1
Q
What is the delegation consideration for measuring oxygen saturation?
A
- The task can be delegated to unregulated care providers (UCPs)
- Nurse is responsible for assessing effect of oxygen saturation changes
2
Q
What should the UCP be informed about when delegating this task?
A
- Notify nurse immediately if SpO2 < 90%
- How to select appropriate sensor site and probe
- Frequency of measurements for the patient
- Factors that can falsely lower SpO2
3
Q
What equipment is needed for measuring oxygen saturation?
A
- Oximeter
- Oximeter probe appropriate for patient per manufacturer
- Acetone or nail polish remover, if needed
- Pen and vital sign flow sheet/documentation form
4
Q
How do you identify the patient for this procedure?
A
- Use at least two person-specific identifiers (e.g. name and date of birth, name and medical record number)
- Follow employer policy
5
Q
How do you determine the need to measure oxygen saturation?
A
- Use clinical judgment for assessment
- Note risk factors like respiratory issues, recent anesthesia/sedation, chest trauma, ventilator use, activity intolerance, oxygen therapy changes
- Assess for abnormal respiratory rate, depth, rhythm, adventitious sounds, cyanosis, restlessness, confusion, labored breathing
6
Q
What factors influence SpO2 measurement?
A
- Oxygen therapy
- Hemoglobin level
- Temperature (hypothermia can cause vasoconstriction)
- Medications like bronchodilators
7
Q
What should you review before measuring SpO2?
A
- Check for pulse oximetry order in patient’s medical record
- Consult agency policy/procedure for standard of care
8
Q
How do you determine the appropriate sensor probe site?
A
- Assess capillary refill (choose another site if <3 seconds)
- Check skin condition
- Requires pulsating vascular bed to detect hemoglobin
- SpO2 changes reflected in 30 seconds for finger, 5-10 seconds for earlobe
9
Q
What are requirements for the sensor probe site?
A
- Adequate circulation
- Free of moisture (moisture prevents SpO2 detection)
- If using digit, free of polish/artificial nails (interferes with accuracy)
10
Q
What site do you use if tremors are present?
A
- Use earlobe as site
- Motion artifact is the most common cause of false readings
11
Q
What if the patient has obesity?
A
- Clip-on probe may not fit
- Obtain a single-use tape-on probe
12
Q
Why determine previous baseline SpO2?
A
- Provides basis for comparison
- Assists in assessing current status and evaluating interventions
13
Q
Why explain the procedure to the patient?
A
- Promotes patient cooperation
- Increases adherence
14
Q
How should the patient be positioned?
A
- Comfortably
- If using finger, support lower arm
- Enables probe positioning and decreases motion artifact
15
Q
Why use acetone to remove nail polish?
A
- Nail polish interferes with accuracy
- Opaque coatings decrease light transmission
- Blue pigment can absorb light and falsely alter measurement
16
Q
Why instruct patient to breathe normally?
A
- Prevents large fluctuations in respiratory rate/depth
- Prevents possible errors in SpO2 reading
17
Q
How do you attach the sensor probe?
A
- Attach sensor probe to monitoring site
- Inform patient clip-on probe feels like clothespin on finger but won’t hurt
- Prepare patient for pressure of probe’s spring tension on digit or earlobe
18
Q
What are critical decision points for probe placement?
A
- Do not use if area is edematous or skin integrity compromised
- Do not use on hypothermic fingers
- Use ear or nose bridge if patient has peripheral vascular disease
- Do not use on earlobe/nose bridge for infants/toddlers due to skin fragility
- Do not use disposable adhesive probes if latex allergy
- Do not use same extremity as blood pressure cuff
19
Q
What do you do once the sensor is in place?
A
- Turn on oximeter
- Observe pulse waveform, intensity display, listen for audible beep
- Correlate oximeter heart rate with patient’s radial pulse
- Re-evaluate probe placement if rates differ
20
Q
Why correlate oximeter and radial pulse rates?
A
- Pulse waveform/intensity enables valid pulse detection for SpO2
- Double-checking heart rates ensures oximeter accuracy
21
Q
How long do you leave the probe in place?
A
- Until oximeter readout is constant
- Until pulse display reaches full strength each cycle
- Inform patient alarm will sound if probe falls off/moves
- Read SpO2 on digital display
22
Q
How long does the SpO2 reading take?
A
10-30 seconds, depending on site selected
23
Q
What should be done if SpO2 monitoring is continuous?
A
- Verify SpO2 alarm limits and volume (preset at 85-100%)
- Determine appropriate SpO2 and heart rate alarm limits based on patient condition
- Verify alarms are functional
- Assess skin integrity under sensor probe every 2 hours
- Relocate sensor probe at least every 4 hours or more frequently if skin integrity is compromised
24
Q
Why must alarms be set at appropriate limits and volumes?
A
To avoid frightening patients and visitors
25
Why can sensor probe cause skin irritation?
* Spring tension of sensor probe
* Sensitivity to disposable sensor probe adhesive
26
Why should the patient be assisted to a comfortable position?
* Restores patient's comfort
* Promotes sense of well-being
27
Why is hand hygiene important?
* Reduces transmission of microorganisms between patient and nurse
28
Why should findings be discussed with the patient?
* Promotes patient's participation in care
* Promotes understanding of health status
29
What should be done if SpO2 measurements are intermittent/spot-checked?
* Remove probe and turn oximeter off between measurements
* Store probe appropriately
30
Why should SpO2 readings be compared to baseline/acceptable values?
* Comparison reveals presence of abnormality
31
Why should SpO2 be correlated with SaO2 from arterial blood gas?
* Documents reliability of noninvasive assessments
32
Why should SpO2 be correlated with respiratory rate, depth and rhythm?
* Measurements of ventilation, perfusion and diffusion are interrelated
33
What should be done if SpO2 is less than 90%?
* Verify oximeter probe is intact and no outside light interference
* Observe for signs of decreased oxygenation (anxiety, restlessness, tachycardia, cyanosis)
* Verify supplemental oxygen delivery system is functioning properly
* Minimize factors altering SpO2 (lung secretions, increased activity, hyperthermia)
* Position patient for optimal ventilation (e.g. high Fowler's for obesity)
* Recheck SpO2 after interventions and notify physician if still <90%
34
What should be done if heart rate on oximeter is lower than patient's pulse?
* Reposition sensor probe to alternative site with increased blood flow
* Assess for signs of altered cardiac output (decreased BP, cool skin, confusion)
35
How should SpO2 readings be recorded and reported?
* Record SpO2 value, oxygen therapy used, and any desaturation signs/symptoms
* Report abnormal findings to nurse in charge or provider
* Document SpO2 after specific therapies
* Record use of continuous or intermittent pulse oximetry
36
What are community care considerations for pulse oximetry?
* Used to noninvasively monitor oxygen therapy/changes
* Instruct caregivers to examine site before applying sensor
* Instruct procedure if oxygen saturation is unacceptable
37
What factors related to light transmission can interfere with SpO2 readings?
- Outside light sources
- Carbon monoxide (smoke inhalation/poisoning)
- Patient motion
- Jaundice
- Intravascular dyes (e.g. methylene blue)
- Nail polish, artificial nails, metal nail studs
- Dark skin pigment
38
What factors that reduce arterial pulsations can interfere with SpO2 readings?
- Peripheral vascular disease (atherosclerosis)
- Hypothermia at assessment site
- Pharmacological vasoconstrictors (epinephrine, dopamine)
- Low cardiac output and hypotension
- Peripheral edema
- Tight probe recording venous pulsations
39
What is the key consideration for oxygen therapy in palliative care?
- Patient comfort is the priority, not oxygen saturation levels
- Assess if the patient appears uncomfortable or in respiratory distress
- Oxygen therapy may be unnecessary if the patient is peaceful and resting
40
Nursing 20G - Vital Signs
flashcards
Decks in class (19)
# Cards
-
1) Key Terms64
-
2) Guidelines For Measuring Vital Signs17
-
3) Acceptable Readings For Vital Signs ADULTS10
-
4) Body Temperature: Physiology59
-
5) Factors Affecting Body Temperature62
-
6) Nursing Process And Thermoregulation67
-
7) Advantages and Disadvantages of Select Temperature Measurement Sites31
-
8) Nursing Diagnosis & Planning Phase For Temperature20
-
9) Implementation Acute Care Fever34
-
10) Pulse: Physiology And Regulation20
-
11) Assessment Of Pulse59
-
12) Character Of The Pulse31
-
13) Respiration95
-
14) Measuring Oxygen Saturation40
-
15) Blood Pressure90
-
16) Measuring Blood Pressure120
-
17) Health Promotion And Vital Signs36
-
18) Recoding Vital Signs5
-
19) Key Concepts17
