objects.	Promotes participation in care, thus decreasing anxiety
11	Relocate finger sensor at least every 4 hr. Relocate spring tension sensor at least every 2 hr.	Prevents tissue necrosis
12	Check adhesive sensors at least every shift.	Reduces risk of irritation from adhesive

Were desired outcomes achieved? Examples of evaluation include

Desired outcome met: Pulse oximeter reading 97%.
Desired outcome met: Client alert and oriented × 3.
Desired outcome met: Respirations are even and nonlabored with rate of 12 breaths/min.

The following should be noted on the client's record:

Type and location of sensor
Presence of pulse proximal to sensor and status of capillary refill
Percentage of oxygen saturation in arterial blood (SaO₂)
Rotation of sensor according to guidelines and status of site
Percentage of oxygen (or room air) client is receiving
Interventions as a result of deviations from the norm

section name header

Purpose ⬇

Equipment ⬆ ⬇

Assessment ⬆ ⬇

Nursing Diagnoses ⬆ ⬇

Outcome Id ⬆ ⬇

Implementation ⬆ ⬇

Evaluation ⬆ ⬇

Documentation ⬆