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Pulse Oximetry Revisited: "But His O2 Sat was Normal!"

Article  in  Clinical Nurse Specialist · November 2006

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Pulse Oximetry Revisited
‘‘But His O2 Sat was Normal!’’
ANGELA P. CLARK, PhD, RN, CNS, FAAN, FAHA; KAREN GIULIANO, PhD, RN, FAAN;
HSING-MEI CHEN, MSN, RN
Several years ago, our journal published an article providing
recommendations for pulse oximetry interpretation that were
gleaned from a review of several malpractice cases, including
depositions, and medical records. The purpose of this brief
article is to update the original recommendations with the inte-
gration of other recent literature on the topic of pulse oximetry.
N urses are the interface between technology and
individual patients. We use an array of technology
for patient monitoring to provide nursing care in a variety
of healthcare settings.1 According to the National Associ-
ation of Clinical Nurse Specialists Statement on Practice
and Education,2 one of the core competencies for clinical
nurse specialists is the selection, design, and use of
technology, including products and devices, to improve
patient outcomes. We serve as expert clinicians, teachers,
and consultants to nurses in the use and interpretation of
data obtained through trend assessment.
One of the most common technological devices used in
hospitals and ambulatory care settings is the pulse oxim-
eter, a device that measures oxygen saturation (and also
pulse rate). It is used as an estimate of arterial oxygen sat-
uration (SaO2). When oxygen saturation is obtained with a
pulse oximeter, it is abbreviated as SpO2, with the reference
range of 97% to 99% in a healthy individual breathing
room air.3 An SpO2 of 95% is considered clinically accept-
able in a patient with a normal hemoglobin. An oxygen
saturation value of 90% is the lowest value that is accept-
able and is generally equated with an arterial blood oxygen
(PaO2) of 60 mm Hg.3 A saturation of 90% and below
should be a red flag alert for cliniciansVit is considered as
From The University of Texas at Austin, Austin, Tex (Dr Clark
and Ms Chen); and the Philips Medical Systems, Andover, Mass
(Dr Giuliano).
Corresponding author: Angela P. Clark, PhD, RN, CNS, FAAN, FAHA,
The University of Texas at Austin School of Nursing, 1700 Red River,
Austin, TX 78701 (e-mail: apclark@mail.utexas.edu).
Clinical Nurse SpecialistA Copyright B 2006 by Lippincott Williams &
Wilkins, Inc.
268
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
legal and ethical
Angela P. Clark, PhD, RN, CNS, FAAN, FAHA
Column Editor
a marker for hospitalization for conditions such as pneu-
monia or acute heart failure.4,5
Continuous monitoring of oxygen saturation (SpO2) has
become a standard of care in the operating room, post-
anesthesia care, critical care, emergency departments, and
environments where conscious sedation is used.6 Pulse
oximeters are economical, do not require calibration, are
relatively easy to use, and provide a quick evaluation of the
patient’s oxygen saturation. As the acuity level of hospi-
talized patients has increased on the past 10 years, so too
has the need for oxygen saturation monitoring outside the
critical care areas. In a systematic review of data from
21,773 perioperative patients in randomized, controlled
trials of pulse oximetry versus no pulse oximetry, Pederson
et al7 reported that the incidence of hypoxemia was 1.5 to
3 times less in the pulse oximetry groups. In the future,
more applications of this technology may be seen. An in-
novative use of pulse oximetry was recently reported that
when placed on the big toe site (patients lying down, toes
elevated 12µ), pulse oximetry readings predicted lower
arterial extremity disease in people with diabetes and com-
pared favorably to assessment of the ankle-brachial index.8
However, as with all technology, nurses must be familiar
with how pulse oximeters work, what patient characteristics
affect their accuracy, and how to troubleshoot potentially
erroneous readings. Although nurses’ knowledge on the use
of pulse oximetry has improved in recent years, knowledge
gaps continue to exist.9 These gaps, however, can be filled
with targeted educational initiatives. Attin and colleagues10
evaluated the extent of current knowledge about pulse
oximetry among nurses, physicians, and respiratory thera-
pists before and after providing an education program on
the subject. Significant improvements in scores were seen in
all 3 groups after the intervention.
HOW DOES PULSE OXIMETRY WORK?
Sensing an arterial pulse is necessary for pulse oximetry to
work. The pulsatile variation in light returning to the probe
detector at the tissue surface results from arterial blood
flow during systole and provides a means of isolating
the contribution of arterial blood to the overall light
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CLINICAL NURSE SPECIALIST
absorption.11 When light is detected by the pulse oximetry
sensor, it is converted to a photoplethysmographic signal
that quantifies the drop in light intensity at each arterial
pulse beat.11
In the clinical measurement of SpO2, 2 light emitting di-
odes send out light with different wavelengthsVred and
infraredVthat is passed through the tissues of the finger, toe,
earlobe, or nose. The bridge of the nose has been used in
infants.12 Researchers have also suggested the esophagus as
an alternative site for people whose peripheral perfusion is
compromised, as in burned patients or those with serious
injuries.13 Of these sites, the finger is the most commonly
used, and there are data to suggest a higher level of inaccu-
racy associated with the other sites. The tissue, blood, and
bone absorb much of the emitted light, but some passes all
the way through and is measured by a light-sensitive pho-
todiode that is placed opposite to the light emitting diodes.
The absorption of both red and infrared light by tissue,
bone, venous blood, and a small amount of the arterial
blood is constant over time, and empirical, in vivo data are
used by all manufacturers to calibrate commercially avail-
able pulse oximeters.9,13,14 Clinically, the more oxygenated
the blood is, the more red light is transmitted, with less
infrared light passing through. The opposite is also trueV
when blood oxygen is low, less red light and more infrared
light passes through.9
LIMITATIONS TO PULSE OXIMETRY
All clinical monitoring devices have their limitations and it
is essential to understand the limits of the technology in
order to make appropriate adjustments and to properly inter-
pret the data. Pulse oximeters may be affected by several
conditions including exposure to ambient fluorescent and
xenon light, low perfusion states, motion artifacts, elevated
carboxyhemoglobin and methemoglobin levels, intravenous
dyes, dark skin pigmentation, and nail polish.15,16 Acrylic
nails generally do not cause inaccurate readings,16 but the
color of the polish may do so.
The biggest limitations to SpO2 monitoring include the
following: it is an indirect measure for arterial oxygen satu-
ration (SaO2), which physiologically reflects arterial oxygen
tension (PaO2), and potential measurement problems during
patient motion and low perfusion states (see Table 1). Re-
gardless of the specific manufacturer, SpO2 measurement
uses algorithms that are based on certain assumptions, mak-
ing this measurement an approximation of the arterial oxy-
gen saturation (SaO2). It is not an absolute value. Although
the continuous and noninvasive properties of conventional
pulse oximetry make it amenable to everyday clinical use,
anytime exact and directly measured oxygen saturation is
required for definitive clinical assessment of the patient; it
is probably best to obtain that data by direct measurement
of the arterial oxygen levels using a co-oximeter.6,13,17
Of the major limitations of SpO2, probably the biggest
disadvantage, particularly of conventional pulse oximetry,
is the excessive motion artifact that occurs when a patient
moves causing the SpO2 monitor to incorrectly interpret
patient movement as a pulse signal. The resulting increase
in false alarms and erroneous measurements can desensitize
clinicians to the alarms over time and increase the chance
of missing a significant true alarm, something that has been
VOLUME 20 | NUMBER 6
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Table 1. Factors That May Affect Pulse
Oximetry Readings3,6,9,12,16,24
Low perfusion states (eg, hypothermia, peripheral vascular
disease, hypovolemia, sepsis, and shock)
Anemia
Peripheral skin temperature of the digit or areas of sensor
Finger thickness
Skin color
Cardiac arrhythmias (causing poor signal quality)
Nail polish (dark, brown, blue, black, and green)
External light sources (fluorescent and xenon)
Skin pigmentation (dark skin may affect-evidence inconsistent)
Abnormal hemoglobin (eg, carboxyhemoglobin and
methemoglobin)
Movement of the patient causing artifact (including shivering)
Intravascular or intradermal dyes
widely reported in the literature on conventional pulse
oximetry. In fact, there is evidence that indicates that most
of the low oxygen saturation alarms that occur with
conventional pulse oximetry are false readings due to
motion artifact.18,19
Because of the clinical challenges of patient motion and
low perfusion in the measurement of SpO2, manufacturers of
pulse oximeters have created newer algorithms that are
specifically designed to detect and filter out motion artifact
as well as provide accurate measurements during low
perfusion. These new technologies are referred to as ‘‘motion
tolerant’’ or ‘‘new generation’’ pulse oximeters.6 Hence, a
basic part of the correct use of SpO2 devices is knowing
whether you have a conventional (no motion tolerance) or
a new generation device because the performance of these
2 types of devices is very different.
LESSONS FROM LEGAL CASES
Not using or incorrectly interpreting pulse oximetry results
continues to be the subject of medical malpractice cases. The
following recommendations are provided that have been
gleaned from the review of depositions and medical records
where oxygenation status and pulse oximetry were key
issues.
(1) Use pulse oximetry for patients at risk for respira-
tory arrests.
A typical patient who can benefit from pulse oximetry is
often someone who is not in the intensive care unit, who has
a patient-controlled analgesia pump, and who is receiving
morphine in the prescribed dose. Respiratory depression
secondary to the sedation is frequently antecedent to a re-
spiratory arrest, and although patient outcomes vary, typi-
cally those cases that are part of litigation reflect death or
disability as a result of the arrest. The nurse may well have
checked and documented routine vital signs for the patient,
as well as level of consciousness, color, and breath sounds,
but not used or correctly interpreted pulse oximetry values.
However, it can be argued that the standard of care in
similar situations mandates use of oxygen saturation trend
data. There is good evidence that desaturation is detected
earlier by pulse oximetry than by clinical observation,12 even
269
by expert clinicians. (During a cardiopulmonary arrest,
however, pulse oximetry should never be used as a measure
of oxygenation because of low tissue perfusion.)
The following testimony is from a deposition of a nurse
expert who proposed that the lack of oxygen saturation
data may have influenced the outcome (death), thus setting
a higher standard than was in the hospital policy and
procedure manual:
Q (question by the attorney): Do you think pulse oximetry and
the use of pulse oximetry would have altered the outcome in
this case?
A (answer by the deponent, nurse expert): There’s a very good
possibility that it could have.
Several research studies have been conducted on post-
operative patients using pulse oximetry as one of the vari-
ables. Researchers compared continuous pulse oximetry
readings to daily intermittent arterial blood gases (ABG) in
20 patients with long bone fractures and found that the
ABG analysis never detected the severe desaturation periods
that were seen with pulse oximetry.20 The lowest SaO2 was
down to 60% with the longest episode lasting 1.47 hours.
Because hypoxemia is an important antecedent component
in fat embolism syndrome, early detection of desaturation
was deemed essential. Another study of 1,219 postsurgical
patients showed that pulse oximetry was associated with
reduced postoperative admissions to the intensive care unit
for pulmonary complications but not for overall decreased
transfers to intensive care unit, particularly for cardiac
reasons.21
(2) Know the patient’s hemoglobin and use it in critical
thinking about SaO2 values.
Hemoglobin is the primary carrier of oxygen in the ar-
terial blood and is based on an affinity for oxygen molecules
that is a characteristic of hemoglobin, forming oxyhemoglo-
bin.22 Oxyhemoglobin accounts for 97% to 98% of the
oxygen that is transported to the issues for use in cellular
metabolism. There is a small amount of dissolved oxygen as
well, but that really plays a much more important role in the
diffusion of oxygen at the tissue level from the blood to the
tissue and is not an important consideration in the total
blood oxygen content. The total oxygen content of arterial
blood is much more dependent on the amount of hemoglo-
bin present in the blood than it is on the oxygen saturation,
with the normal value for oxygen content being approxi-
mately 20 mL 02/dL (or 20 vol %).23,24
Figure 1 shows 4 different parameters and 4 different
patient situations. One is PaO2Varterial blood oxygen, a
value that is measured by arterial blood gas analysis; the
second is oxygen saturation, which is measured by the
oxygen saturation probe or the SpO2 probe; and the third is
hemoglobin. With those 3 factors in varying degrees, you
can calculate the fourth valueVthe blood oxygen volumes
percent. Note that even when the SpO2 is consistent at 98%,
the total oxygen content can range from normal to danger-
ously low. So while SpO2 is an extremely important value, it
does not tell the whole story of oxygen, certainly oxygen
delivery to the tissue. It is not unusual, especially in the
setting of critical care, to have a patient with a normal SpO2
who does not have a normal oxygen transport.24
The meaning of this is profoundly important in interpret-
ing pulse oximetry readings and confounds many malprac-
270
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1. Prediction of O2 volume given knowledge of PaO2, O2
saturation, and hemoglobin
tice cases. A patient may be ‘‘fully saturated,’’ meaning all
hemoglobin molecules have the requisite 4 oxygen molecules
attached, yet because of significant anemia, still lack an
adequate oxygen supply to the tissues. The nurse can obtain
normal oximeter readings of oxygen saturation, yet the
patient is oxygen deprived and may suffer physiologic
consequences. Postoperative patients should be carefully
evaluated for this, even if postoperative hemoglobin values
are not known. Often in malpractice cases, nurses have re-
ported that in this cost-containment era, there were no post-
operative hemoglobin measures taken, which prevented
them from recognizing the presence of severe anemia. Here,
the type of surgery, the estimated amount of blood loss, and
other known data should be used to predict possible post-
operative anemia and justify the laboratory test. If a post-
operative patient’s data (as skin color, heart rate, and level
of consciousness) do not match the SpO2 readings, it may
well be due to postoperative anemia.
(3) Know the relationship of oxygen saturation and
arterial oxygen (PaO2).
Because the oxyhemoglobin dissociation curve has a sig-
moid shape, oximetry is relatively insensitive in detecting the
development of hypoxemia in patients with high baseline
levels of PaO2.15 An SaO2 reading of 90% correlates with a
PaO2 reading of greater than or equal to 60 mm Hg.24 See
Figure 2 for other expected correlations between oxygen sat-
uration and ABG readings. Treatment interventions should
be considered when the SaO2 is less than 90%, assuming
that other variables that can affect the oxygen hemoglobin
dissociation curve are normal (as blood pH, PCO2, and
body temperature).
(4) Know the basic filtering strategy of the pulse
oximeter you are using: cardiac-based or saturation-based.
With a saturation-based strategy, the underlying assump-
tion is that all signal artifact created during motion is related
to the movement of venous blood and can therefore be
correlated with both the red and infrared signals. Because
venous blood has a pattern of red and infrared light ab-
sorption that differs from the arterial signal, the red and in-
frared ratios can be used to separate the venous signals from
the arterial signals. The SpO2 measurement is created by
subtracting the venous signals from the total signals, using
only the arterial to calculate the SpO2 value. The disadvan-
tage of this strategy is that when red or infrared signals be-
come influenced by sources other than moving arterial and
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CLINICAL NURSE SPECIALIST

Figure 2. Comparison of arterial oxygenation (PaO2) with arterial
oxygen saturation (SaO2)24
venous blood, the artifact can result in uncorrelated red and
infrared signals and an erroneous SpO2 value. Therefore,
this method has the potential to display falsely high satu-
rations created by nonvenous artifact. However, saturation-
based filtering performs very well when the motion artifact
is rhythmic and is of a consistent frequency.9
Cardiac-based filtering strategies are based on the as-
sumption that on average and over several seconds of time,
signal noise coming from patient motion does not occur at
the same frequency as the patient’s cardiac signals. The
underlying assumption is that patient artifact is random and
chaotic in both amplitude and occurrence, an assumption
that is supported by clinical data on patient motion. Thus,
patient motion artifact can be distinguished from the
patient’s cardiac rhythm because cardiac rhythm is assumed
to be the only consistent signal source over a given window
of time. To generate the SpO2 value, the random and chaotic
signals are filtered out, and the measurement is based only
on those signals that the algorithm judges to be cardiac in
origin.9,25
(5) Realize the limitations of pulse oximetry oxygen
saturation (SpO2) compared to oxygen saturations obtained
with arterial blood gases (SaO2) and obtain periodic arterial
blood gases.
Pulse oximetry uses light wavelengths to measure oxy-
hemoglobin saturation23; however, it only uses 2 light wave-
lengths to measure the functional saturation of hemoglobin.
Most laboratories use an 8-wavelength light source so that
fractional hemoglobin saturation is reported.23 One example
of this difference is found in dysfunctional hemoglobins,
which can be measured by PaO2 (as in ABGs) but not by
SpO2 (oximetry). Hemoglobin may combine with other
substances besides oxygen, as in the case seen in heavy
smokers or people with chronic lung diseases who may have
high carboxyhemoglobin levels detectable with ABGs but
not by pulse oximetry. Here, the SpO2 reading will be falsely
elevated, contributing to a sense of false security, but the
oxygen saturation obtained with ABGs will be low.22
Pulse oximetry is primarily used to assess oxygenation
but not ventilation. Decreased SpO2 measured by pulse oxim-
VOLUME 20 | NUMBER 6
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
etry may indicate the need for arterial blood gas analysis to
determine if the arterial hypoxemia is due to hypoventila-
tion, or mismatching of ventilation and pulmonary perfu-
sion. Then, appropriate treatment can be administered.26
(6) Consider the patient’s blood pressure in interpreta-
tion of pulse oximetry readings.
When the patient’s blood pressure is low, the oximeter
has difficulty differentiating the light wavelengths of arterial
blood. Pulse oximetry is considered reliable with a systolic
blood pressure of at least 80 mm Hg and higher.27 Typi-
cally, the manufacturers limits of bias are T2%. If the blood
pressure is low, the pulse oximetry readings will also be low,
leading to a bias up to a 45% lower reading, which is the
corresponding reading during normal perfusion.27 As the
most common site for SpO2 measurement, the digits are most
susceptible to decreases in perfusion during states of low
blood pressure. Most of the newer SpO2 devices have signal
quality indicators that can help the bedside nurse decide if the
signal is strong enough to obtain an accurate reading. In
addition, at least one manufacturer has a forehead sensor
that often works better than the digit sensors in states of low
blood pressure and low perfusion. However, as with any
measurement device, if there is any question about the ac-
curacy of the measurement, such as serious vasoconstriction
because of hypothermia, hypovolemia, sepsis, or shock,27
pulse oximetry should not be used for patient assessment or
treatment decisions.
(7) Evaluate the amount of lighting used in the environ-
ment of the pulse oximeter.
Bright light sources within the patient’s immediate vicin-
ity can compete with the pulse oximetry sensor light source
and affect the accuracy of the readings.22 Examples include
fluorescent light, surgical light, and sunlight.23 This can lead
to a higher reading than is actually present. To remedy the
situation, the oximeter probe can be covered with a bed
sheet, sheltering it from the light source. Several sources
indicate that bilirubin lights do not cause altered readings,3
although some clinicians may still have concerns.
(8) Always document use of pulse oximetry in the
patient’s medical record.
It is important to always document the results of SpO2
monitoring in the patient’s medical records, including either
continuous monitoring trends or periodic spot-checks.
Documentation should include the liter flow and method
or fraction of inspired oxygen (FIO2) if the patient is receiv-
ing supplemental oxygen, the sensor site, oximeter alarm
settings on, unexpected outcomes, clinical assessment at the
time of the saturation measurement if abnormal or a change,
and ABG measures if available.3 If the patient receives spot-
check pulse oximetry readings, always chart the clinical
indication for the measure, the findings, and to whom it was
reported if abnormal.
Heralded as a major safety measure, pulse oximetry pro-
vides useful data for patient assessment, yet thought must be
given to accurately interpret it for a given patient. There is
concern that we are becoming increasingly dependent on
oxygen saturation readings without full knowledge of criti-
cally important variables that affect the interpretation of
those readings. The role of the clinical nurse specialist in
mentoring other nurses to use critical thinking and in pro-
viding education about pulse oximetry is extremely valu-
able. Sandelowski28 noted that a consequence of technology
271
 dependence is the illusion of certainty, yet people must be
used to interpret the information machines.
References
1. Stone K. Managing technology and complex care. In: Funk
SG, Tornquist EM, Champagne MT, Wiese RA eds. Key
Aspects of Caring for the Acutely Ill: Technological Aspects,
Patient Education and Quality of Life. New York: Springer
Publishing Company; 1995:23.
2. National Association of Clinical Nurse Specialists. In: State-
ment on Clinical Nurse Specialist Practice and Education.
2nd ed. Harrisburg, Pa: NACNS; 2004:46Y47.
3. Schutz SL. Oxygen saturation monitoring by pulse oximetry.
In: Wiegand DJ, Carlson KK, eds. AACN Procedure Manual
for Critical Care. 5th ed. St. Louis, Mo: Elsevier Saunders;
2005:101Y107.
4. Carratala J, Fernandez-Sabe N, Ortega L, et al. Outpatient
care compared with hospitalization for community-acquired
pneumonia: a randomized trial in low-risk patients. Ann
Intern Med. 2005;142:165Y172.
5. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to
identify low-risk patients with community-acquired pneumo-
nia. N Engl J Med. 1997;336:243Y250.
6. Guiliano KK, Higgins TL. New generation pulse oximetry in
the care of critically ill patients. Am J Crit Care. 2005;14(1):
26Y39.
7. Pedersen T, MLller AM, Pedersen BD. Pulse oximetry for
perioperative monitoring: systematic review of randomized,
controlled trials. Anesth Analg. 2003;96:426Y431.
8. Parameswaran G, Brand K, Dolan J. Pulse oximetry as a
potential screening tool for lower extremity arterial disease in
asymptomatic patients with diabetes mellitus. Arch Intern
Med. 2005;165:442Y446.
9. Giuliano KK, Liu L. Knowledge of pulse oximetry among
critical care nurses. Dimens Crit Care Nurs. 2006;25(1):1Y6.
10. Attin M, Cardin S, Dee V, et al, from the Nursing Practice
Research Council, University of California, Los Angeles,
Medical Center, Los Angeles, California. An education proj-
ect to improve knowledge related to pulse oximetry. Am J
Crit Care. 2002;11:529Y534.
11. Reuss JL, Siker D. The pulse in reflectance pulse oximetry:
modeling and experimental studies. J Clin Monit Comput.
2004;18:289Y299.
272
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
View publication stats
12. Vora VA, Ahmedzai SH. Pulse oximetry in supportive and
palliative care. Support Care Cancer. 2004;12(11):758Y761.
13. Kyriacou PA. Pulse oximetry in the oesophagus. Physiol
Meas. 2006;27(1):R1Y35.
14. Lee J, Jung W, Kang I, Kim Y, Lee G. Design of filter to reject
motion artifact of pulse oximetry. Comput Stand Interfaces.
2004;26(3):241Y249.
15. Jubran A. Pulse oximetry. Intensive Care Med. 2004;30(11):
2017Y2020.
16. McMorrow RC, Mythen MG. Pulse oximetry. Curr Opin
Crit Care. 2006;12(3):269Y271.
17. Matthews P. Co-oximetry. Respir Care Clin N Am. 1995;
12(1):47Y48.
18. Lawless S. Crying wolf: false alarms in a pediatric intensive
care unit. Crit Care Med. 1994;22(6):981Y985.
19. Meredith C, Edworthy J. Are there too many alarms in the
intensive care unit? An overview of the problems. J Adv Nurs.
1995;21(1):15Y20.
20. Wong MWN, Tsui HF, Yung SH, Chan KM, Cheng JCY.
Continuous pulse oximeter monitoring for inapparent hyp-
oxemia after long bone fractures. J Trauma. 2004;56(2):
356Y362.
21. Ochrock EA, Russell MW, Hanson WC, et al. The impact of
continuous pulse oximetry monitoring on intensive care unit
admissions from a postsurgical care floor. Anesth Analg.
2006;102:868Y875.
22. Wagner KD. Arterial blood gas analysis. In: Kidd PS, Wagner
KD, eds. High Acuity Nursing. 3rd ed. Upper Saddle River,
NJ: Prentice Hall; 2001:144Y161.
23. Rutherford K. Hemoglobin saturation (SaO2) and DO2.
In: Ahrens T, Rutherford K, eds. Essentials of Oxygenation.
Boston: Jones and Bartlett Publishers; 1993:43Y46.
24. White KM. Respiratory. In: Fast Facts for Adult Critical
Care. Mobile, Ala: Kathy White Learning Systems; 2005:3Y4.
25. Tobin RM, Pologe JA, Batchelder PB. A characterization
of motion affecting pulse oximetry in 350 patients. Anesth
Analg. 2002;94(15):554Y561.
26. Fu ES, Downs JB, Schweiger JW, Miguel RV, Smith RA.
Supplemental oxygen impairs detection of hypoventilation by
pulse oximetry. Chest. 2004;126(5):1552Y1558.
27. Hinkelbein J, Genzwuerker HV, Fiedler F. Detection of a
systolic pressure threshold for reliable readings in pulse
oximetry. Resuscitation. 2005;64(3):315Y319.
28. Sandelowski M. Toward a theory of technology dependency.
Nurs Outlook. 1993;41:40.
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CLINICAL NURSE SPECIALIST