Name: ___________________________________________________________________ Date: ______________

Evaluator/Signature: ________________________________________________________ Grade: _____________

APPLYING AND MONITORING PULSE OXIMETER

Purpose:

Equipment:

Assessment:

Nursing Diagnoses:

Outcome Identification and Planning:

Desired Outcomes
Special Considerations in Planning and Implementation
Pediatric

Geriatric

Transcultural
Keloids may be present on the earlobes of clients of African descent and may not allow accurate SaO 2 readings. These ropelike scars result from an
exaggerated wound-healing process after ear piercing.

Delegation
Pulse oximetry measurement can be performed by unlicensed assistive personnel.
 PERFORMED
ACTION RATIONALE REMARKS
YES NO
1. Perform hand washing and organize
equipment. -Prevent transfer of microorganisms
-conserve time and energy

2. Explain the procedure to client (if -Explanation relieves anxiety and facilitates cooperation
conscious).

3. Plug in oximeter and choose sensor. Sensor

types may vary according to the client's To ensure accurate and reliable readings
weight and site considerations. If using a
disposable sensor, connect sensor to cable.
4. Prepare site. Use alcohol swab to cleanse site
gently. Get rid of nail polish or acrylic nails, Skin oils, dirt or grime on the site can interfere with the passage of light
if needed, if a finger is being used as the waves
checking site.
5. Check capillary refill and pulse proximal to
the chosen site. -prolonged capillary indicates a reduction in blood flow

6. Assess the alignment of the light-emitting

diodes (LEDs) and the photodetector (light-
receiving sensor). These sensors should be Secure attachment and proper alignment promote satisfactory operation of
directly opposite each other (Fig. 6.25). the equipment and accurate recording of the Sp02

7. Turn on the pulse oximeter. DISPOSABLE

SENSORS NEED TO BE ATTACHED TO To ensure accurate and reliable readings
THE CLIENT CABLE BEFORE TURNING
THE PULSE OXIMETER ON.
8. Listen for a beep and note waveform or bar
of light on front of pulse oximeter.
Audible beep represents the arterial pulse, and fluctuating waveform or
light bar indicates the strength of pulse. A weak signal will produce an
inaccurate reading of the Sp02. Tone of Spo2 beeps reflects Sp02 reading.
If Sp02 drops, tone becomes lower in pitch

PERFORMED
ACTION RATIONALE REMARKS
YES NO
9. Listen for a beep and note waveform or bar
of light on front of pulse oximeter.

10. Check and monitor alarm limits. Reset if

necessary. Make sure that both high and low Alarm provides additional safeguard and signals when high or low limits
alarms are on before leaving the client's have been surpassed.
room. Alarm limits for both high and low
SaO2 and high and low pulse rate are preset
by the manufacturer but can be easily reset in
response to doctor's orders.
11. Tell the client that common position changes To ensure accurate and reliable readings
may trigger the alarm, such as bending the
elbow or gripping the side rails or other
objects.
12. Relocate finger sensor at least every 4 hours.
Shift spring tension sensor at least every 2 Prolonged pressure may lead to tissue necrosis.
hours.
13. Evaluate adhesive sensors at least every
shift. Adhesive sensors may cause skin irritation

Evaluation
Documentation

Learner’s Reflection: (What did you learn most of the activity? Instructor’s Comments:
What is its impact to you?)

References:
Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3 rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses’ Guide to Clinical Procedures. 5 th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW