| Measuring Oxygen Saturation with Pulse Oximetry | 測量脈搏氧飽和度 |
| Assessment | 評估 |
| 1. Identify clients at risk for unstable oxygen status. | 確認病人有氧飽和度不穩(wěn)危險?！?/td> |
| 2. Identify medication/treatments that may influence oxygen saturation. | 確認藥物/治療可能影響氧飽和度?！?/td> |
| 3. Identify altered Hgb that may affect oxygen saturation. | 確認血紅蛋白變化可能影響氧飽和度。 |
| 4. Identify factors likely to interfere with accuracy of pulse oximeter . | 確認可能影響脈氧儀精確度的各種因素。 |
| 5. Assess pertinent laboratory values （Hgb and ABGs）. | 評估相關(guān)化驗值（血紅蛋白和動脈血氣）。 |
| 6. Determine client-specific site appropriate to place pulse oximeter probe by measuring capillary refill. | 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。 |
| 7. Determine previous baseline SpO2 from client's record. | 根據(jù)病歷記錄確定先前動脈血氧飽和度基線。 |
| Implementation | 實施 |
| 1. Use Standard Protocol. | 應用標準護理措施。 |
| 2. Select site （ear, nail bed, or bridge of nose）. If finger is selected, remove fingernail polish with acetone or polish remover. | 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。 |
| 3. Determine capillary refill at site. If less than 3 seconds, select alternative site. | 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?！?/td> |
| 4. If finger is chosen as monitoring site, support lower arm. Instruct client to keep sensor probe site still. | 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?！?/td> |
| 5. Attach sensor probe to selected site, making sure photodetectors of light sensors are aligned opposite each other. | 將探測夾貼住所選部位，確保光敏原件感測器兩側(cè)對齊?！?/td> |
| 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。 |
| 6. Turn on oximeter by activating power. Observe pulse waveform/intensity display and audible beep. Compare oximeter pulse rate with client's radial pulse. | 打開電源，接通血氧計。觀察脈搏波形/強度和嘟嘟聲。對比血氧計脈率與病人橈動脈搏動?！?/td> |
| 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. | 留置探測器直到血氧計達到恒定值，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?！?/td> |
| 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. | 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于85%和高于100%。確認報警器打開。評估探測器下皮膚完整性。至少每4小時重新放置探測器一次?！?/td> |
| 9. If intermittent or spot-checking SpO2 measurements are planned, remove probe and turn oximeter power off. Store probe in appropriate location. | 如是間斷性或抽樣檢查，除去探測器并關(guān)閉血氧計電源，將探測器貯藏于適當位置?！?/td> |
| 10. Use Completion Protocol. | 應用護理操作結(jié)束程序。 |
| Evaluation | 評價 |
| 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. | 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?！?/td> |
| 2. Observe for indications of hypoxemia, which include the presence of cyanosis, restlessness, altered respiratory patterns, and tachycardia. | 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。 |
| 3. Identify Unexpected Outcomes and Nursing Interventions | 確認意外結(jié)果及護理措施?！?/td> |
| Record and Report | 記錄與報告 |
| 1. Use of oximetry. | 血氧定量法使用情況 |
| 2. Site. | 部位 |
| 3. SpO2. | 動脈血氧飽和度 |
| 4. Use of O2. | 氧氣使用 |
| 5. Skin assessment at site | 測量部位皮膚評估情況 |
| 6. Client's response. | 病人反應 |
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