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Measuring Oxygen Saturation with Pulse Oximetry |
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測量脈氧飽和度 |
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Assessment |
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評估 |
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1. Identify clients at risk for unstable oxygen status. |
1、確認病人存在氧飽和度不穩(wěn)危險。 | |
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2. Identify medication/treatments that may influence oxygen saturation. |
2、確認藥物/治療可能影響氧飽和度。 | |
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3. Identify altered Hgb that may affect oxygen saturation. |
3、確認血紅蛋白變化可能影響氧飽和度。 | |
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4. Identify factors likely to interfere with accuracy of pulse oximeter. |
4、確認可能影響脈氧儀精確度的各種因素。 | |
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5. Assess pertinent laboratory values (Hgb and ABGs). |
5、評估相關化驗結(jié)果(血紅蛋白和動脈血氣)。 | |
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6. Determine client-specific site appropriate to place pulse oximeter probe by measuring capillary refill. |
6、測定毛細血管再充盈情況，決定特定病人脈氧儀探針放置部位。 | |
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7. Determine previous baseline SpO2 from client's record. |
7、根據(jù)病歷記錄確定先前動脈血氧飽和度基線。 | |
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Implementation |
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實施 |
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1. Use Standard Protocol. |
1、根據(jù)標準程序開始操作。 | |
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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、選擇部位(耳、甲床或鼻梁)。如選擇手指，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. 醫(yī)學全在線www.med126.com |
3、確定測量部位毛細血管再充盈情況。如慢于3秒，則另選他處。 | |
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4. If finger is chosen as monitoring site, support lower arm. Instruct client to keep sensor probe site still. |
4、如選擇手指為測量部位，請支撐小臂。囑咐病人穩(wěn)定探測部位。 | |
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5. Attach sensor probe to selected site, making sure photodetectors of light sensors are aligned opposite each other. |
5、將探測夾貼住所選部位，確保光敏元件感測器兩側(cè)對齊。 | |
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Nurse Alert: Wrong probe can cause burns. Check for latex allergies/sensitivity. |
注意：探測器選錯會導致灼傷。檢查有無乳膠過敏/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、打開電源，接通血氧儀。觀察脈搏波形/強度和嘟嘟聲。對比血氧儀脈率與病人橈動脈搏動。 | |
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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、留置探測器直到血氧儀值穩(wěn)定，每心動周期脈搏顯示達到充分強度。讀取數(shù)字顯示器的動脈血氧飽和度。 | |
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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、如計劃連續(xù)測量動脈血氧飽和度，則檢查動脈血氧飽和報警設置，出廠時預設的值為低85%、高100%。確認報警器打開。評估探測器下皮膚完整性。至少每4小時重置探測器一次。 | |
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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、若為間斷性或抽樣檢查，可除去探測器并關閉血氧儀電源，將探測器貯藏于適當位置。 | |
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10. Use Completion Protocol. |
10、按標準程序完成操作。 | |
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Evaluation |
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評價 |
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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、比較氧療開始或結(jié)束、睡前和睡眠期間、活動前和活動時、及抽吸分泌物后的動脈血氧飽和度。 | |
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2. Observe for indications of hypoxemia, which include the presence of cyanosis, restlessness, altered respiratory patterns, and tachycardia. |
2、觀察是否出現(xiàn)低氧血癥跡象，包括發(fā)紺、不安、呼吸形態(tài)改變及心動過速。 | |
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3. Identify Unexpected Outcomes and Nursing Interventions |
3、確認意外結(jié)果及護理措施。 | |
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Record and Report |
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記錄與報告 |
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1. Use of oximetry. |
1、血氧定量法使用情況。 | |
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2. Site. |
2、部位。 | |
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3. SpO2. |
3、動脈血氧飽和度。 | |
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4. Use of O2. |
4、氧氣使用。 | |
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5. Skin assessment at site |
5、測量部位皮膚評估情況。 | |
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6. Client's response. |
6、病人反應。 |
