| Measuring Oxygen Saturation with Pulse Oximetry | 測(cè)量脈搏氧飽和度 |
| Assessment | 評(píng)估 |
| 1. Identify clients at risk for unstable oxygen status. | 確認(rèn)病人有氧飽和度不穩(wěn)危險(xiǎn)?！?/td> |
| 2. Identify medication/treatments that may influence oxygen saturation. | 確認(rèn)藥物/治療可能影響氧飽和度?！?/td> |
| 3. Identify altered Hgb that may affect oxygen saturation. | 確認(rèn)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(rèn)可能影響脈氧儀精確度的各種因素。 |
| 5. Assess pertinent laboratory values （Hgb and ABGs）. | 評(píng)估相關(guān)化驗(yàn)值（血紅蛋白和動(dòng)脈血?dú)猓?。?/td> |
| 6. Determine client-specific site appropriate to place pulse oximeter probe by measuring capillary refill. | 測(cè)定毛細(xì)血管再充盈情況，決定特定病人脈氧儀探針放置部位?！?/td> |
| 7. Determine previous baseline SpO2 from client's record. | 根據(jù)病歷記錄確定先前動(dòng)脈血氧飽和度基線?！?/td> |
| Implementation | 實(shí)施 |
| 1. Use Standard Protocol. | 應(yīng)用標(biāo)準(zhǔn)護(hù)理措施?！?/td> |
| 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?！?/td> |
| 3. Determine capillary refill at site. If less than 3 seconds, select alternative site. | 確定測(cè)量部位毛細(xì)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(cè)量部位，請(qǐng)支撐小臂。囑咐病人穩(wěn)定探測(cè)部位?！?/td> |
| 5. Attach sensor probe to selected site, making sure photodetectors of light sensors are aligned opposite each other. | 將探測(cè)夾貼住所選部位，確保光敏原件感測(cè)器兩側(cè)對(duì)齊?！?/td> |
| Nurse Alert: Wrong probe can cause burns. Check for latex allergies/sensitivity. | 注意：探測(cè)器選錯(cuò)會(huì)導(dǎo)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(jì)。觀察脈搏波形/強(qiáng)度和嘟嘟聲。對(duì)比血氧計(jì)脈率與病人橈動(dòng)脈搏動(dòng)?！?/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(cè)器直到血氧計(jì)達(dá)到恒定值，每心動(dòng)周期脈搏顯示達(dá)到充分強(qiáng)度。讀取數(shù)字顯示器的動(dòng)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(jì)劃連續(xù)測(cè)量動(dòng)脈血氧飽和度，則檢查動(dòng)脈血氧飽和報(bào)警設(shè)置，出廠時(shí)預(yù)設(shè)的值為低于85%和高于100%。確認(rèn)報(bào)警器打開。評(píng)估探測(cè)器下皮膚完整性。至少每4小時(shí)重新放置探測(cè)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(cè)器并關(guān)閉血氧計(jì)電源，將探測(cè)器貯藏于適當(dāng)位置?！?/td> |
| 10. Use Completion Protocol. | 應(yīng)用護(hù)理操作結(jié)束程序?！?/td> |
| Evaluation | 評(píng)價(jià) |
| 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(dòng)前和活動(dòng)時(shí)、及抽吸分泌物后的動(dòng)脈血氧飽和度。 |
| 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(dòng)過速?！?/td> |
| 3. Identify Unexpected Outcomes and Nursing Interventions | 確認(rèn)意外結(jié)果及護(hù)理措施?！?/td> |
| Record and Report | 記錄與報(bào)告 |
| 1. Use of oximetry. | 血氧定量法使用情況 |
| 2. Site. | 部位 |
| 3. SpO2. | 動(dòng)脈血氧飽和度 |
| 4. Use of O2. | 氧氣使用 |
| 5. Skin assessment at site | 測(cè)量部位皮膚評(píng)估情況 |
| 6. Client's response. | 病人反應(yīng) |
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