Fundamentals:Skills Oxygen Saturation (O2 Sat)

Capnography measures the approximate level of partial pressure CO2(the PaCO2) in the blood at the end of exhalation, also known as

end-tidal

What is the normal range for SpO2?

93%-100%

The most reliable SpO2 measurements are obtained using which of the following? Select all that apply.

-an earlobe probe
-a forehead probe

A nurse is caring for a client whose respiratory rate and depth are elevated. The nurse is going to assess the client's ventilation status by obtaining a capnography measurement. Which results are anticipated through the measurement? Select all that apply.​

-Short EtCO2 waveform (under 45 mmHG line)
-Hyperventilation
-Decreased PaCO2

A nurse is preparing to measure an adult client's SpO2 as part of a routine vital signs assessment. The client asks the nurse what the device is for and if it will hurt. Which responses by the nurse are appropriate? Select all that apply.​

-"This is called a pulse oximeter. This probe has a light-emitting diode (LED) light in it that measures the amount of oxygen in your arteries."
-"It should not hurt your finger tip. It is very loose. You have told me that you do not have any pain in that area and you do not have any skin breakdown or swelling in that area either. Are you comfortable with proceeding?"

The nurse is completing a set of routine vital signs on a client, which includes a SpO2. The nurse obtains a reading of 93%. What is the next step for the nurse to take?

Assess the client

A nurse prepares to obtain a SpO2 reading on a client. Which factors would impact the nurse's choice of measurement site? Select all that apply.​

-The client is anemic.
-The client has atherosclerosis.
-The client has liver disease.
-The client's temperature is 35.9⁰C (103.1⁰F).

A nurse is obtaining a SpO2 measurement on an infant client. Which site will likely be used by the nurse?

Adhesive foot sensor

The nurse caring for a postoperative client is assessing their vital signs. What factors associated with the client's postoperative status may impact oxygen saturation and/or SpO2 measurement? Select all that apply.​

-Air temperature in the surgical suite
-General anesthesia
-Intraoperative use of an intravascular dye
-Postoperative pain
-Intraoperative hemorrhage

The nurse is caring for an adult client whose respiratory rate is 8. The client's breaths are shallow but regular. The nurse prepares to assess the client's ventilation status by obtaining a capnography measurement and is anticipating that it will show which of the following based on this information?

PaCO2 60 mmHg

The nurse is preparing to assess a client's SpO2. For each client below, click to specify which pulse oximeter sites would be the best choice for them. Each client may have more than one appropriate oximeter site.

FOREHEAD
-a mobile toddler

EARLOBE
-a client with a latex allergy
-a diaphoretic client
-a client with artificial nails
BRIDGE OF NOSE
-a client with artificial nails

FINGERTIP
-A client with a latex allergy
-A diaphoretic client
-A client with severe head trauma

A nurse is caring for a client with a nursing diagnosis of "Risk for Ineffective Respiratory Function." Which intervention should be the priority focus for the nurse when caring for this client?

Assess for improvements in respiratory function, including vital signs

Which finding may be contributing to the low pulse oximetry reading?

Using the same arm for blood pressure and SpO2 measurement

The nurse analyzes all of the assessment findings to determine if there are any priorities requiring nursing action. The nurse knows that there are various factors that can impact SpO2 measurement. What do these findings tell the nurse about why it was difficult to get a pulse oximetry reading using the fingertip probe? Select all that apply.

-Dave's blood pressure, temperature, pulse, and SpO2 all mean that it is possible that his cardiac output is diminished and/or there is evidence of peripheral vasoconstriction. Therefore, there is less blood in the peripheral arteries.
-Dave's anemia means that he has a low hemoglobin level, which means that his blood's capacity for carrying oxygen is diminished.

Dave's SpO2 lowers to 89% while the nurse is in the room completing the assessment. Place the following actions in order of priority.

1Address Dave's airway, breathing, and circulation (ABCs) including reassessing vital signs and observing for signs of hypoxia.
2Verify the pulse oximeter is working properly.
3Verify that Dave's supplemental oxygen is flowing and working properly.
4Alert others of the medial emergency (if warranted).

Which assessment finding indicates that respiratory function is improving?

Dave's SpO2 increases to 96% after ensuring that his supplemental oxygen is working properly.