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
Procedure:
- 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
U.S. Food and Drug Administration. (2021, February 19). Pulse oximeter accuracy and limitations: FDA safety communication. Accessed September 15, 2021 from https://www.fda.gov/medical-devices/safety-communications/pulse-oximeter-accuracy-and-limitations-fda-safety-communication
Acknowledgment of Initial 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: September 15, 2021
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.