14) Measuring Oxygen Saturation Flashcards
What is the delegation consideration for measuring oxygen saturation?
- The task can be delegated to unregulated care providers (UCPs)
- Nurse is responsible for assessing effect of oxygen saturation changes
What should the UCP be informed about when delegating this task?
- Notify nurse immediately if SpO2 < 90%
- How to select appropriate sensor site and probe
- Frequency of measurements for the patient
- Factors that can falsely lower SpO2
What equipment is needed for measuring oxygen saturation?
- Oximeter
- Oximeter probe appropriate for patient per manufacturer
- Acetone or nail polish remover, if needed
- Pen and vital sign flow sheet/documentation form
How do you identify the patient for this procedure?
- Use at least two person-specific identifiers (e.g. name and date of birth, name and medical record number)
- Follow employer policy
How do you determine the need to measure oxygen saturation?
- Use clinical judgment for assessment
- Note risk factors like respiratory issues, recent anesthesia/sedation, chest trauma, ventilator use, activity intolerance, oxygen therapy changes
- Assess for abnormal respiratory rate, depth, rhythm, adventitious sounds, cyanosis, restlessness, confusion, labored breathing
What factors influence SpO2 measurement?
- Oxygen therapy
- Hemoglobin level
- Temperature (hypothermia can cause vasoconstriction)
- Medications like bronchodilators
What should you review before measuring SpO2?
- Check for pulse oximetry order in patient’s medical record
- Consult agency policy/procedure for standard of care
How do you determine the appropriate sensor probe site?
- Assess capillary refill (choose another site if <3 seconds)
- Check skin condition
- Requires pulsating vascular bed to detect hemoglobin
- SpO2 changes reflected in 30 seconds for finger, 5-10 seconds for earlobe
What are requirements for the sensor probe site?
- Adequate circulation
- Free of moisture (moisture prevents SpO2 detection)
- If using digit, free of polish/artificial nails (interferes with accuracy)
What site do you use if tremors are present?
- Use earlobe as site
- Motion artifact is the most common cause of false readings
What if the patient has obesity?
- Clip-on probe may not fit
- Obtain a single-use tape-on probe
Why determine previous baseline SpO2?
- Provides basis for comparison
- Assists in assessing current status and evaluating interventions
Why explain the procedure to the patient?
- Promotes patient cooperation
- Increases adherence
How should the patient be positioned?
- Comfortably
- If using finger, support lower arm
- Enables probe positioning and decreases motion artifact
Why use acetone to remove nail polish?
- Nail polish interferes with accuracy
- Opaque coatings decrease light transmission
- Blue pigment can absorb light and falsely alter measurement
Why instruct patient to breathe normally?
- Prevents large fluctuations in respiratory rate/depth
- Prevents possible errors in SpO2 reading
How do you attach the sensor probe?
- Attach sensor probe to monitoring site
- Inform patient clip-on probe feels like clothespin on finger but won’t hurt
- Prepare patient for pressure of probe’s spring tension on digit or earlobe
What are critical decision points for probe placement?
- Do not use if area is edematous or skin integrity compromised
- Do not use on hypothermic fingers
- Use ear or nose bridge if patient has peripheral vascular disease
- Do not use on earlobe/nose bridge for infants/toddlers due to skin fragility
- Do not use disposable adhesive probes if latex allergy
- Do not use same extremity as blood pressure cuff
What do you do once the sensor is in place?
- Turn on oximeter
- Observe pulse waveform, intensity display, listen for audible beep
- Correlate oximeter heart rate with patient’s radial pulse
- Re-evaluate probe placement if rates differ
Why correlate oximeter and radial pulse rates?
- Pulse waveform/intensity enables valid pulse detection for SpO2
- Double-checking heart rates ensures oximeter accuracy
How long do you leave the probe in place?
- Until oximeter readout is constant
- Until pulse display reaches full strength each cycle
- Inform patient alarm will sound if probe falls off/moves
- Read SpO2 on digital display
How long does the SpO2 reading take?
10-30 seconds, depending on site selected
What should be done if SpO2 monitoring is continuous?
- Verify SpO2 alarm limits and volume (preset at 85-100%)
- Determine appropriate SpO2 and heart rate alarm limits based on patient condition
- Verify alarms are functional
- Assess skin integrity under sensor probe every 2 hours
- Relocate sensor probe at least every 4 hours or more frequently if skin integrity is compromised
Why must alarms be set at appropriate limits and volumes?
To avoid frightening patients and visitors