| Measuring Oxygen Saturation with Pulse Oximetry |
测量脉搏氧饱和度 |
| Assessment |
评估 |
| 1. Identify clients at risk for unstable oxygen status. |
确认病人有氧饱和度不稳危险。 |
| 2. Identify medication/treatments that may influence oxygen saturation. |
确认药物/治疗可能影响氧饱和度。 |
| 3. Identify altered Hgb that may affect oxygen saturation. |
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 . |
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）. |
评估相关化验值（血红蛋白和动脉血气）。 |
| 6. Determine client-specific site appropriate to place pulse oximeter probe by measuring capillary refill. |
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. |
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. |
应用标准护理措施。 |
| 2. Select site （ear, nail bed, or bridge of nose）. If finger is selected, remove fingernail polish with acetone or polish remover. |
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. |
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. |
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. |
将探测夹贴住所选部位，确保光敏原件感测器两侧对齐。 |
| 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. |
打开电源，接通血氧计。观察脉搏波形/强度和嘟嘟声。对比血氧计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. |
留置探测器直到血氧计达到恒定值，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. |
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于85%和高于100%。确认报警器打开。评估探测器下皮肤完整性。至少每4小时重新放置探测器一次。 |
| 9. If intermittent or spot-checking SpO2 measurements are planned, remove probe and turn oximeter power off. Store probe in appropriate location. |
如是间断性或抽样检查，除去探测器并关闭血氧计电源，将探测器贮藏于适当位置。 |
| 10. Use Completion Protocol. |
应用护理操作结束程序。 |
| 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. |
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. |
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 |
确认意外结果及护理措施。 |
| Record and Report |
记录与报告 |
| 1. Use of oximetry. |
血氧定量法使用情况 |
| 2. Site. |
部位 |
| 3. SpO2. |
动脉血氧饱和度 |
| 4. Use of O2. |
氧气使用 |
| 5. Skin assessment at site |
测量部位皮肤评估情况 |
| 6. Client's response. |
病人反应 |
