Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Nursing 20G - Vital Signs > 14) Measuring Oxygen Saturation > Flashcards

14) Measuring Oxygen Saturation Flashcards

1
Q

What is the delegation consideration for measuring oxygen saturation?

A
  • The task can be delegated to unregulated care providers (UCPs)
  • Nurse is responsible for assessing effect of oxygen saturation changes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What should the UCP be informed about when delegating this task?

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What equipment is needed for measuring oxygen saturation?

A
  • Oximeter
  • Oximeter probe appropriate for patient per manufacturer
  • Acetone or nail polish remover, if needed
  • Pen and vital sign flow sheet/documentation form
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How do you identify the patient for this procedure?

A
  • Use at least two person-specific identifiers (e.g. name and date of birth, name and medical record number)
  • Follow employer policy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How do you determine the need to measure oxygen saturation?

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What factors influence SpO2 measurement?

A
  • Oxygen therapy
  • Hemoglobin level
  • Temperature (hypothermia can cause vasoconstriction)
  • Medications like bronchodilators
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What should you review before measuring SpO2?

A
  • Check for pulse oximetry order in patient’s medical record
  • Consult agency policy/procedure for standard of care
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How do you determine the appropriate sensor probe site?

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are requirements for the sensor probe site?

A
  • Adequate circulation
  • Free of moisture (moisture prevents SpO2 detection)
  • If using digit, free of polish/artificial nails (interferes with accuracy)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What site do you use if tremors are present?

A
  • Use earlobe as site
  • Motion artifact is the most common cause of false readings
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What if the patient has obesity?

A
  • Clip-on probe may not fit
  • Obtain a single-use tape-on probe
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Why determine previous baseline SpO2?

A
  • Provides basis for comparison
  • Assists in assessing current status and evaluating interventions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Why explain the procedure to the patient?

A
  • Promotes patient cooperation
  • Increases adherence
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How should the patient be positioned?

A
  • Comfortably
  • If using finger, support lower arm
  • Enables probe positioning and decreases motion artifact
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Why use acetone to remove nail polish?

A
  • Nail polish interferes with accuracy
  • Opaque coatings decrease light transmission
  • Blue pigment can absorb light and falsely alter measurement
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Why instruct patient to breathe normally?

A
  • Prevents large fluctuations in respiratory rate/depth
  • Prevents possible errors in SpO2 reading
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

How do you attach the sensor probe?

A
  • 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
18
Q

What are critical decision points for probe placement?

A
  • 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
19
Q

What do you do once the sensor is in place?

A
  • 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
20
Q

Why correlate oximeter and radial pulse rates?

A
  • Pulse waveform/intensity enables valid pulse detection for SpO2
  • Double-checking heart rates ensures oximeter accuracy
21
Q

How long do you leave the probe in place?

A
  • 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
22
Q

How long does the SpO2 reading take?

A

10-30 seconds, depending on site selected

23
Q

What should be done if SpO2 monitoring is continuous?

A
  • 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
24
Q

Why must alarms be set at appropriate limits and volumes?

A

To avoid frightening patients and visitors

25
Q

Why can sensor probe cause skin irritation?

A
  • Spring tension of sensor probe
  • Sensitivity to disposable sensor probe adhesive
26
Q

Why should the patient be assisted to a comfortable position?

A
  • Restores patient’s comfort
  • Promotes sense of well-being
27
Q

Why is hand hygiene important?

A
  • Reduces transmission of microorganisms between patient and nurse
28
Q

Why should findings be discussed with the patient?

A
  • Promotes patient’s participation in care
  • Promotes understanding of health status
29
Q

What should be done if SpO2 measurements are intermittent/spot-checked?

A
  • Remove probe and turn oximeter off between measurements
  • Store probe appropriately
30
Q

Why should SpO2 readings be compared to baseline/acceptable values?

A
  • Comparison reveals presence of abnormality
31
Q

Why should SpO2 be correlated with SaO2 from arterial blood gas?

A
  • Documents reliability of noninvasive assessments
32
Q

Why should SpO2 be correlated with respiratory rate, depth and rhythm?

A
  • Measurements of ventilation, perfusion and diffusion are interrelated
33
Q

What should be done if SpO2 is less than 90%?

A
  • 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%
34
Q

What should be done if heart rate on oximeter is lower than patient’s pulse?

A
  • Reposition sensor probe to alternative site with increased blood flow
  • Assess for signs of altered cardiac output (decreased BP, cool skin, confusion)
35
Q

How should SpO2 readings be recorded and reported?

A
  • 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
36
Q

What are community care considerations for pulse oximetry?

A
  • Used to noninvasively monitor oxygen therapy/changes
  • Instruct caregivers to examine site before applying sensor
  • Instruct procedure if oxygen saturation is unacceptable
37
Q

What factors related to light transmission can interfere with SpO2 readings?

A
  • 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
38
Q

What factors that reduce arterial pulsations can interfere with SpO2 readings?

A
  • Peripheral vascular disease (atherosclerosis)
  • Hypothermia at assessment site
  • Pharmacological vasoconstrictors (epinephrine, dopamine)
  • Low cardiac output and hypotension
  • Peripheral edema
  • Tight probe recording venous pulsations
39
Q

What is the key consideration for oxygen therapy in palliative care?

A
  • 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
40
Q
A

Nursing 20G - Vital Signs (19 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions