Pulse Oximeter Monitoring

<< RESPIRATORY

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 download skill competency

  1. Gather supplies and place on a clean surface
  2. Review student’s Individualized Healthcare Plan and/or healthcare provider’s orders
  3. Wash hands
  4. Explain procedure to student at a level he/she will understand
  5. Turn on pulse oximeter
  6. Select a distal extremity (usually a fingertip) that can be held still and is void of nail pol­ish, false nail, moisture, and sweat
  7. 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
  8. Place pulse oximeter probe on distal extremity
  9. Wait 20-30 seconds
  10. Read oxygen saturation level on pulse oximeter
  11. Remove pulse oximeter probe
  12. Turn off pulse oximeter
  13. Follow healthcare provider’s orders with appropriate follow up care
  14. Wash hands
  15. Document oxygen saturation level in student’s healthcare record
  16. Follow up with parents/guardian and healthcare provider, as necessary

Continuous Pulse Oximetry

  1. If the pulse oximetry is indicated to be continuous, the probe needs to be secured in place per manufacturer’s instructions
  2. An order for continuous pulse oximetry requires an oximeter with an alarm
  3. Alarm parameters are to be set per the students Individualized Healthcare Plan
  4. 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