Skill 05[1]..Pulse Oximetry.pdf

SKILL 5

Pulse Oximetry

EQUIPMENT

Pulse oximeter

Appropriate sensor probe

3. Cleanse site. Remove nail polish or artificial nails. Nail

polish and artificial nails alter results.

4. Follow manufacturer’s instructions for setting up oxime-

ter. Connect sensor to oximeter and set alarms as

ordered.

5. Position sensor with light-emitting diode (LED) and

photosensor aligned on opposite sides of the selected

site. Prevents optical shunting and ensures accurate

results.

6. Obtain reading.

7. Watch pulse bar for pulse sensing.

8. Obtain arterial blood gas (ABG) if ordered. Promotes

confidence in oximetry readings.

9. Cover sensor. Ambient light can skew readings.

GENERAL GUIDELINES FOR VITAL SIGNS

1. Check record for baseline and factors (age, illness, med-

ications, etc.) influencing vital signs. Provides parame-

ters and helps in device and site selection.

2. Gather equipment, including paper and pen, for record-

ing vital signs. Promotes organization and efficiency.

3. Wash hands. Reduces transmission of microorganisms.

4. Prepare child and family in a quiet and nonthreatening

manner. Enhances cooperation and participation;

reduces anxiety and fear, which can affect readings.

NOTE: Infants and young children may be quiet and

more cooperative if vitals signs are obtained while

child is sitting on caregiver’s lap.

PREPROCEDURE

1. Determine if the child has undergone a test that used an

intravenous dye. Intravenous dyes may interfere with

pulse oximeter readings.

2. Evaluate client status.

PROCEDURE

1. Follow steps 1–4 of General Guidelines.

2. Select sensor site that is free of moisture and drainage.

Assess capillary refill and proximal pulse. Adequate per-

fusion necessary for accurate reading.

a. Infant: Big toe or foot. (Figures 7 and 8)

b. Toddler through adolescent: finger.

NOTE: May also use earlobe.

FIGURE 7 Placement of pulse oximeter on

toe.

FIGURE 8 Placement of pulse oximeter on

foot.

continued

SKILL 5

Pulse Oximetry

continued

10. Assess probe/sensor site every 2–4 hours. Protects

against skin breakdown; ensures correct placement.

11. Rotate probe/sensor site every 2 hours for a spring-

loaded sensor and every 4 hours for an adhesive sensor.

Maintains skin integrity.

12. Wash hands. Reduces transmission of microorganisms.

DOCUMENTATION

1. Pulse oximetry readings at regular intervals per agency

policy.

2. Site sensor applied, when changed.

4. Skin condition at sensor site.

3. Setting of alarm limits.

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