USING A PULSE OXIMETER

(Measuring Oxygen Saturation)

Purposes:
 To estimate the arterial blood oxygen saturation.
 To detect the presence of hypoxemia before visible signs develop.
Equipment
 Pulse Oximeter
 Alcohol wipe(s) or disposable cleansing cloth
 Nail polish remover (if necessary)
Criteria Ginagawa Rationale

ASSESSMENT
1. Assess for signs and symptoms of
alterations in oxygen saturation (e.g.,
altered respiratory rate, depth, or
rhythm; adventitious breath sounds;
cyanotic nails, lips, mucous membranes,
or skin; restlessness; difficulty
breathing).

2. Assess for factors that influence

measurement of SpO2 (e. g., oxygen
therapy, respiratory therapy such as
postural drainage and percussion,
hemoglobin level, hypertension,
temperature, nail polish [Cicek et al.,
2011], and medications such as
bronchodilators).

PLANNING
1. Identify the patient using at least
two methods.

2. Explain what you are going to do and

why you are going to do it to the
patient.

3. Perform hand hygiene.

IMPLEMENTATION
1. Select an adequate site for
application of the sensor.

Pinakita ung middle

a. Use the patient’s index, middle, or
finger, index and
ring finger.
ring finger ni
 patient
Pigain ung proximal To know if the oxygen
b. Check the proximal pulse and
pulse or pinaka tip circulation of the
capillary refill at the pulse closest to
ng fingers . patient is adequate.
the site.
There are several
different types of
sensors are available,
c. If circulation at site is inadequate,
including disposable and
consider using the earlobe or bridge of
nondisposable sensors,
nose.
which may be applied
over a variety of
d. Use a toe only if the lower extremity
vascular beds, including
circulation is not compromised.
the digit, earlobe, nasal
bridge or septum, and
forehead.

Use pulse oximeter sa

lower extremities
especially sa toe if the
patients circulation is
inadequate.

2. Select proper equipment.

There are kinds of pulse
a. If one finger is too large for the
oximeter use
probe, use a smaller one.  A pediatric
appropriate probe for
probe may be used for a small adult.
patients age and size to
check their oxygen
b. Use probe appropriate for patient’s
saturation
age and size.

c. Check if patient is allergic to

adhesive.  A non – adhesive finger clip
or reflectance sensor is available.  

3. 3. Prepare the monitoring site.  Cleanse Buksan alcohol pad

the selected area with the alcohol wipe punasan yung
or disposable cleansing cloth.  Allow the fingers ni patient
area to dry.  If necessary, remove nail from the to the
polish and artificial nails after checking body. Then discard
manufacturer’s instructions. the alcohol pad

4. Apply probe securely to skin.  Make Ilagay na s afinger

sure that the light – emitting sensor ung pulse oximeter
and the light – receiving sensor are Pindutin ung pulse
aligned opposite each other (not oximeter.
necessary to check if placed on
forehead or bridge of nose).

5. Connect the sensor probe to the

pulse oximeter, turn the oximeter on,
and check the operation of the
equipment (audible beep, fluctuation, or
bar of light or waveform on face of
oximeter.

6. Set alarms on pulse oximeter.  Check

manufacturer’s alarm limits for high
and low pulse rate settings.

7. Check oxygen saturation at regular

intervals, as ordered by physician and
signaled by alarms.  Monitor hemoglobin
level.

8. Remove sensor on a regular basis and

check for skin irritation or signs of
pressure (every 2 hours for spring
tension sensor or every 4 hours for
adhesive finger or toe sensor).

9. Clean non – disposable sensors

according to the manufacturer’s
directions.  Perform hand hygiene.

EVALUATION
1. Compare SpO2 reading with
patient’s previous baseline and
acceptable SpO2 values.

DOCUMENTATION
1. Record SpO2 value on vital sign flow
sheet, or nurses’ notes.
2. Record any signs and symptoms of
alterations in oxygen saturation in
narrative form in nurses’ notes.
3. Report abnormal findings to the
health care provider.