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 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 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 medication-induced respiratory depression. ■ Be prepared to manually ventilate or aid in intubation if condition worsens or fails to improve.

Caution: 

Consider readings within overall context of Pt’s medical history and physical exam. Reliability of pulse oximeters is sometimes questionable, and many conditions can produce false readings. Assess Pt’s skin signs, RR, and HR. Ask how Pt is feeling. Repositioning probe to a different location (ears, toes, or

different finger) may help correct suspected false reading. Note: readings > 90% may be considered normal to acceptable in Pts who normally live at higher altitudes.

Conditions That May Produce False Readings

Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . false high

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 or nail infections . . . . . . . . . . . . . . false low

Medication (peripheral vasoconstrictors) . . . . false low

Poor peripheral circulation . . . . . . . . . . . . . . . false low

Raynaud’s disease . . . . . . . . . . . . . . . . . . . . . . false low