Policies,Clinical,UWMF Clinical,UWMF-wide,Clinical Policies and Procedures,Pulmonary

Pulse Oximetry (102.112)

Pulse Oximetry (102.112) - Policies, Clinical, UWMF Clinical, UWMF-wide, Clinical Policies and Procedures, Pulmonary




Effective Date: April, 2002 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education
Reviewed October, 2003 March, 2005 March, 2006 November 2007
May 2010 August 2011

PURPOSE: To provide guidelines for the measurement of oxygen saturation of blood.

DEFINITION: The pulse oximeter uses fiber optics to measure the amount of oxygenated hemoglobin in
arterial blood.

POLICY: The clinical staff will utilize the following guidelines when using a pulse oximeter on UWMF

SUPPLIES: Pulse oximeter, Adult, Pediatric, or Long-term Sensor, Nail polish remover, alcohol wipes

1. Check provider’s order and clarify any inconsistencies.

2. Wash hands and gather equipment.

3. Introduce yourself and identify the patient; include DOB (parent or guardian).

4. Explain procedure and purpose for the pulse oximeter, verify allergy/sensitivity to adhesive if using
adhesive probe.

5. Select adequate site for application of sensor and proper probe for patient age and size:
Infant (3-15 kg)
o Site
 Around a great toe with the cable positioned along the side of the foot
o Probe
 Adhesive wrap-around sensor
Child ( 12-40 kg)
o Site
 Around an index finger with the cable positioned along the medial side of the finger
 Alternative sites are around a thumb, finger, or a great toe.
o Probe
 Adhesive wrap-around sensor - for young child
 Adult finger-clip sensor – for older child and short-term use
Adult (>40 kg)
o Site
 Index finger with cable positioned along the medial side of the finger
 Alternative sites are thumb, finger, or great toe
o Probe
 Adult finger-clip sensor - for short-term use
 Adhesive wrap-around sensor - for long term


6. Prepare monitoring site:
Cleanse selected area, if necessary, and allow the area to dry
Remove nail polish
 Check capillary refill and skin color/integrity at site.

7. Apply probe securely to patient.

8. Make sure light-emitting sensor and light-receiving sensor are aligned opposite each other.

9. Connect sensor probe to pulse oximeter and check operation of equipment (presence of audible beep
and fluctuation of bar of light or waveform on oximeter display).

10. Check oxygen saturation at regular intervals or as ordered by the provider.

LONG TERM USE IN ADULTS - For long-term situations (more than 20 minutes) use the adhesive wrap-
around sensor.
Note: When placing the adhesive wrap-around sensor on a finger or toe, the WHITE sensor pad
must be placed on the NAIL SIDE

Begin by removing the metal or plastic case from probe. (C, D, E, & F below)

Remove tab (band-aid like covering) and connect the ‘wrap-around’ probe cover to the sensor. (See
diagram below).

Place finger down on one sensor – then wrap second sensor around the top of first sensor. White
sensor must be placed on top/nail side. (See the two diagrams below).

Remove sensor on a regular basis and check for skin irritation or signs of pressure (approximately
every 4 hours)

Note: When placing the adhesive wrap-around sensor on a finger or toe, the WHITE sensor pad
must be placed on the NAIL SIDE

Do NOT use standard metal or plastic probe for long-term use as clip can compromise skin integrity
or cause neural damage.
Do NOT expose sensor to bright light as this will cause an inaccurate reading.
Most pulse ox models CANNOT be used in the MRI scanner.

Problem Solving: (for malfunctions or problems with equipment)
Sensor does not track pulse reliably
o Check position of probe
o Consider problems with site selection – site may be too thick, thin, or deeply colored (nail
polish, dye, or pigmented cream)
For absent or weak signal
o check patient's vital signs and condition. If satisfactory, check connections and circulation to
the site.
If bright light (sunlight or fluorescent light) is suspected of causing equipment malfunction
o cover sensor/site with a dry washcloth.

11. Report abnormal SaO2 saturation (less than 95%) immediately to provider.

12. Documentation in patient’s record (in Progess Notes section of HealthLink using SmartPhrase .npox)
Patient education
Assessment & Vital Signs – as appropriate
Pulse oximeter application site and SaO2 reading
How patient tolerated procedure

13. Cleaning Pulse Oximeter – after each use
The sensor may be surface cleaned with alcohol wipe; if low-level disinfection is required, use a
1:10 bleach solution
Use of cleaning solutions other than those recommended may cause permanent damage to sensor
Do NOT expose connector pins to cleaning solution as this may damage sensor
Do NOT sterilize by irradiation, steam, or ethylene oxide.

REVISED BY: LaVay Morrison, RN, BSN, Clinical Staff Educator
Carol Decker, RN, MSN, Clinical Staff Educator

REVIEWED BY: Janice Sydow, RN, Team Leader, East Towne Pediatrics
Melinda Hanson, CMA, Fitchburg Pediatrics

WRITTEN BY: Ronnie Peterson, R.N., M.S., Manager of Clinical Support

REFERENCES: http://pediatrics.aappublications.org/content/99/5/681.full
Nellcor Puritan Bennett Inc., 2003. OxiMax N-65 Operator’s Manual.


Medical Director Date