102 CHAPTER 5 VITAL SIGNS
PROCEDURAL GUIDELINE 5.2 Measuring Oxygen Saturation (Pulse Oximetry)
NSO Nursing Skills Online Airway Management Module / Lesson 6
Pulse oximetry is the noninvasive measurement of arterial blood
oxygen saturation, the percent to which hemoglobin is filled with
oxygen. A pulse oximeter is a probe with a light-emitting diode
(LED) connected by cable to an oximeter. The LED emits light
wavelengths that are absorbed differently by the oxygenated and
deoxygenated hemoglobin molecules. The more hemoglobin
saturated by oxygen, the higher the oxygen saturation. Normally
oxygen saturation (SpO2) is greater than 95%. A saturation less
than 90% is a clinical emergency (WHO, 2011)
Pulse oximetry measurement of SpO2 is simple and painless
and has few of the risks associated with more invasive measure-
ments of oxygen saturation such as arterial blood gas sampling.
A vascular, pulsatile area is needed to detect the change in the
transmitted light when making measurements with a finger or
earlobe probe. Conditions that decrease arterial blood flow such
as peripheral vascular disease, hypothermia, pharmacological
vasoconstrictors, hypotension, or peripheral edema affect accu-
rate determination of oxygen saturation in these areas. For
patients with decreased peripheral perfusion, you can apply a
forehead sensor. Factors that affect light transmission such as
outside light sources or patient motion also affect the measure-
ment of oxygen saturation. Carbon monoxide in the blood, jaun-
dice, and intravascular dyes can influence the light reflected from
hemoglobin molecules.
In adults you can apply reusable and disposable oximeter
probes to the earlobe, finger, toe, bridge of the nose, or forehead
(Box 5.8). Pulse oximetry is indicated in patients who have an
unstable oxygen status or are at risk for impaired gas exchange.
Delegation and Collaboration
The skill of SpO2 measurement can be delegated to nursing assis-
tive personnel (NAP). The nurse instructs the NAP by:
• Communicating specific factors related to the patient that
can falsely lower SpO2.
• Informing NAP about appropriate sensor site and probe.
• Notifying frequency of SpO2 measurements for a specific
patient.
• Instructing to notify nurse immediately of any reading lower
than SpO2 of 95% or value for specific patient.
• Instructing to refrain from using pulse oximetry to obtain
heart rate because oximeter will not detect an irregular
pulse.
Equipment
• Oximeter
• Oximeter probe appropriate for patient and recommended by
oximeter manufacturer
• Acetone or nail-polish remover if needed
• Pen and vital sign flow sheet in chart or electronic health
record (EHR)
Procedural Steps
1. Identify patient using at least two identifiers (e.g., name
and birthday or name and medical record number)
according to agency policy (TJC, 2016).
2. Determine need to measure patient’s oxygen saturation.
Assess risk factors for decreased oxygen saturation (e.g.,
Video Clip
BOX 5.8
Characteristics of Pulse Oximeter Sensor Probes
and Sites
Finger Probe
• Easy to apply, conforms to various sizes
Earlobe Probe
• Clip-on smaller and lighter, although more positional than finger
probe
• Yields strong correlation with oxygen saturation
• Good when uncontrollable or rhythmic movements (e.g., hand
tremors during exercise) are present
• Vascular bed least affected by decreased blood flow
Forehead Sensor
• Greater accuracy during decreased perfusion (Nesseler et al.,
2012)
• Reliable for patients on vasoactive medications
• Detects desaturation quicker than other sites (Yont et al.,
2011)
• Does not require a pulsatile vascular bed
• Good when uncontrollable or rhythmic movements (e.g., hand
tremors) are present
• Requires headband to secure sensor
Disposable Sensor Pad
• Can be applied to a variety of sites: earlobe of adult, nose bridge,
palm or sole of infant
• Less restrictive for continuous oxygen saturation monitoring
• Expensive
• Contains latex
• Skin under adhesive may become moist and harbor pathogens
• Available in variety of sizes; pad can be matched to infant
weight
acute or chronic compromised respiratory problems,
change in oxygen therapy, chest wall injury, recovery from
anesthesia).
3. Perform hand hygiene. Assess for signs and symptoms of
alterations in oxygen saturation (e.g., altered respiratory
rate, depth, or rhythm; adventitious breath sounds [see
Chapter 6]; cyanotic nails, lips, mucous membranes, or
skin; restlessness; difficulty breathing).
4. Determine if patient has a latex allergy; disposable
adhesive sensors are made of latex.
5. Assess for factors that influence measurement of SpO2
(e.g., oxygen therapy, respiratory therapy such as postural
drainage and percussion; hemoglobin level, hypotension,
temperature, nail polish [Chan et al., 2013], and
medications such as bronchodilators).
6. Review patient’s medical record for health care provider’s
order or consult agency procedure manual for standard of
care for measurement of SpO2.
7. Determine previous baseline SpO2 (if available) from
patient’s record.

PROCEDURAL GUIDELINE 5.2 Measuring Oxygen Saturation (Pulse Oximetry)—cont’d
8. Perform hand hygiene. Determine most appropriate
patient-specific site (e.g., finger, earlobe, bridge of nose,
forehead) for sensor probe placement by measuring
capillary refill (see Chapter 6). If capillary refill is greater
than 2 seconds, select alternative site.
• Site must have adequate local circulation and be free of
moisture.
• A finger free of black or brown nail polish is preferred
(Chan et al., 2013).
• If patient has tremors or is likely to move, use earlobe or
forehead. Motion artifact is the most common cause of
inaccurate readings (Chan et al., 2013).
• If patient’s finger is too large for the clip on probe, as
may be the case with obesity or edema, the clip-on
probe may not fit properly; obtain a disposable (tape-on)
probe.
9. Arrange equipment at the bedside.
10. Position patient comfortably. Instruct him or her to
breathe normally.
11. Attach sensor to monitoring site (see illustration). If using
finger, remove fingernail polish from digit with acetone or
polish remover. Instruct patient that clip-on probe will feel
like a clothespin on the finger but will not hurt.
STEP 11 Oximeter sensor attached to finger.
Clinical Decision Point Do not attach probe to finger, ear, or bridge
of nose if area is edematous or skin integrity is compromised. Do not use
earlobe and bridge of nose sensors for infants and toddlers because of skin
fragility. Do not attach sensor to fingers that are hypothermic. Select ear
or bridge of nose if adult patient has a history of peripheral vascular disease.
Do not use disposable adhesive sensors if patient has a latex allergy. Do
not place sensor on same extremity as electronic blood pressure cuff
because blood flow to finger will be interrupted temporarily when cuff
inflates and cause inaccurate reading that can trigger alarms (Skirton
et al., 2011).
CHAPTER 5 VITAL SIGNS 103
12. Once sensor is in place, turn on oximeter by activating
power. Observe pulse waveform/intensity display and
audible beep. Correlate oximeter pulse rate with patient’s
radial pulse.
13. Leave sensor in place 10 to 30 seconds or until oximeter
readout reaches constant value and pulse display reaches
full strength during each cardiac cycle. Inform patient that
oximeter alarm will sound if sensor falls off or patient
moves it. Read SpO2 on digital display.
14. If you plan to monitor SpO2 continuously, verify SpO2
alarm limits preset by manufacturer at a low of 85% and a
high of 100%. Determine limits for SpO2 and pulse rate as
indicated by patient’s condition. Verify that alarms are on.
Assess skin integrity under sensor probe every 2 hours;
relocate sensor at least every 4 hours and more
frequently if skin integrity is altered or tissue perfusion
compromised.
15. If you plan intermittent or spot-checking of SpO2, remove
probe and turn oximeter power off. Clean sensor and store
sensor in appropriate location.
16. Discuss findings with patient. Perform hand hygiene.
17. Compare SpO2 with patient’s previous baseline and
acceptable SpO2.
18. Record SpO2 on vital sign flow sheet in chart or EHR;
indicate type and amount of oxygen therapy used by
patient during assessment; record any signs or symptoms of
alterations in oxygen saturation in narrative form in
nurses’ notes in EHR or chart.
19. Report abnormal findings to nurse in charge or health care
provider.
20. Use Teach-Back: “I want to be sure I explained why you
need to keep the probe on your finger. Tell me why this
measurement is important and how moving your finger
affects reading.” Revise your instruction now or develop a
plan for revised patient or family caregiver teaching if
patient or family caregiver is not able to teach back
correctly.