Safety

• To avoid burns, do not mix sensors from different manufacturers.
• Do not attach the probe to a finger, ear, or the bridge of the nose if the area is edematous or if skin integrity is impaired.
• Do not use sensors on the earlobe or on the bridge of the nose in infants and toddlers, because their skin is fragile.
• Do not attach the sensor to fingers that are hypothermic.
• Do not use disposable adhesive sensors if the patient has a latex allergy.
• Do not place a sensor on the same extremity as an electronic blood pressure cuff, because blood flow to the finger will be temporarily interrupted when the cuff inflates, causing an inaccurate reading that can trigger an alarm.
• Relocate the sensor at least every 4 hours, and more frequently if skin integrity is impaired or tissue perfusion compromised.

Equipment

(Roll cursor over items to see labels)

Oximeter

Oximeter Probe

Oximeter Probe

Alcohol Swab

Nail polish remover pad

Wristwatch with a second hand or digital display

Delegation

The skill of oxygen saturation measurement can be delegated to nursing assistive personnel (NAP). Be sure to inform NAP of the following:

• Specific factors related to the patient that can falsely lower the oxygen saturation reading
• Selection of an appropriate sensor site and probe
• The frequency of oxygen saturation measurements for a specific patient
• The importance of notifying you, the nurse, immediately of any peripheral oxygen saturation reading of 95% or lower
• The need to refrain from using pulse oximetry to assess heart rate, because the oximeter cannot detect an irregular pulse

Preparation

• Identify risk factors for altered oxygen saturation, such acute or chronic compromised respiration, a change in oxygen therapy, chest wall injury, or recovery from anesthesia.
• Assess for medications, treatments, and other factors that may influence the oxygen saturation reading, such as oxygen therapy; respiratory therapy, such as postural drainage and percussion; hemoglobin level; hypotension; temperature; presence of nail polish; and medications such as bronchodilators.
• Assess for signs and symptoms of altered oxygen saturation, such as altered respiratory rate, depth, or rhythm; adventitious breath sounds; cyanotic nails, lips, mucous membranes, or skin; restlessness; and difficulty breathing.
• Review the patient’s medical record for the health care provider’s order, or consult your agency’s procedure manual for the standard of care for measurement of peripheral oxygen saturation.
• Determine the previous baseline peripheral oxygen saturation from the patient’s record.
• Identify conditions that decrease arterial blood flow, such as peripheral vascular disease, hypothermia, pharmacological vasoconstrictors, hypotension, and peripheral edema.
• Identify factors that affect light transmission, such as outside light sources and patient motion.
• Identify factors that affect the amount of light reflected from hemoglobin molecules, such as carbon monoxide in the blood, jaundice, and intravascular dyes.
• Determine the most appropriate patient-specific site for sensor probe placement.
• Verify SpO₂ alarm limits for continuous monitoring are pre-set by the manufacturer at a low of 85% and a high of 100%.

Follow-up

• If this is the patient’s first oxygen saturation assessment, establish this as the baseline and compare it with the acceptable range for his or her age.
• Compare the peripheral oxygen saturation with the patient’s baseline and acceptable range whenever oxygen therapy begins or ends, before and during sleep, before and after secretion removal with suctioning, when the patient complains of shortness of breath or chest pain, and during activity.
• Report abnormal findings to the nurse in charge or to the health care provider.

Documentation

• Record the SpO₂ in the electronic medical record (EMR), on the vital sign flow sheet, or in your nurse’s notes.
• Indicate the type and amount of oxygen therapy used by the patient during assessment.
• Record any signs or symptoms of alteration in SpO₂.
• Report abnormal findings to the nurse in charge or to the health care provider.