Measuring Oxygen Saturation with Pulse Oximetry

测量脉氧饱和度

Assessment

评估

1. Identify clients at risk for unstable oxygen status.

1、确认病人存在氧饱和度不稳危险。

2. Identify medication/treatments that may influence oxygen saturation.

2、确认药物/治疗可能影响氧饱和度。

3. Identify altered Hgb that may affect oxygen saturation.

3、确认血红蛋白变化可能影响氧饱和度。

4. Identify factors likely to interfere with accuracy of pulse oximeter.

4、确认可能影响脉氧仪精确度的各种因素。

5. Assess pertinent laboratory values (Hgb and ABGs).

5、评估相关化验结果(血红蛋白和动脉血气)。

6. Determine client-specific site appropriate to place pulse oximeter probe by measuring capillary refill.

6、测定毛细血管再充盈情况，决定特定病人脉氧仪探针放置部位。

7. Determine previous baseline SpO2 from client's record.

7、根据病历记录确定先前动脉血氧饱和度基线。

Implementation

实施

1. Use Standard Protocol.

1、根据标准程序开始操作。

2. Select site (ear, nail bed, or bridge of nose). If finger is selected, remove fingernail polish with acetone or polish remover.

2、选择部位(耳、甲床或鼻梁)。如选择手指，用丙酮或除甲油除去指甲油。

3. Determine capillary refill at site. If less than 3 seconds, select alternative site. 医学全在线www.med126.com

3、确定测量部位毛细血管再充盈情况。如慢于3秒，则另选他处。

4. If finger is chosen as monitoring site, support lower arm. Instruct client to keep sensor probe site still.

4、如选择手指为测量部位，请支撑小臂。嘱咐病人稳定探测部位。

5. Attach sensor probe to selected site, making sure photodetectors of light sensors are aligned opposite each other.

5、将探测夹贴住所选部位，确保光敏元件感测器两侧对齐。

Nurse Alert: Wrong probe can cause burns. Check for latex allergies/sensitivity.

注意：探测器选错会导致灼伤。检查有无乳胶过敏/敏感性。

6. Turn on oximeter by activating power. Observe pulse waveform/intensity display and audible beep. Compare oximeter pulse rate with client's radial pulse.

6、打开电源，接通血氧仪。观察脉搏波形/强度和嘟嘟声。对比血氧仪脉率与病人桡动脉搏动。

7. Leave sensor probe in place until oximeter reaches constant value and pulse display reaches full strength during each cardiac cycle. Read SpO2 on digital display.

7、留置探测器直到血氧仪值稳定，每心动周期脉搏显示达到充分强度。读取数字显示器的动脉血氧饱和度。

8. If continuous SpO2 monitoring is planned, check SpO2 alarm limits, which are preset by the manufacturer at a low of 85% and a high of 100%. Verify that alarms are on. Assess skin integrity under sensor probe and relocate sensor probe at least every 4 hours.

8、如计划连续测量动脉血氧饱和度，则检查动脉血氧饱和报警设置，出厂时预设的值为低85%、高100%。确认报警器打开。评估探测器下皮肤完整性。至少每4小时重置探测器一次。

9. If intermittent or spot-checking SpO2 measurements are planned, remove probe and turn oximeter power off. Store probe in appropriate location.

9、若为间断性或抽样检查，可除去探测器并关闭血氧仪电源，将探测器贮藏于适当位置。

10. Use Completion Protocol.

10、按标准程序完成操作。

Evaluation

评价

1. Compare SpO2 levels whenever oxygen therapy is initiated or discontinued, before and during sleep, before and during activity, and after removal of secretions with suctioning.

1、比较氧疗开始或结束、睡前和睡眠期间、活动前和活动时、及抽吸分泌物后的动脉血氧饱和度。

2. Observe for indications of hypoxemia, which include the presence of cyanosis, restlessness, altered respiratory patterns, and tachycardia.

2、观察是否出现低氧血症迹象，包括发绀、不安、呼吸形态改变及心动过速。

3. Identify Unexpected Outcomes and Nursing Interventions

3、确认意外结果及护理措施。

Record and Report

记录与报告

1. Use of oximetry.

1、血氧定量法使用情况。

2. Site.

2、部位。

3. SpO2.

3、动脉血氧饱和度。

4. Use of O2.

4、氧气使用。

5. Skin assessment at site

5、测量部位皮肤评估情况。

6. Client's response.

6、病人反应。