Pulse Oximeters

Pulse Oximeters
Finding	Intervention
SpO2 > 95%	■ Considered normal and requires no intervention. ■ Continue routine monitoring of Pt.
SpO2 91%–94%	■ Considered acceptable. ■ Assess probe placement and adjust if necessary. ■ Continue to monitor Pt.
SpO2 85%–90%	■ Raise head of bed (HOB) and stimulate Pt to breathe deeply. ■ Assess airway and encourage coughing. ■ Suction airway if needed. ■ Administer oxygen and titrate to SpO2 > 90%. ■ Notify physician and respiratory therapist (RT) if SpO2 fails to improve after a few minutes.
SpO2 < 85%	■ Administer 100% oxygen, position Pt to facilitate breathing, suction airway if needed, and notify physician and RT immediately. ■ Check medication record and consider naloxone or flumazenil for medicationinduced respiratory depression. ■ Be prepared to manually ventilate or aid in intubation if condition worsens or fails to improve.

Caution: Consider readings within the overall context of the Pt’s medical history and physical exam. The reliability of pulse oximeters is sometimes questionable and many conditions can produce false readings. Assess the Pt’s skin signs, respiratory rate (RR), and heart rate (HR). Ask how the Pt is feeling. Repositioning the probe to a different location (ears, toes, or a different finger) may help correct a suspected false reading.

Conditions That May Produce False Readings

Anemia	false high
Carbon monoxide (CO) poisoning	false high
Hypovolemia	false high
Pt movement	erratic readings
Cool extremities	false low
Dark pigment	false low
Nail polish	false low
Medication (peripheral vasoconstrictors)	false low
Poor peripheral circulation	false low
Raynaud’s disease	false low