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Measuring Oxygen Saturation with Pulse Oximetry |
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测量脉氧饱和度 |
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Assessment |
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评估 |
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1. Identify clients at risk for unstable oxygen status. |
1、确认病人存在氧饱和度不稳危险。 | |
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2. Identify medication/treatments that may influence oxygen saturation. |
2、确认药物/治疗可能影响氧饱和度。 | |
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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。 | |
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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。 | |
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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)。 | |
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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。 | |
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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。 | |
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Implementation |
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实施 |
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1. Use Standard Protocol. |
1、根据标准程序开始操作。 | |
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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。 | |
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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。 | |
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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。 | |
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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。 | |
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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。 | |
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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。 | |
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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。 | |
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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。 | |
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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。 | |
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10. Use Completion Protocol. |
10、按标准程序完成操作。 | |
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Evaluation |
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评价 |
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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。 | |
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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。 | |
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3. Identify Unexpected Outcomes and Nursing Interventions |
3、确认意外结果及护理措施。 | |
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Record and Report |
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记录与报告 |
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1. Use of oximetry. |
1、血氧定量法使用情况。 | |
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2. Site. |
2、部位。 | |
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3. SpO2. |
3、动脉血氧饱和度。 | |
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4. Use of O2. |
4、氧气使用。 | |
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5. Skin assessment at site |
5、测量部位皮肤评估情况。 | |
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6. Client's response. |
6、病人反应。 |
