Considerations:
- Provide student with as much privacy as possible given the urgency of the situation
- Skin temperature may affect reading, the student’s finger should not be cold
Supplies:
- Pulse Oximeter
- Student’s Individualized Healthcare Plan (IHP)
- Healthcare provider’s order
- Parent/Guardian authorization form
- Stethoscope
Procedure:
- Review healthcare provider’s order and student’s individualized healthcare plan
- Ensure proper documentation of parent/guardian authorization to perform this procedure
- Gather supplies and place on a clean surface
- Wash hands
- Explain procedure to student at a level he/she will understand
- Turn on pulse oximeter
- Select a distal extremity (usually a fingertip) that can be held still and is void of nail polish, false nail, moisture, and sweat
- Minimize excessive environmental light
- an accurate oxygen saturation reading requires that the pulse oximeter is able to consistently detect the student’s pulse
- all pulse oximeters have some form of light signal or bar graph that correlates with detecting the pulse; and a consistent high level of detection for at least 20–30 seconds is necessary to determine an accurate reading
- Place pulse oximeter probe on distal extremity
- Check operation of the equipment (audible beep, fluctuation of bar of light or waveform on the face of oximeter)
- Make sure that the light emitting sensor and light receiving sensor are aligned opposite
- Wait 20-30 seconds
- Read oxygen saturation level on pulse oximeter
- Remove pulse oximeter probe
- Turn off pulse oximeter
- Follow healthcare provider’s orders with appropriate follow up care
- Wash hands
- Document oxygen saturation level in student’s healthcare record
- Follow up with parents/guardian and healthcare provider, as necessary
- Clean the pulse oximeter per manufacturer’s recommendations
Continuous Pulse Oximetry
- If the pulse oximetry is indicated to be continuous, the probe needs to be secured in place per manufacturer’s instructions
- An order for continuous pulse oximetry requires an oximeter with an alarm
- Alarm parameters are to be set per the healthcare provider’s order
- If the alarm sounds, the student requires immediate assessment to determine if it is a “false alarm” (commonly due to excessive movement) or a true emergency that reflects a sudden deterioration in the student’s respiratory status
References:
Lynn, P. (2019). Using pulse oximeter. In Skill checklists for Taylor’s clinical nursing skills. A nursing process approach. (5th ed.). (pp. 308-309).
Perry, A. G., Potter, P.A., Ostendorf, W., & Laplante, N. (2021). Procedural guideline 5.2 measuring oxygen saturation (pulse oximetry). In Clinical nursing skills and techniques. (10th ed.). (pp. 216-220). St. Louis, MO: Elsevier.
U.S. Food and Drug Administration. (2021, February 19). Pulse oximeter accuracy and limitations: FDA safety communication. Retrieved June 6, 2023, from https://www.fda.gov/medical-devices/safety-communications/pulse-oximeter-accuracy-and-limitations-fda-safety-communication
Page last reviewed: February 28, 2025
Page last updated: February 28, 2025
The information and materials presented in this Website are intended for informational purposes only and are not designed to diagnose or treat a health problem or disease, or assist in diagnosis or treatment of the same. The information is not intended to substitute for, supplement or replace clinical judgment. If there are any concerns or questions about or relating to a nursing or medical procedure, contact the individual’s healthcare provider. The information provided on this Website is not intended to be a substitute for medical orders and persons without the proper education, training, supervision and/or licensure should not perform the procedures.