A pulse oximeter is a non-invasive device which has a selected wavelength of light passed through a vascular bed to estimate arterial oxyhaemoglobin saturation. The pulse oximeter uses infrared light and a process known as spectrophotometry to measure the amount of oxygenated haemoglobin in arterial blood.
The Pulse oximeter unit display indicates;
- Capillary O2, saturation and pulse rate.
- The oximeter unit also has provision for setting alarms (high and low) for pulse rate and O2 saturation.
Purposes
- To measure the capillary blood oxygen saturation.
- To detect the presence of hypoxemia before visible signs develop.
- To assess the response to therapy.
- To assess the need to decrease the number of arterial blood gas specimens drawn.
Indications
- Patients who may experience sudden change in blood oxygen level (unstable conditions).
- Patients who will need evaluation for home oxygen therapy.
- Patients who need supplemental oxygen at rest and with exercise.
Procedure
| Nursing action | Rationale |
| Before procedure 1. Explain procedure to patient. During procedure 2. Perform hand hygiene. 3. Select an appropriate site for application of the sensor. a. Use the patient’s index, middle or ring finger. b. Check the proximal pulse and capillary refill of the pulse closest to the site C. If circulation at site is inadequate, the earlobe or bridge of nose may be considered. d. Use a toe only if lower extremity circulation is not compromised. 4. Use the proper equipment: a. If one finger is too large for the probe, use a smaller one. A pediatric probe may be used for a small adult. b. Use probes appropriate for patient’s age and size. c. Check if patient is allergic to adhesive. A no adhesive finger clip or reflectance sensor is available. 5. Prepare the monitoring site: a. Cleanse the selected area and allow it to dry. b. Remove nail polish and artificial nails. 6. Apply the probe securely to the skin, make sure that light emitting sensor are aligned opposite to each other (not necessary to check if placed on the forehead or bridge of the nose) 7.Connect the sensor probe to the pulse oximeter and check operation of the equipment like presence of audible beep and fluctuation of bar of light or waveform on the monitor of the oximeter 8. Set the alarms on the pulse oximeter Check manufacturer’s alarm for high and low pulse rate settings. 9.Check oxygen saturation at regular intervals as ordered by physician and as necessitated by alarms. Monitor patient’s haemoglobin level. 10. Remove sensor on a regular basis and check for skin imitation or signs of pressure. 11. Evaluate any malfunctions or problems with equipment. a. for absent or weak signal, check the patient’s vital signs and condition. If satisfactory, check connections and circulation to site. b. If reading is inaccurate check prescribed medications and history of circulatory disorders. Try device on a healthy person to see if problem is equipment-related or patient-related. c. If bright light (sunlight or fluorescent light) is suspected of causing equipment malfunction, cover probe with a dry washcloth. After procedure 12. Record the application of pulse oximeter, its type and size, and all nursing assessments | Explanation relieves anxiety and facilitates patents cooperation. Prevents spread of microorganisms Inadequate circulation can interfere with the sao2 reading. Brisk capillary refill and a strong pulse indicate that circulation to the site is adequate These sites are highly vascular alternatives Peripheral vascular disease is common in lower extremities. Inadequate reading can result if probe or sensor is not attached correctly. Probes come in adult, pediatric, and infant sizes. A reaction may occur if patient is allergic to adhesive substances. Skin oils, dirt or grime on site, polish, and artificial nails can interfere with the passage of light waves. Ensure accurate recording of sao2. Audible beep represents the arterial pulse, and fluctuating waveform indicates strength of the pulse. A weak signal will produce an inaccurate recording sao2. Tone of beep reflects sao2 reading. If sao2 drops, tone becomes low pitched. Alarm provides additional safeguard for patient and signals when high or low limits have been surpassed Monitoring sao2 provides ongoing assessment of patient’s condition. A low haemoglobin level may be satisfactorily saturated yet not be adequate to meet a patient’s oxygen needs. (normal oxygen saturation is 96-100%) Prolonged pressure may lead to tissue necrosis and adhesive sensor may cause skin irritation. Hypotension makes an accurate recording difficult. Restraint and BP cuff may compromise circulation to site and cause venous blood to pulsate, giving an inaccurate reading. If extremity is cold, cover with warm blanket. Drugs that cause vasoconstriction interfere with accurate recording of oxygen saturation; Bright light can interfere with operation of light sensors and cause report unreliable. Documentation ensures continuity of care and ongoing assessment record. |
Special Considerations
- Do not use oximeter if light indicates low battery.
- The patient with diabetic, peripheral disease or hypothyroidism may have thickened or discolored nail beds. Assess the patient and move the sensor to an alternate site if required.
- Finger sensors are generally not sized appropriately for children and are not intended for neonatal or pediatric use. Adhesive sensors can be used on the hand or feet of children or on the hand of the neonate.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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