Pulse OximetryPulse Oximetry

Dr. Abdul-Monim BatihaDr. Abdul-Monim BatihaAssistant ProfessorAssistant ProfessorCritical Care NursingCritical Care Nursing

Philadelphia university Philadelphia university

• Pulse oximetry is Pulse oximetry is a noninvasive monitoring a noninvasive monitoring techniquetechnique used used to estimate the to estimate the measurement of arterial oxygen saturation measurement of arterial oxygen saturation (Sao2) of hemoglobin.(Sao2) of hemoglobin.

• Oxygen saturation is Oxygen saturation is an indicator of the an indicator of the percentage of hemoglobin saturated with percentage of hemoglobin saturated with oxygenoxygen at the time of the measurement . at the time of the measurement .

• The reading, obtained through pulse The reading, obtained through pulse oximetry, oximetry, uses a light sensor containing two uses a light sensor containing two sources of lightsources of light (red and infrared ) (red and infrared ) that are that are absorbed by hemoglobin and transmitted absorbed by hemoglobin and transmitted through tissues to a photodetector.through tissues to a photodetector.

• The infrared light is absorbed by the The infrared light is absorbed by the oxyhemoglobinoxyhemoglobin ,and ,and the red light is absorbed the red light is absorbed by the reduced hemoglobinby the reduced hemoglobin. .

• The amount and type of light transmitted The amount and type of light transmitted through the tissue is through the tissue is converted to a digital converted to a digital value representing the percentage of value representing the percentage of hemoglobin saturated with oxygenhemoglobin saturated with oxygen..

• Oxygen saturation values obtained from Oxygen saturation values obtained from pulse oximetry (Spo2) pulse oximetry (Spo2) represent one part of a represent one part of a complete assessment of a patient's complete assessment of a patient's oxygenation status and are not a substitute oxygenation status and are not a substitute for measurement of arterial partial pressure for measurement of arterial partial pressure of oxygen (PaO2) or of ventilationof oxygen (PaO2) or of ventilation (as (as measured by arterial partial pressure of measured by arterial partial pressure of carbon dioxide(PaCO2)carbon dioxide(PaCO2)

• The accuracy of Spo2 measurements The accuracy of Spo2 measurements requires consideration of many physiologic requires consideration of many physiologic variables. Patient variablesvariables. Patient variables include the include the following following

1- 1- Hemoglobin level,Hemoglobin level,2-2- Arterial blood flow to vascular bed, Arterial blood flow to vascular bed,3-3- Temperature of digit or the area where the Temperature of digit or the area where the

oximetry sensor is located,oximetry sensor is located,4-4- Patient oxygenation ability, Patient oxygenation ability,5-5- Fraction of inspired oxygen (percentage of Fraction of inspired oxygen (percentage of

inspired oxygen),inspired oxygen),6- 6- Evidence of ventilation perfusion mismatch,Evidence of ventilation perfusion mismatch,7-7- Amount of ambient light seen by the sensor, Amount of ambient light seen by the sensor,8-8- Venous return at the sensor location. Venous return at the sensor location.

• A complete assessment of oxygenation A complete assessment of oxygenation includes includes evaluation of oxygen content evaluation of oxygen content and delivery,and delivery, which includes the which includes the following parameters: following parameters:

• PaO2,PaO2,

• Sao2, Sao2,

• Hemoglobin, Hemoglobin,

• Cardiac output, Cardiac output,

• Mixed venous oxygen saturation Mixed venous oxygen saturation (when (when available)available)

• Normal oxygen saturation values are Normal oxygen saturation values are 97% to 99% 97% to 99% in a healthy individual on in a healthy individual on

room air. room air.

• An oxygen saturation value of An oxygen saturation value of 95% is 95% is clinically accepted in a patient with a clinically accepted in a patient with a normal hemoglobin level. normal hemoglobin level.

• Using the Using the –– oxyhemoglobin oxyhemoglobin dissociation curve, dissociation curve, an oxygen an oxygen saturation value of 90% is generally saturation value of 90% is generally equated with a PaO2 of 60 mm Hg.equated with a PaO2 of 60 mm Hg.

•Tissue oxygenation Tissue oxygenation is not is not reflected by arterial or oxygen reflected by arterial or oxygen saturation obtained by pulse saturation obtained by pulse oximetry.oximetry.

•The affinity of hemoglobin to The affinity of hemoglobin to oxygen oxygen may impair or enhance may impair or enhance oxygen release at the tissue oxygen release at the tissue level.level.

•Oxygen is Oxygen is more readily released to more readily released to the tissues the tissues (decreased oxygen (decreased oxygen affinity) whenaffinity) when

– Decreased Ph Decreased Ph (acidosis),(acidosis),– Increased PaCO2 Increased PaCO2 (respiratory acidosis)(respiratory acidosis)– Increased body temperature Increased body temperature

(hyperthermia) (hyperthermia) – Increased 2,3-diphosphoglycerate Increased 2,3-diphosphoglycerate

level level (a by (a by ––product of glucose product of glucose metabolism also found in stored blood metabolism also found in stored blood products)products)

•When hemoglobin has greater When hemoglobin has greater affinity for oxygen, less is available affinity for oxygen, less is available to the tissue (increased oxygen to the tissue (increased oxygen affinity) increase oxygen binding to affinity) increase oxygen binding to the hemoglobin and the hemoglobin and limit its release limit its release to the tissue.to the tissue. Conditions such as Conditions such as

– Increased ph Increased ph (alkalosis)(alkalosis) – Decreased PaCO2 Decreased PaCO2 (respiratory alkalosis)(respiratory alkalosis)– Decreased temperature Decreased temperature (hypothermia)(hypothermia)– Decreased 2,3-diphosphoglycerate level.Decreased 2,3-diphosphoglycerate level.

• Oxygen saturation values may vary Oxygen saturation values may vary with the amount of oxygen usage by with the amount of oxygen usage by the tissues . In some patients, the tissues . In some patients, there is there is a difference in Spo2 values at rest a difference in Spo2 values at rest compared with values during activity , compared with values during activity , such as ambulation or positioning.such as ambulation or positioning.

• Oxygen saturation Oxygen saturation does not reflect does not reflect the patient's ability to ventilatethe patient's ability to ventilate. The . The true measure of ventilation is true measure of ventilation is determination of the determination of the PaCO2 in arterial PaCO2 in arterial blood .blood .

• Use of Spo2 in a patient with obstructive Use of Spo2 in a patient with obstructive pulmonary disease may result in erroneous pulmonary disease may result in erroneous clinical assessment of condition. As the clinical assessment of condition. As the degree of lung disease increases, the degree of lung disease increases, the patient's drive to breathe may patient's drive to breathe may shift from an shift from an increased carbon dioxide stimulus to a increased carbon dioxide stimulus to a hypoxic stimulus.hypoxic stimulus. Enhancing the patient's Enhancing the patient's Spo2 may limit his or her ability to ventilate. Spo2 may limit his or her ability to ventilate.

• The normal baseline Spo2 for a patient with The normal baseline Spo2 for a patient with known severe restrictive disease and more known severe restrictive disease and more definitive methods of determining the definitive methods of determining the effectiveness of ventilation effectiveness of ventilation must be known must be known before considering intervention that before considering intervention that enhance oxygenationenhance oxygenation

• Any discoloration of the nail bed can affect Any discoloration of the nail bed can affect the transmission of light through the digit. the transmission of light through the digit. dark nail polish, such as blue, green, brown, dark nail polish, such as blue, green, brown, or black colors, and bruising under the nail or black colors, and bruising under the nail can limit the transmission of light and result can limit the transmission of light and result in an artificially decreased Spo2 value.in an artificially decreased Spo2 value. If If the nail polish cannot be removed, the the nail polish cannot be removed, the sensor can be placed in a lateral side-to-sensor can be placed in a lateral side-to-side position on the finger to obtain side position on the finger to obtain readings if no other method of sampling the readings if no other method of sampling the arterial bed is availablearterial bed is available

• Pulse oximetry has Pulse oximetry has not been shown to be not been shown to be affected by the presence of an elevated affected by the presence of an elevated bilirubinbilirubin

• Pulse oximeters are unable to differentiate Pulse oximeters are unable to differentiate between oxygen and carbon monoxide bound between oxygen and carbon monoxide bound to hemoglobin. to hemoglobin. Readings in the presence of Readings in the presence of carbon monoxide are falsely elevated. pulse carbon monoxide are falsely elevated. pulse oximetry should never be used in suspected oximetry should never be used in suspected cases of carbon monoxide exposure.cases of carbon monoxide exposure. An An arterial blood gas reading always should be arterial blood gas reading always should be obtained to determine the accurate oxygen obtained to determine the accurate oxygen saturation.saturation.

• It has been suggested that It has been suggested that dark skin may dark skin may affect the ability of the pulse oximeter to affect the ability of the pulse oximeter to detect arterial pulsations.detect arterial pulsations. one study found a one study found a more frequent difference between the spo2 more frequent difference between the spo2 and sao2 with black patients compared with and sao2 with black patients compared with lighter skinned patient ,another study did not lighter skinned patient ,another study did not find a significant differencefind a significant difference

• A pulse oximeter A pulse oximeter should not be used as a should not be used as a predictive indicator of the actual arterial predictive indicator of the actual arterial blood gas saturationblood gas saturation

• A pulse oximeter A pulse oximeter should never be used should never be used during a cardiac arrest situationduring a cardiac arrest situation because because of of

- The extreme limitations of blood flow- The extreme limitations of blood flow during cardiopulmonary resuscitation during cardiopulmonary resuscitation - The pharmacological action of- The pharmacological action of vasoactive agents administered vasoactive agents administered

duringduring the resuscitation effortthe resuscitation effort

EquipmentEquipment

• Oxygen saturation meter and monitor,Oxygen saturation meter and monitor,

• Oxygen saturation cable and sensor,Oxygen saturation cable and sensor,

• Manufacturer's recommended Manufacturer's recommended germicidal agent for cleaning the non- germicidal agent for cleaning the non- disposable sensor disposable sensor (used for cleaning (used for cleaning between patients).between patients).

Patient assessmentPatient assessment

• Assess Assess signs and symptoms of decreased ability to signs and symptoms of decreased ability to oxygenateoxygenate to determine the need for continuous pulse to determine the need for continuous pulse oximetry monitoring. Anticipation of conditions in which oximetry monitoring. Anticipation of conditions in which hypoxia could be present allows earlier intervention before hypoxia could be present allows earlier intervention before unfavorable outcomes occur unfavorable outcomes occur

• CyanosisCyanosis• DyspneaDyspnea• TachypneaTachypnea• Decreased level of consciousnessDecreased level of consciousness• Increased work of breathingIncreased work of breathing• Loss of protective airwayLoss of protective airway• AgitationAgitation• ConfusionConfusion• DisorientationDisorientation• TachycardiaTachycardia• BradypneaBradypnea

• Assess Assess the extremity (digit) or area where the sensor the extremity (digit) or area where the sensor will be placedwill be placed to identify factors that may inhibit to identify factors that may inhibit accuracy of the measurement of oxygenation before accuracy of the measurement of oxygenation before attempting to obtain the spo2 reading to enhance attempting to obtain the spo2 reading to enhance the validity of the measurement and allow for the validity of the measurement and allow for correction of factors as possiblecorrection of factors as possible

• Decreased peripheral pulse Decreased peripheral pulse • Peripheral cyanosisPeripheral cyanosis• Decreased body temperature Decreased body temperature • Decreased blood pressureDecreased blood pressure• Exposure to excessive environmental light source Exposure to excessive environmental light source

(e.g., examination lights)(e.g., examination lights)• Excessive movement or tremor in the digitExcessive movement or tremor in the digit• Presence of dark nail polish or bruising under the Presence of dark nail polish or bruising under the

nailnail• Presence of artificial nailsPresence of artificial nails• Clubbing of digit tips Clubbing of digit tips

Patient preparationPatient preparation

• Explain Explain the need for determination of the need for determination of oxygen saturation with a pulse oximeteroxygen saturation with a pulse oximeter to to inform the patient of the purpose of inform the patient of the purpose of monitoring and to enhance patient monitoring and to enhance patient cooperation and decrease patient anxietycooperation and decrease patient anxiety

• Explain that Explain that the value displayed may vary by the value displayed may vary by patient movement, amount of environmental patient movement, amount of environmental light, patient level of consciousness light, patient level of consciousness ( awake ( awake or aor a sleep),sleep), and position of the sensor and position of the sensor to to decrease patient and family anxiety over the decrease patient and family anxiety over the constant variability of the valuesconstant variability of the values

• Explain that Explain that the use of pulse oximetry the use of pulse oximetry is part of a much larger assessment is part of a much larger assessment of oxygenation statusof oxygenation status to prepare the to prepare the patient and family for other possible patient and family for other possible diagnostic tests of oxygenation (e.g., diagnostic tests of oxygenation (e.g., arterial blood gases)arterial blood gases)

• Explain Explain the equipmentthe equipment to the patient to the patient to facilitate patient cooperation in to facilitate patient cooperation in maintaining sensor placement maintaining sensor placement

• Explain Explain the need for an audible alarm the need for an audible alarm systemsystem for determination of oxygen for determination of oxygen saturation values below a set saturation values below a set acceptable limit .Demonstrate the acceptable limit .Demonstrate the alarm system, alerting the patient and alarm system, alerting the patient and family to the possibility of alarms, family to the possibility of alarms, including causes of false alarms to including causes of false alarms to provide an understanding of the use of provide an understanding of the use of an alarm system and its importance in an alarm system and its importance in the overall management of the patient the overall management of the patient and of circumstances in which a false and of circumstances in which a false alarm may occur assists in patient alarm may occur assists in patient understanding of the values seen while understanding of the values seen while at the bedside.at the bedside.

• Explain Explain the need to move or remove the the need to move or remove the sensor on a routine basissensor on a routine basis to prevent to prevent complications related to the type of sensor complications related to the type of sensor used or the degree of tightness in which the used or the degree of tightness in which the sensor is secured around the finger to sensor is secured around the finger to provide an understanding of the need to provide an understanding of the need to move the sensor routinely assists in patient move the sensor routinely assists in patient understanding of the frequency of sensor understanding of the frequency of sensor movement. movement.

• Ensure that Ensure that the patient understands pre-the patient understands pre-procedural teaching. Answer questions as procedural teaching. Answer questions as they arise, and reinforce information as they arise, and reinforce information as neededneeded to evaluate and reinforce to evaluate and reinforce understanding of previously taught understanding of previously taught information. information.

ProcedureProcedure

• Wash handsWash hands to reduce the transmission of to reduce the transmission of microorganisms and body secretions (standard microorganisms and body secretions (standard precautions)precautions)

• Use personal protective equipmentUse personal protective equipment to reduce the to reduce the transmission of microorganisms and body secretions transmission of microorganisms and body secretions (standard precautions)(standard precautions)

• Select the appropriate pulse oximeter sensor for the Select the appropriate pulse oximeter sensor for the area with the best pulsatile vascular bedarea with the best pulsatile vascular bed to be sampled to be sampled to obtain accurate spo2 measurements (Use of finger to obtain accurate spo2 measurements (Use of finger sensors produce the best results over other sites) to sensors produce the best results over other sites) to optimize signal capture and minimize artifact-related optimize signal capture and minimize artifact-related difficulties ( several different types of sensors are difficulties ( several different types of sensors are available, including disposable and non-disposable available, including disposable and non-disposable sensors that may be applied over a variety of vascular sensors that may be applied over a variety of vascular beds)beds)

• Do not use one manufactur's sensor with Do not use one manufactur's sensor with another manufacturer's pulse oimeteranother manufacturer's pulse oimeter unless unless compatibility has been verifiedcompatibility has been verified

• Select desired sensor site .Select desired sensor site .If using the If using the digit ,digit ,assess for warmth and capillary refillassess for warmth and capillary refill. . Confirm the presence of an arterial blood flow Confirm the presence of an arterial blood flow to the area monitoredto the area monitored because adequate because adequate arterial pulse strength is necessary for arterial pulse strength is necessary for obtaining accurate Spo2 measurements obtaining accurate Spo2 measurements

• Avoid sites distal to indwelling arterial; Avoid sites distal to indwelling arterial; catheters, blood pressure cuffs, military catheters, blood pressure cuffs, military antishock trousers (MAST),or venous antishock trousers (MAST),or venous engorgement (e.g., arteriovenous fistula, engorgement (e.g., arteriovenous fistula, blood transfusions)blood transfusions) to obtain accurate Spo2 to obtain accurate Spo2 measurements.measurements.

• Plug oximeter into grounded wall Plug oximeter into grounded wall outletoutlet if the unit is not portable. If the if the unit is not portable. If the unit is portable , unit is portable , ensure sufficient ensure sufficient battery chargebattery charge by turning it on before by turning it on before using . Plug patient cable into monitor using . Plug patient cable into monitor to decrease occurrence of electrical to decrease occurrence of electrical interference (portable systems have interference (portable systems have rechargeable batteries and depend on rechargeable batteries and depend on sufficient time plugged into an sufficient time plugged into an electrical outlet to maintain the electrical outlet to maintain the proper level of battery charge. When proper level of battery charge. When system is used in the portable mode, system is used in the portable mode, always check battery capacity.always check battery capacity.

•Check battery capacity always Check battery capacity always when the system is used in the when the system is used in the portable modeportable mode ( portable ( portable systems have rechargeable systems have rechargeable batteries and depend on batteries and depend on sufficient time plugged into an sufficient time plugged into an electrical outlet to maintain the electrical outlet to maintain the proper level of battery charge)proper level of battery charge)

• Apply the sensor in a manner that allows Apply the sensor in a manner that allows the light source (light- emitting diodes) to the light source (light- emitting diodes) to be directly opposite the light detector be directly opposite the light detector (photodetector) to determine a pulse (photodetector) to determine a pulse oximetry value properly,Shielded from oximetry value properly,Shielded from excessive environmental light because light excessive environmental light because light from sources such as examination lights or from sources such as examination lights or overhead lights can cause elevated oximetry overhead lights can cause elevated oximetry values ( if the oximeter sensor fails to values ( if the oximeter sensor fails to detect a pulse when perfusion seems detect a pulse when perfusion seems adequate, excessive environmental light adequate, excessive environmental light (overhead examination lights,phototherapy (overhead examination lights,phototherapy lights,infrared warmers) may be blinding lights,infrared warmers) may be blinding the light sensor. Troubleshoot by the light sensor. Troubleshoot by reapplying the sensor or shielding the reapplying the sensor or shielding the sensor with a towel or blanket.sensor with a towel or blanket.

• Positioned so that all sensor emitted Positioned so that all sensor emitted light comes in contact with perfused light comes in contact with perfused tissue beds and is not seen by the other tissue beds and is not seen by the other side of the sensor \or without coming in side of the sensor \or without coming in contact with the area to be read because contact with the area to be read because if the light is seen directly from the if the light is seen directly from the sensor without coming in contact with sensor without coming in contact with the vascular bed , too much light can be the vascular bed , too much light can be seen by the sensor, resulting in either a seen by the sensor, resulting in either a falsely high reading or no reading falsely high reading or no reading ( known as optical shunting, the light ( known as optical shunting, the light bypass the vascular bed; shielding the bypass the vascular bed; shielding the sensor does not eliminate this if the sensor does not eliminate this if the sensor is too large or not properly sensor is too large or not properly positionedpositioned

• Gently position the sensorGently position the sensor so that it does not so that it does not cause restriction to arterial flow or venous cause restriction to arterial flow or venous return because return because the pulse oximeter is unable the pulse oximeter is unable to distinguish between true arterial to distinguish between true arterial pulsations and fluid wavespulsations and fluid waves (e.g., venous (e.g., venous engorgement or fluid accumulation)engorgement or fluid accumulation)

• Restriction of arterial blood flow can cause a Restriction of arterial blood flow can cause a falsely low valuefalsely low value and lead to vascular and lead to vascular compromise , causing potential loss of viable compromise , causing potential loss of viable tissues.tissues.

• Edema from restriction of venous return can Edema from restriction of venous return can cause venous pulsation. cause venous pulsation. Evaluating the site Evaluating the site above the level of the heart reduces the above the level of the heart reduces the possibility of venous pulsationpossibility of venous pulsation (Moving the (Moving the sensor to another site on a routine schedule sensor to another site on a routine schedule also reduces tissue compromisealso reduces tissue compromise

• Never place the sensor on an extremity that Never place the sensor on an extremity that has decreased or absent sensationhas decreased or absent sensation because because the patient may not be able to identify the patient may not be able to identify discomfort or the signs and symptoms of discomfort or the signs and symptoms of loss of circulation or tissue compromise loss of circulation or tissue compromise

• Plug sensor into oximeter patient cablePlug sensor into oximeter patient cable to to connect the sensor to the oximeter, connect the sensor to the oximeter, allowing Spo2 measurement and analysis of allowing Spo2 measurement and analysis of waveformswaveforms

• Turn instrument on with the power switchTurn instrument on with the power switch

• Allow 30 seconds for self-testing procedures Allow 30 seconds for self-testing procedures and for detection and analysis of waveformsand for detection and analysis of waveforms before value are displayed before value are displayed

• Determine Determine accuracy of detected waveformaccuracy of detected waveform by by comparing the numeric heart rate value comparing the numeric heart rate value with that of a monitored heart rate or an with that of a monitored heart rate or an apical heart rate or bothapical heart rate or both ( if there is ( if there is insufficient arterial blood flow through the insufficient arterial blood flow through the sensor, the heart rate values vary sensor, the heart rate values vary significantly. (consider moving the sensor to significantly. (consider moving the sensor to another site, such as the earlobe or the another site, such as the earlobe or the nose) ( if the pulse rate detected by nose) ( if the pulse rate detected by oximeter does not correlate with the oximeter does not correlate with the patient's heart rate, the oximeter is not patient's heart rate, the oximeter is not detecting sufficient arterial blood flow of detecting sufficient arterial blood flow of accurate values ( this problem occurs accurate values ( this problem occurs particularly with the use of the fingers and particularly with the use of the fingers and the toes in conditions of low blood flow .the toes in conditions of low blood flow .

• Set appropriate alarm limitsSet appropriate alarm limits according according to the patient's condition. (oxygen to the patient's condition. (oxygen saturation limits should be saturation limits should be 5% less than 5% less than patient acceptable baselinepatient acceptable baseline & heart & heart rate alarm should be consistent with rate alarm should be consistent with the cardiac monitoring limits (if the cardiac monitoring limits (if monitored)monitored)

• Wash handsWash hands to reduce transmission of to reduce transmission of microorganisms to other patientsmicroorganisms to other patients

• Cleanse non-disposable sensor, if used, Cleanse non-disposable sensor, if used, between patientsbetween patients with manufacturer's with manufacturer's recommended germicidal agent to recommended germicidal agent to reduce transmission of microorganisms reduce transmission of microorganisms to other patients to other patients

Unexpected outcomeUnexpected outcome

1-1- Accurate pulse oximetry is not Accurate pulse oximetry is not obtainable because of movement obtainable because of movement artifact.artifact.

2-2- Low perfusion state or excessive edema Low perfusion state or excessive edema prevents accurate pulse oximetry prevents accurate pulse oximetry measurements.measurements.

3-3- Disagreements occur in Sao2 and Disagreements occur in Sao2 and oximeter Spo2oximeter Spo2

Patient monitoring and Patient monitoring and carecare

• Evaluate laboratory data along with the Evaluate laboratory data along with the patient for evidence of poor oxygenation.patient for evidence of poor oxygenation. (Spo2 values are one segment of a complete (Spo2 values are one segment of a complete evaluation of oxygenation and supplemental evaluation of oxygenation and supplemental oxygen therapy. oxygen therapy.

• Data should be integrated into a complete Data should be integrated into a complete assessment to determine the overall status of assessment to determine the overall status of the patients. the patients.

• If Spo2 is used as an indicator of Sao2 ,an If Spo2 is used as an indicator of Sao2 ,an arterial blood gas should be done to arterial blood gas should be done to determine if the values correlate consistently.determine if the values correlate consistently.

• Evaluate sensor site every 2 to 4 Evaluate sensor site every 2 to 4 hourshours (if a disposable sensor is (if a disposable sensor is used )used )or every 2 hoursor every 2 hours (if a rigid (if a rigid encased nondisposable sensor is encased nondisposable sensor is used ).(assessment of the skin and used ).(assessment of the skin and tissues under the sensor identifies tissues under the sensor identifies skin breakdown or loss of vascular skin breakdown or loss of vascular flow, allowing appropriate flow, allowing appropriate interventions to be initiated.interventions to be initiated.

• Rotate the site of a reusable sensor Rotate the site of a reusable sensor every 4 hoursevery 4 hours

• Replace a disposable sensor every 24 Replace a disposable sensor every 24 hourshours or more frequently if the securing or more frequently if the securing mechanism is compromised or soiled.mechanism is compromised or soiled.

• Monitor the site for excessive Monitor the site for excessive movement movement ( excessive movement of the ( excessive movement of the sampled site may result in unreliable sampled site may result in unreliable saturation values. Moving the sensor to saturation values. Moving the sensor to a less physically active site reduces a less physically active site reduces motion artifact; using a lightweight motion artifact; using a lightweight sensor also helps . if the digits are used sensor also helps . if the digits are used ,ask the patient to rest the hand on a ,ask the patient to rest the hand on a flat or secure surface flat or secure surface

•Compare and monitor the actual Compare and monitor the actual heart rate with the pulse rate heart rate with the pulse rate value from the oximetervalue from the oximeter to to determine accuracy of values . determine accuracy of values . (The two numeric heart rate (The two numeric heart rate values should correlate closely. values should correlate closely. A difference in heart rate values A difference in heart rate values may indicate excessive may indicate excessive movement or a loss of pulsatile movement or a loss of pulsatile flow detection . flow detection .

Reportable conditionsReportable conditions

• Inability to maintain oxygen saturation Inability to maintain oxygen saturation levels as desired, levels as desired,

• Change in skin color,Change in skin color,• Loss of warmth of tissue unrelated to Loss of warmth of tissue unrelated to

vasoconstriction,vasoconstriction,• Loss of blood flow to the digit, Loss of blood flow to the digit, • Evidence of skin breakdown due to the Evidence of skin breakdown due to the

sensor,sensor,• Change in color of the nail bed indicating Change in color of the nail bed indicating

compromised circulation at the nail,compromised circulation at the nail,• Inability to correlate actual heart rate and Inability to correlate actual heart rate and

pulse rate from oximeter.pulse rate from oximeter.

DocumentationDocumentation

• Patient and family education, Patient and family education, • Indications for use of pulse oximetry,Indications for use of pulse oximetry,• Patient's pulse with Spo2 measurements,Patient's pulse with Spo2 measurements,• Fraction of inspired oxygen delivered (if patient is Fraction of inspired oxygen delivered (if patient is

receiving oxygen),receiving oxygen),• Patient clinical assessment at the time of the Patient clinical assessment at the time of the

saturation measurement, saturation measurement, • Sensor site, Sensor site, • Simultaneous arterial blood gases (if available),Simultaneous arterial blood gases (if available),• Recent hemoglobin measurement (if available),Recent hemoglobin measurement (if available),• Skin assessment at sensor site,Skin assessment at sensor site,• Oximeter alarm settings,Oximeter alarm settings,• Events precipitating acute desaturation,Events precipitating acute desaturation,• Unexpected outcomes,Unexpected outcomes,• Nursing interventions.Nursing interventions.