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Measuring Oxygen Saturation with Pulse Oximetry |
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測(cè)量脈氧飽和度 |
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Assessment |
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評(píng)估 |
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1. Identify clients at risk for unstable oxygen status. |
1、確認(rèn)病人存在氧飽和度不穩(wěn)危險(xiǎn)。 | |
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2. Identify medication/treatments that may influence oxygen saturation. |
2、確認(rèn)藥物/治療可能影響氧飽和度。 | |
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3. Identify altered Hgb that may affect oxygen saturation. |
3、確認(rèn)血紅蛋白變化可能影響氧飽和度。 | |
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4. Identify factors likely to interfere with accuracy of pulse oximeter. |
4、確認(rèn)可能影響脈氧儀精確度的各種因素。 | |
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5. Assess pertinent laboratory values (Hgb and ABGs). |
5、評(píng)估相關(guān)化驗(yàn)結(jié)果(血紅蛋白和動(dòng)脈血?dú)?。 | |
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6. Determine client-specific site appropriate to place pulse oximeter probe by measuring capillary refill. |
6、測(cè)定毛細(xì)血管再充盈情況，決定特定病人脈氧儀探針?lè)胖貌课弧? | |
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7. Determine previous baseline SpO2 from client's record. |
7、根據(jù)病歷記錄確定先前動(dòng)脈血氧飽和度基線。 | |
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Implementation |
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實(shí)施 |
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1. Use Standard Protocol. |
1、根據(jù)標(biāo)準(zhǔn)程序開(kāi)始操作。 | |
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2. Select site (ear, nail bed, or bridge of nose). If finger is selected, remove fingernail polish with acetone or polish remover. |
2、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。 | |
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3. Determine capillary refill at site. If less than 3 seconds, select alternative site. 醫(yī)學(xué)全在線www.med126.com |
3、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。 | |
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4. If finger is chosen as monitoring site, support lower arm. Instruct client to keep sensor probe site still. |
4、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。 | |
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5. Attach sensor probe to selected site, making sure photodetectors of light sensors are aligned opposite each other. |
5、將探測(cè)夾貼住所選部位，確保光敏元件感測(cè)器兩側(cè)對(duì)齊。 | |
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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(wú)乳膠過(guò)敏/敏感性。 | |
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6. Turn on oximeter by activating power. Observe pulse waveform/intensity display and audible beep. Compare oximeter pulse rate with client's radial pulse. |
6、打開(kāi)電源，接通血氧儀。觀察脈搏波形/強(qiáng)度和嘟嘟聲。對(duì)比血氧儀脈率與病人橈動(dòng)脈搏動(dòng)。 | |
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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. |
7、留置探測(cè)器直到血氧儀值穩(wěn)定，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。 | |
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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. |
8、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85%、高100%。確認(rèn)報(bào)警器打開(kāi)。評(píng)估探測(cè)器下皮膚完整性。至少每4小時(shí)重置探測(cè)器一次。 | |
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9. If intermittent or spot-checking SpO2 measurements are planned, remove probe and turn oximeter power off. Store probe in appropriate location. |
9、若為間斷性或抽樣檢查，可除去探測(cè)器并關(guān)閉血氧儀電源，將探測(cè)器貯藏于適當(dāng)位置。 | |
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10. Use Completion Protocol. |
10、按標(biāo)準(zhǔn)程序完成操作。 | |
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Evaluation |
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評(píng)價(jià) |
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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. |
1、比較氧療開(kāi)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。 | |
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2. Observe for indications of hypoxemia, which include the presence of cyanosis, restlessness, altered respiratory patterns, and tachycardia. |
2、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(guò)速。 | |
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3. Identify Unexpected Outcomes and Nursing Interventions |
3、確認(rèn)意外結(jié)果及護(hù)理措施。 | |
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Record and Report |
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記錄與報(bào)告 |
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1. Use of oximetry. |
1、血氧定量法使用情況。 | |
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2. Site. |
2、部位。 | |
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3. SpO2. |
3、動(dòng)脈血氧飽和度。 | |
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4. Use of O2. |
4、氧氣使用。 | |
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5. Skin assessment at site |
5、測(cè)量部位皮膚評(píng)估情況。 | |
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6. Client's response. |
6、病人反應(yīng)。 |
