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
Why can sensor probe cause skin irritation?
- Spring tension of sensor probe
- Sensitivity to disposable sensor probe adhesive
Why should the patient be assisted to a comfortable position?
- Restores patient’s comfort
- Promotes sense of well-being
Why is hand hygiene important?
- Reduces transmission of microorganisms between patient and nurse
Why should findings be discussed with the patient?
- Promotes patient’s participation in care
- Promotes understanding of health status
What should be done if SpO2 measurements are intermittent/spot-checked?
- Remove probe and turn oximeter off between measurements
- Store probe appropriately
Why should SpO2 readings be compared to baseline/acceptable values?
- Comparison reveals presence of abnormality
Why should SpO2 be correlated with SaO2 from arterial blood gas?
- Documents reliability of noninvasive assessments
Why should SpO2 be correlated with respiratory rate, depth and rhythm?
- Measurements of ventilation, perfusion and diffusion are interrelated
What should be done if SpO2 is less than 90%?
- Verify oximeter probe is intact and no outside light interference
- Observe for signs of decreased oxygenation (anxiety, restlessness, tachycardia, cyanosis)
- Verify supplemental oxygen delivery system is functioning properly
- Minimize factors altering SpO2 (lung secretions, increased activity, hyperthermia)
- Position patient for optimal ventilation (e.g. high Fowler’s for obesity)
- Recheck SpO2 after interventions and notify physician if still <90%
What should be done if heart rate on oximeter is lower than patient’s pulse?
- Reposition sensor probe to alternative site with increased blood flow
- Assess for signs of altered cardiac output (decreased BP, cool skin, confusion)
How should SpO2 readings be recorded and reported?
- Record SpO2 value, oxygen therapy used, and any desaturation signs/symptoms
- Report abnormal findings to nurse in charge or provider
- Document SpO2 after specific therapies
- Record use of continuous or intermittent pulse oximetry
What are community care considerations for pulse oximetry?
- Used to noninvasively monitor oxygen therapy/changes
- Instruct caregivers to examine site before applying sensor
- Instruct procedure if oxygen saturation is unacceptable
What factors related to light transmission can interfere with SpO2 readings?
- Outside light sources
- Carbon monoxide (smoke inhalation/poisoning)
- Patient motion
- Jaundice
- Intravascular dyes (e.g. methylene blue)
- Nail polish, artificial nails, metal nail studs
- Dark skin pigment
What factors that reduce arterial pulsations can interfere with SpO2 readings?
- Peripheral vascular disease (atherosclerosis)
- Hypothermia at assessment site
- Pharmacological vasoconstrictors (epinephrine, dopamine)
- Low cardiac output and hypotension
- Peripheral edema
- Tight probe recording venous pulsations
What is the key consideration for oxygen therapy in palliative care?
- Patient comfort is the priority, not oxygen saturation levels
- Assess if the patient appears uncomfortable or in respiratory distress
- Oxygen therapy may be unnecessary if the patient is peaceful and resting
