Name: Patricia Feb G.

De Los Santos Date: December 2020

Evaluator/Signature: Jude D. Positos, RN, MAN Grade: _____________

APPLYING AND MONITORING PULSE OXIMETER

Purpose:

 Provides a noninvasive method for monitoring O2 Saturation of arterial blood.

Equipment:

 Pulse oximeter
 Sensor (permanent or disposable)
 Alcohol wipe (s)
 Nail polish remover, if indicated

Assessment:
 Signs and symptoms of hypoxemia (restlessness, confusion, dusky skin, nailbeds or mucous membranes.)
 Quality of pulse and capillary refill proximal to potential sensor application site.
 Respiratory rate and character.
 Previous pulse oximetry readings.
 Amount and type of O2 administration, if applicable.
 Arterial blood gases, if available.

Nursing Diagnoses:
 Impaired gas exchange related to excessive secretions.
 Ineffective tissue perfusion.

Outcome Identification and Planning:

Desired Outcomes

 Clients arterial oxygen saturation (SaO2) remains between 95% and 100%.
  Client exhibits signs of adequate gas exchange evidenced by respirations of 18-20 (for adult), nailbeds pink, and capillary refill time is less than 3
seconds.
 Client demonstrates knowledge of factors affecting pulse oximeter readings.

Special Considerations in Planning and Implementation

Pediatric
 For children, choose an appropriate- sized sensor.

Geriatric
 Be sensitive to probe placement in elderly client, avoid tension on the probe site and be careful when applying tape to dry, thin skin.

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.

ACTION
1. Perform hand washing and organize
equipment.
2. Explain the procedure to client (if conscious).
3. Plug in oximeter and choose sensor. Sensor
types may vary according to the client's 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, if
needed, if a finger is being used as the
checking site.
5. Check capillary refill and pulse proximal to the
chosen site.
PERFORMED
RATIONALE REMARKS
YES NO
Deters the spread of microorganism.
To promote cooperation and alleviate anxiety.
Probes come in adult, pediatric, and infant sizes. Inaccurate readings can result
if probe or sensor is not attached correctly.
Skin oils, dirt, or grime on the site, polish and artificial nails can interfere the
passage of light waves.
Brisk capillary refill indicates circulation to the site is adequate.
 6. Assess the alignment of the light-emitting Secure attachment and proper alignment promote satisfactory operation of the
diodes (LEDs) and the photodetector (light- equipment and accurate reading of SpO2
receiving sensor). These sensors should be
directly opposite each other (Fig. 6.25).
7. Turn on the pulse oximeter. DISPOSABLE To get accurate data.
SENSORS NEED TO BE ATTACHED TO
THE CLIENT CABLE BEFORE TURNING
THE PULSE OXIMETER ON.
8. Listen for a beep and note waveform or bar of Audible beep represents the arterial pulse, fluctuating waveform indicates the
light on front of pulse oximeter. strength of pulse. Weak signal will produce an inaccurate recording of the
SpO2. Tone of the beep reflects SpO2 reading. If SpO2 drops, tones become
low pitch.
9. Check and monitor alarm limits. Reset if Alarm provides additional safeguard of signals when high or low limits have
necessary. Make sure that both high and low been surpassed.
alarms are on before leaving the client's 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.
10. Tell the client that common position changes To prevent false alarm.
may trigger the alarm, such as bending the
elbow or gripping the side rails or other
objects.
11. Relocate finger sensor at least every 4 hours. Prolonged pressure may lead to tissue necrosis.
Shift spring tension sensor at least every 2
hours.
12. Evaluate adhesive sensors at least every shift. Adhesive sensors may cause skin irritations.

Evaluation
 Desired outcome met: Pulse oximeter reading 97%.
 Desired outcome met: Client alert and oriented x 3.
 Desired outcome met: Respirations even and nonlabored with rate of 12 breaths per minute.
Documentation
 Types of location of sensor.
 Presence of pulse proximal to sensor and status of capillary refill.
  Percentage of O2 saturation in arterial blood (SaO2)

Learner’s Reflection: (What did you learn most of the activity? What Instructor’s Comments:
is its impact to you?)
During our 2nd year clinical exposure at GTLMH, we have actually
used a pulse oximeter, numerous times. Pulse oximetry checks how
well your heart is pumping oxygen through your body. It may be used
to monitor the health of individuals with any type of condition that
can affect blood oxygen levels, especially while they're in the
hospital. For me it is important to learn this skill especially we don’t
know the possibility where we would be required to use this due to
unavailability of the portable ones.

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