Purpose

• Pulse oximetry measures the oxygen (O₂) concentration in arterial blood. Oxygen concentration is the amount (percent) of hemoglobin containing O₂. The normal range is 95% to 100%. For example, if 97% of all hemoglobin (100%) carries O₂, tissues get enough oxygen. If only 90% contains O₂, tissues do not get enough.
• A sensor attaches to a finger, toe, earlobe, nose, or forehead. A good sensor site is needed. Avoid swollen sites and sites with skin breaks. Sometimes blood flow to the fingers or toes is poor. Then the earlobe, nose, and forehead sites are used.
• Nail polish, fake nails, and movements affect measurements. Remove nail polish or use another site. Do not use a finger site if the person has fake nails. Blood pressure cuffs affect blood flow. If using a finger site, do not measure blood pressure on that side.
• Oxygen concentration is often measured with vital signs. Or it is monitored continuously. Alarms are set for continuous monitoring. An alarm sounds if the O₂ concentration is low. Report and record oxygen concentration according to agency policy. An agency may use one of these terms:
  • Pulse oximetry or pulse ox
  • O₂ saturation or O₂ sat
  • SpO₂ (saturation of peripheral oxygen)

Equipment

Roll cursor over items to see labels. For the purposes of clearly depicting the equipment, a barrier is not shown in this photo. When providing care, a barrier should always be placed on the surface before placing the equipment.

Oximeter and sensor

Tape

Towel

Delegation

• Follow delegation guidelines. Before using a pulse oximeter, obtain this information from the nurse and care plan:
  • What site to use
  • How to use the equipment
  • What sensor to use
  • What type of tape to use, if needed
  • The person’s normal range of SpO₂
  • Alarm limits for SpO₂ and pulse rate, if set
  • When to do the measurement
  • How often to check the sensor site—usually every 2 hours
  • What observations to report and record
  • When to report observations
  • What patient or resident concerns to report at once

Preparation

• Observe quality-of-life measures.
• Review the information under Delegation and Safety and Comfort.
• Practice hand hygiene.
• Collect the equipment.
• Arrange your work area.
• Identify the person. Check the ID bracelet against the assignment sheet. Also call the person by name.
• Provide for privacy.

Safety

• The person’s condition can change quickly. Pulse oximetry does not lessen the need for good observations. Observe for signs and symptoms of hypoxia and altered respiratory system function, such as abnormal breathing patterns. These patterns may include:
  • Tachypnea (rapid breathing)
  • Bradypnea (slow breathing)
  • Apnea (no breathing)
  • Cheyne-Stokes respirations (respirations that increase in rate and depth and then become shallow and slow)
  • Kussmaul respirations (deep, rapid respirations)

Comfort

• A clip-on sensor feels like a clothespin. It should not hurt or cause discomfort. Ask the person to tell you at once if it causes pain, discomfort, or too much pressure. Change the sensor site as directed by the nurse.

Follow-up Care

• Provide for comfort.
• Place the call light within reach.
• Unscreen the person.
• Complete a safety check of the room.
• Return the device to its proper place (unless monitoring is continuous).
• Practice hand hygiene.

Reporting/Recording

• Report and record your observations, including:
  • The date and time
  • The SpO₂ and display pulse rate
  • Apical or radial pulse rate
  • What the person was doing at the time
  • Oxygen flow rate and the device used
  • Reason for the measurement: routine, continuous monitoring, or condition change
• Report patient or resident concerns at once:
  • An SpO₂ below the alarm limit (usually 95%)
  • A pulse rate above or below the alarm limit
  • Presence of signs and symptoms of hypoxia, such as dizziness, agitation, increased pulse and respiratory rates, forward-leaning position, cyanosis (bluish skin, lips, mucous membranes, and nail beds), and dyspnea