Assessing Oxygen Saturation

This skill is related to: Vital Signs

Specifications

This procedure is based on the use of pulse oximeters with a separate sensor and a machine. It is common to rely entirely on pocket pulse oximeters that can provide a reading directly. A study (2016) compared pocket vs standard pulse oximeters and found a minimal mean difference (0.01%).

Assessing respirations is done to:

• Estimate the arterial blood oxygen saturation
• Detect the presence of hypoxemia before visible signs develop

Phase	Nursing Activities
Assessment	Assess the best location for a pulse oximeter based on the client’s age and physical condition. The finger is usually used for adults. Overall condition including risk actors for developing hypoxemia and hemoglobin level should be considered. Signs of perfusion— vital signs, skin color and temperature, nail bed color, and tissue perfusion of extremities are used a baseline data. For adhesive-type pulse oximeters, determine whether or not the client may have an allergy to the type of adhesive used.
Planning	Assign: pulse oximetry may be assigned to APs. The nurse interprets the oxygen saturation value and determines appropriate interventions. Equipment: nail polish remover if needed, pulse oximeter.
Implementation	Check that the oximeter equipment is functioning normally. Prior to performing the procedure, the nurse must introduce themselves and verify the client’s identity using agency protocol. Explanation of the nurse’s purpose, the procedure, and how the patient will participate. Perform hand hygiene and observe appropriate infection prevention procedures. Provide client privacy. Choose a sensor appropriate for the client’s size and desired location. If the client is allergic to adhesive, use a clip or sensor without adhesive. For oximeters using extremities, ensure that perfusion is adequate. Prepare the site. It must be clean and dark nail polish must be removed to avoid inaccuracies. Apply the sensor, and connect it to the pulse oximeter. These may beep, indicating the detecting of arterial pulsations. Set and turn on the alarm when using continuous monitoring. Presets for high and low oxygen saturation and high and low pulse rates may be set according to agency policy. Audio and visual alarms are double-checked as enabled before leaving the client. Ensure client safety. Adhesive sensors are inspected (for irritation) and switched sites every 4 hours, and sprint-tension (clip) sensors are inspected and switched sites every 2 hours. Minimize sources of error: Minimize motion artifacts; use adhesive-type sensors, change sensor site, or immobilize the client if absolutely necessary. Cover the sensor with a sheet or towel to block large amounts of light from external sources, which may interfere with readings. Comparisons of the reported pulse rate and radial pulse should be done periodically. Document the oxygen saturation on the appropriate record at designated intervals.
Evaluation	Compare the oxygen saturation to the client’s previous oxygen saturation level. Relate to pulse rate and other vital signs. Conduct appropriate follow-up such as notifying the primary care provider, adjusting oxygen therapy, or providing breathing treatments.