Considerations:
- Provide student with as much privacy as possible given the urgency of the situation
Supplies:
- Pulse Oximeter
- Student’s Individualized Healthcare Plan (IHP)/Healthcare provider’s order
- Stethoscope
- Gather supplies and place on a clean surface
- Review student’s Individualized Healthcare Plan and/or healthcare provider’s orders
- 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
- 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
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 students Individualized Healthcare Plan
- 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:
Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures (Third Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Connecticut State Department of Education. (2012). Clinical Procedure Guidelines for Connecticut School Nurses. Available at:
http://www.sde.ct.gov/sde/lib/sde/pdf/publications/clinical_guidelines/clinical_guidelines.pdf
Acknowledgment of Reviewers:
Marcia Creasy, BSN, RN
Retired School Nurse
Cynthia C. Griffith, RN, BSN
Nurse Clinician
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin
Jill Krueger, RN, BSN
Director/Health Officer
Forest County Health Department
Carole Wegner, MSN, RN
Clinical Nurse Specialist
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin
Page last updated: April 1, 2015
