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Pulse Oximetry Revisited: "But His O2 Sat was Normal!"

Article  in  Clinical Nurse Specialist · November 2006

DOI: 10.1097/00002800-200611000-00004 · Source: PubMed


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3 authors, including:

Karen Giuliano Hsing-Mei Chen

Northeastern University Kaohsiung Medical University


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legal and ethical

Angela P. Clark, PhD, RN, CNS, FAAN, FAHA

Column Editor

Pulse Oximetry Revisited

‘‘But His O2 Sat was Normal!’’

Several years ago, our journal published an article providing a marker for hospitalization for conditions such as pneu-
recommendations for pulse oximetry interpretation that were monia or acute heart failure.4,5
gleaned from a review of several malpractice cases, including Continuous monitoring of oxygen saturation (SpO2) has
depositions, and medical records. The purpose of this brief become a standard of care in the operating room, post-
article is to update the original recommendations with the inte-
anesthesia care, critical care, emergency departments, and
gration of other recent literature on the topic of pulse oximetry.
environments where conscious sedation is used.6 Pulse
oximeters are economical, do not require calibration, are
N urses are the interface between technology and
individual patients. We use an array of technology
for patient monitoring to provide nursing care in a variety
relatively easy to use, and provide a quick evaluation of the
patient’s oxygen saturation. As the acuity level of hospi-
talized patients has increased on the past 10 years, so too
of healthcare settings.1 According to the National Associ- has the need for oxygen saturation monitoring outside the
ation of Clinical Nurse Specialists Statement on Practice critical care areas. In a systematic review of data from
and Education,2 one of the core competencies for clinical 21,773 perioperative patients in randomized, controlled
nurse specialists is the selection, design, and use of trials of pulse oximetry versus no pulse oximetry, Pederson
technology, including products and devices, to improve et al7 reported that the incidence of hypoxemia was 1.5 to
patient outcomes. We serve as expert clinicians, teachers, 3 times less in the pulse oximetry groups. In the future,
and consultants to nurses in the use and interpretation of more applications of this technology may be seen. An in-
data obtained through trend assessment. novative use of pulse oximetry was recently reported that
One of the most common technological devices used in when placed on the big toe site (patients lying down, toes
hospitals and ambulatory care settings is the pulse oxim- elevated 12µ), pulse oximetry readings predicted lower
eter, a device that measures oxygen saturation (and also arterial extremity disease in people with diabetes and com-
pulse rate). It is used as an estimate of arterial oxygen sat- pared favorably to assessment of the ankle-brachial index.8
uration (SaO2). When oxygen saturation is obtained with a However, as with all technology, nurses must be familiar
pulse oximeter, it is abbreviated as SpO2, with the reference with how pulse oximeters work, what patient characteristics
range of 97% to 99% in a healthy individual breathing affect their accuracy, and how to troubleshoot potentially
room air.3 An SpO2 of 95% is considered clinically accept- erroneous readings. Although nurses’ knowledge on the use
able in a patient with a normal hemoglobin. An oxygen of pulse oximetry has improved in recent years, knowledge
saturation value of 90% is the lowest value that is accept- gaps continue to exist.9 These gaps, however, can be filled
able and is generally equated with an arterial blood oxygen with targeted educational initiatives. Attin and colleagues10
(PaO2) of 60 mm Hg.3 A saturation of 90% and below evaluated the extent of current knowledge about pulse
should be a red flag alert for cliniciansVit is considered as oximetry among nurses, physicians, and respiratory thera-
pists before and after providing an education program on
the subject. Significant improvements in scores were seen in
From The University of Texas at Austin, Austin, Tex (Dr Clark all 3 groups after the intervention.
and Ms Chen); and the Philips Medical Systems, Andover, Mass
Corresponding author: Angela P. Clark, PhD, RN, CNS, FAAN, FAHA,
The University of Texas at Austin School of Nursing, 1700 Red River,
Sensing an arterial pulse is necessary for pulse oximetry to
Austin, TX 78701 (e-mail: work. The pulsatile variation in light returning to the probe
detector at the tissue surface results from arterial blood
Clinical Nurse SpecialistA Copyright B 2006 by Lippincott Williams & flow during systole and provides a means of isolating
Wilkins, Inc. the contribution of arterial blood to the overall light


Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
absorption.11 When light is detected by the pulse oximetry
sensor, it is converted to a photoplethysmographic signal Table 1. Factors That May Affect Pulse
that quantifies the drop in light intensity at each arterial Oximetry Readings3,6,9,12,16,24
pulse beat.11
In the clinical measurement of SpO2, 2 light emitting di- Low perfusion states (eg, hypothermia, peripheral vascular
odes send out light with different wavelengthsVred and disease, hypovolemia, sepsis, and shock)
infraredVthat is passed through the tissues of the finger, toe, Anemia
earlobe, or nose. The bridge of the nose has been used in Peripheral skin temperature of the digit or areas of sensor
infants.12 Researchers have also suggested the esophagus as Finger thickness
an alternative site for people whose peripheral perfusion is Skin color
compromised, as in burned patients or those with serious Cardiac arrhythmias (causing poor signal quality)
injuries.13 Of these sites, the finger is the most commonly Nail polish (dark, brown, blue, black, and green)
used, and there are data to suggest a higher level of inaccu- External light sources (fluorescent and xenon)
racy associated with the other sites. The tissue, blood, and
Skin pigmentation (dark skin may affect-evidence inconsistent)
bone absorb much of the emitted light, but some passes all
Abnormal hemoglobin (eg, carboxyhemoglobin and
the way through and is measured by a light-sensitive pho-
todiode that is placed opposite to the light emitting diodes.
Movement of the patient causing artifact (including shivering)
The absorption of both red and infrared light by tissue,
bone, venous blood, and a small amount of the arterial Intravascular or intradermal dyes
blood is constant over time, and empirical, in vivo data are
used by all manufacturers to calibrate commercially avail- widely reported in the literature on conventional pulse
able pulse oximeters.9,13,14 Clinically, the more oxygenated oximetry. In fact, there is evidence that indicates that most
the blood is, the more red light is transmitted, with less of the low oxygen saturation alarms that occur with
infrared light passing through. The opposite is also trueV conventional pulse oximetry are false readings due to
when blood oxygen is low, less red light and more infrared motion artifact.18,19
light passes through.9 Because of the clinical challenges of patient motion and
low perfusion in the measurement of SpO2, manufacturers of
LIMITATIONS TO PULSE OXIMETRY pulse oximeters have created newer algorithms that are
specifically designed to detect and filter out motion artifact
All clinical monitoring devices have their limitations and it as well as provide accurate measurements during low
is essential to understand the limits of the technology in perfusion. These new technologies are referred to as ‘‘motion
order to make appropriate adjustments and to properly inter- tolerant’’ or ‘‘new generation’’ pulse oximeters.6 Hence, a
pret the data. Pulse oximeters may be affected by several basic part of the correct use of SpO2 devices is knowing
conditions including exposure to ambient fluorescent and whether you have a conventional (no motion tolerance) or
xenon light, low perfusion states, motion artifacts, elevated a new generation device because the performance of these
carboxyhemoglobin and methemoglobin levels, intravenous 2 types of devices is very different.
dyes, dark skin pigmentation, and nail polish.15,16 Acrylic
nails generally do not cause inaccurate readings,16 but the
color of the polish may do so.
The biggest limitations to SpO2 monitoring include the Not using or incorrectly interpreting pulse oximetry results
following: it is an indirect measure for arterial oxygen satu- continues to be the subject of medical malpractice cases. The
ration (SaO2), which physiologically reflects arterial oxygen following recommendations are provided that have been
tension (PaO2), and potential measurement problems during gleaned from the review of depositions and medical records
patient motion and low perfusion states (see Table 1). Re- where oxygenation status and pulse oximetry were key
gardless of the specific manufacturer, SpO2 measurement issues.
uses algorithms that are based on certain assumptions, mak- (1) Use pulse oximetry for patients at risk for respira-
ing this measurement an approximation of the arterial oxy- tory arrests.
gen saturation (SaO2). It is not an absolute value. Although A typical patient who can benefit from pulse oximetry is
the continuous and noninvasive properties of conventional often someone who is not in the intensive care unit, who has
pulse oximetry make it amenable to everyday clinical use, a patient-controlled analgesia pump, and who is receiving
anytime exact and directly measured oxygen saturation is morphine in the prescribed dose. Respiratory depression
required for definitive clinical assessment of the patient; it secondary to the sedation is frequently antecedent to a re-
is probably best to obtain that data by direct measurement spiratory arrest, and although patient outcomes vary, typi-
of the arterial oxygen levels using a co-oximeter.6,13,17 cally those cases that are part of litigation reflect death or
Of the major limitations of SpO2, probably the biggest disability as a result of the arrest. The nurse may well have
disadvantage, particularly of conventional pulse oximetry, checked and documented routine vital signs for the patient,
is the excessive motion artifact that occurs when a patient as well as level of consciousness, color, and breath sounds,
moves causing the SpO2 monitor to incorrectly interpret but not used or correctly interpreted pulse oximetry values.
patient movement as a pulse signal. The resulting increase However, it can be argued that the standard of care in
in false alarms and erroneous measurements can desensitize similar situations mandates use of oxygen saturation trend
clinicians to the alarms over time and increase the chance data. There is good evidence that desaturation is detected
of missing a significant true alarm, something that has been earlier by pulse oximetry than by clinical observation,12 even

VOLUME 20 | NUMBER 6 269

Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
by expert clinicians. (During a cardiopulmonary arrest,
however, pulse oximetry should never be used as a measure
of oxygenation because of low tissue perfusion.)
The following testimony is from a deposition of a nurse
expert who proposed that the lack of oxygen saturation
data may have influenced the outcome (death), thus setting
a higher standard than was in the hospital policy and
procedure manual:

Q (question by the attorney): Do you think pulse oximetry and

the use of pulse oximetry would have altered the outcome in
this case?
A (answer by the deponent, nurse expert): There’s a very good
possibility that it could have.
Several research studies have been conducted on post- Figure 1. Prediction of O2 volume given knowledge of PaO2, O2
operative patients using pulse oximetry as one of the vari- saturation, and hemoglobin
ables. Researchers compared continuous pulse oximetry
readings to daily intermittent arterial blood gases (ABG) in tice cases. A patient may be ‘‘fully saturated,’’ meaning all
20 patients with long bone fractures and found that the hemoglobin molecules have the requisite 4 oxygen molecules
ABG analysis never detected the severe desaturation periods attached, yet because of significant anemia, still lack an
that were seen with pulse oximetry.20 The lowest SaO2 was adequate oxygen supply to the tissues. The nurse can obtain
down to 60% with the longest episode lasting 1.47 hours. normal oximeter readings of oxygen saturation, yet the
Because hypoxemia is an important antecedent component patient is oxygen deprived and may suffer physiologic
in fat embolism syndrome, early detection of desaturation consequences. Postoperative patients should be carefully
was deemed essential. Another study of 1,219 postsurgical evaluated for this, even if postoperative hemoglobin values
patients showed that pulse oximetry was associated with are not known. Often in malpractice cases, nurses have re-
reduced postoperative admissions to the intensive care unit ported that in this cost-containment era, there were no post-
for pulmonary complications but not for overall decreased operative hemoglobin measures taken, which prevented
transfers to intensive care unit, particularly for cardiac them from recognizing the presence of severe anemia. Here,
reasons.21 the type of surgery, the estimated amount of blood loss, and
(2) Know the patient’s hemoglobin and use it in critical other known data should be used to predict possible post-
thinking about SaO2 values. operative anemia and justify the laboratory test. If a post-
Hemoglobin is the primary carrier of oxygen in the ar- operative patient’s data (as skin color, heart rate, and level
terial blood and is based on an affinity for oxygen molecules of consciousness) do not match the SpO2 readings, it may
that is a characteristic of hemoglobin, forming oxyhemoglo- well be due to postoperative anemia.
bin.22 Oxyhemoglobin accounts for 97% to 98% of the (3) Know the relationship of oxygen saturation and
oxygen that is transported to the issues for use in cellular arterial oxygen (PaO2).
metabolism. There is a small amount of dissolved oxygen as Because the oxyhemoglobin dissociation curve has a sig-
well, but that really plays a much more important role in the moid shape, oximetry is relatively insensitive in detecting the
diffusion of oxygen at the tissue level from the blood to the development of hypoxemia in patients with high baseline
tissue and is not an important consideration in the total levels of PaO2.15 An SaO2 reading of 90% correlates with a
blood oxygen content. The total oxygen content of arterial PaO2 reading of greater than or equal to 60 mm Hg.24 See
blood is much more dependent on the amount of hemoglo- Figure 2 for other expected correlations between oxygen sat-
bin present in the blood than it is on the oxygen saturation, uration and ABG readings. Treatment interventions should
with the normal value for oxygen content being approxi- be considered when the SaO2 is less than 90%, assuming
mately 20 mL 02/dL (or 20 vol %).23,24 that other variables that can affect the oxygen hemoglobin
Figure 1 shows 4 different parameters and 4 different dissociation curve are normal (as blood pH, PCO2, and
patient situations. One is PaO2Varterial blood oxygen, a body temperature).
value that is measured by arterial blood gas analysis; the (4) Know the basic filtering strategy of the pulse
second is oxygen saturation, which is measured by the oximeter you are using: cardiac-based or saturation-based.
oxygen saturation probe or the SpO2 probe; and the third is With a saturation-based strategy, the underlying assump-
hemoglobin. With those 3 factors in varying degrees, you tion is that all signal artifact created during motion is related
can calculate the fourth valueVthe blood oxygen volumes to the movement of venous blood and can therefore be
percent. Note that even when the SpO2 is consistent at 98%, correlated with both the red and infrared signals. Because
the total oxygen content can range from normal to danger- venous blood has a pattern of red and infrared light ab-
ously low. So while SpO2 is an extremely important value, it sorption that differs from the arterial signal, the red and in-
does not tell the whole story of oxygen, certainly oxygen frared ratios can be used to separate the venous signals from
delivery to the tissue. It is not unusual, especially in the the arterial signals. The SpO2 measurement is created by
setting of critical care, to have a patient with a normal SpO2 subtracting the venous signals from the total signals, using
who does not have a normal oxygen transport.24 only the arterial to calculate the SpO2 value. The disadvan-
The meaning of this is profoundly important in interpret- tage of this strategy is that when red or infrared signals be-
ing pulse oximetry readings and confounds many malprac- come influenced by sources other than moving arterial and


Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
etry may indicate the need for arterial blood gas analysis to
determine if the arterial hypoxemia is due to hypoventila-
tion, or mismatching of ventilation and pulmonary perfu-
sion. Then, appropriate treatment can be administered.26
(6) Consider the patient’s blood pressure in interpreta-
tion of pulse oximetry readings.
When the patient’s blood pressure is low, the oximeter
has difficulty differentiating the light wavelengths of arterial
blood. Pulse oximetry is considered reliable with a systolic
blood pressure of at least 80 mm Hg and higher.27 Typi-
cally, the manufacturers limits of bias are T2%. If the blood
pressure is low, the pulse oximetry readings will also be low,
leading to a bias up to a 45% lower reading, which is the
corresponding reading during normal perfusion.27 As the
most common site for SpO2 measurement, the digits are most
susceptible to decreases in perfusion during states of low
blood pressure. Most of the newer SpO2 devices have signal
quality indicators that can help the bedside nurse decide if the
signal is strong enough to obtain an accurate reading. In
Figure 2. Comparison of arterial oxygenation (PaO2) with arterial addition, at least one manufacturer has a forehead sensor
oxygen saturation (SaO2)24 that often works better than the digit sensors in states of low
blood pressure and low perfusion. However, as with any
venous blood, the artifact can result in uncorrelated red and measurement device, if there is any question about the ac-
infrared signals and an erroneous SpO2 value. Therefore, curacy of the measurement, such as serious vasoconstriction
this method has the potential to display falsely high satu- because of hypothermia, hypovolemia, sepsis, or shock,27
rations created by nonvenous artifact. However, saturation- pulse oximetry should not be used for patient assessment or
based filtering performs very well when the motion artifact treatment decisions.
is rhythmic and is of a consistent frequency.9 (7) Evaluate the amount of lighting used in the environ-
Cardiac-based filtering strategies are based on the as- ment of the pulse oximeter.
sumption that on average and over several seconds of time, Bright light sources within the patient’s immediate vicin-
signal noise coming from patient motion does not occur at ity can compete with the pulse oximetry sensor light source
the same frequency as the patient’s cardiac signals. The and affect the accuracy of the readings.22 Examples include
underlying assumption is that patient artifact is random and fluorescent light, surgical light, and sunlight.23 This can lead
chaotic in both amplitude and occurrence, an assumption to a higher reading than is actually present. To remedy the
that is supported by clinical data on patient motion. Thus, situation, the oximeter probe can be covered with a bed
patient motion artifact can be distinguished from the sheet, sheltering it from the light source. Several sources
patient’s cardiac rhythm because cardiac rhythm is assumed indicate that bilirubin lights do not cause altered readings,3
to be the only consistent signal source over a given window although some clinicians may still have concerns.
of time. To generate the SpO2 value, the random and chaotic (8) Always document use of pulse oximetry in the
signals are filtered out, and the measurement is based only patient’s medical record.
on those signals that the algorithm judges to be cardiac in It is important to always document the results of SpO2
origin.9,25 monitoring in the patient’s medical records, including either
(5) Realize the limitations of pulse oximetry oxygen continuous monitoring trends or periodic spot-checks.
saturation (SpO2) compared to oxygen saturations obtained Documentation should include the liter flow and method
with arterial blood gases (SaO2) and obtain periodic arterial or fraction of inspired oxygen (FIO2) if the patient is receiv-
blood gases. ing supplemental oxygen, the sensor site, oximeter alarm
Pulse oximetry uses light wavelengths to measure oxy- settings on, unexpected outcomes, clinical assessment at the
hemoglobin saturation23; however, it only uses 2 light wave- time of the saturation measurement if abnormal or a change,
lengths to measure the functional saturation of hemoglobin. and ABG measures if available.3 If the patient receives spot-
Most laboratories use an 8-wavelength light source so that check pulse oximetry readings, always chart the clinical
fractional hemoglobin saturation is reported.23 One example indication for the measure, the findings, and to whom it was
of this difference is found in dysfunctional hemoglobins, reported if abnormal.
which can be measured by PaO2 (as in ABGs) but not by Heralded as a major safety measure, pulse oximetry pro-
SpO2 (oximetry). Hemoglobin may combine with other vides useful data for patient assessment, yet thought must be
substances besides oxygen, as in the case seen in heavy given to accurately interpret it for a given patient. There is
smokers or people with chronic lung diseases who may have concern that we are becoming increasingly dependent on
high carboxyhemoglobin levels detectable with ABGs but oxygen saturation readings without full knowledge of criti-
not by pulse oximetry. Here, the SpO2 reading will be falsely cally important variables that affect the interpretation of
elevated, contributing to a sense of false security, but the those readings. The role of the clinical nurse specialist in
oxygen saturation obtained with ABGs will be low.22 mentoring other nurses to use critical thinking and in pro-
Pulse oximetry is primarily used to assess oxygenation viding education about pulse oximetry is extremely valu-
but not ventilation. Decreased SpO2 measured by pulse oxim- able. Sandelowski28 noted that a consequence of technology

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used to interpret the information machines. palliative care. Support Care Cancer. 2004;12(11):758Y761.
13. Kyriacou PA. Pulse oximetry in the oesophagus. Physiol
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