Tricks to getting an Spo2 reading on a difficult patient

3 hours ago, Wuzzie said:

Not at all being snarky but what's the need for an SpO2 reading on a 92 year old DNR in no distress?

Hmmm.. I was wondering the same thing.

4 hours ago, mmc51264 said:

A nurse was freaking out because her o2 was reading 66% (the nurse also said she had a HR of 44 and called a rapid). 

It was a good lesson of looking at the pt not the #s. Pt was sitting up, not a care in the world. Looked at all of us as if we were crazy LOL.

So, if a pt has poor perfusion in all digits, ear lobe, what are some places do you all use for getting an 02 reading that is non-invasive (not going to do an ABG/VBG 

While it’s always better to call one rapid too many rather than wait too long, did the nurse try to check the patient’s pulse in any other way than just looking at the pulse oximeter reading? What was the reason for the poor perfusion? Did they check that the pulse oximeter was working properly? They are quite delicate and easily damaged if dropped or handled roughly. 
 

4 hours ago, mmc51264 said:

So, if a pt has poor perfusion in all digits, ear lobe, what are some places do you all use for getting an 02 reading that is non-invasive (not going to do an ABG/VBG on an obviously not in distress pt). 

Lots of things can cause inaccurate readings. Certainly poor perfusion. Also nail polish, artificial nails, skin that is thicker than ”normal”, dark skin color, a pulse oximeter probe that fits too tight and constricts flow, or a probe with loose fit (or forcing a hinged probe onto a very big big toe so that the probe looks like an open jaw instead of both the light-emitting diod and the light detector surface being flush with the finger or toe), patient movement or shivering, hypothermia/peripheral vasoconstriction, low systolic blood pressure (usually needs to be more than ~80 to be reliable), hypovolemia, a cardiac arrhythmia, or bright light directly on the probe. (Not applicable in this case but a smoker or someone who’s inhaled smoke from a fire can have artificially high saturation because carbon monoxide binds to hemoglobin and the pulse oximeter can’t tell the difference). OP, perhaps you aleady know all this. If that’s the case.. just ignore me ?

There aren’t that many locations where you can place a pulse-ox probe. They are all more or less susceptible to poor perfusion. It’s been my experience that the forehead works best if the patient has vasoconstriction due to either hypotension or hypothermia. Fingers are the most unreliable and ear lobes somewhere in between. But your mileage may vary ? 

Honestly, in a non-emergent situation, with a patient isn’t in any distress and you just want to get a routine reading for whatever reason, I would try to gently rub the finger or ear lobe (or have the patient do it) to restore circulation and then try to get a reading. Or let the patient warm their hand for a while if cold hands is the reason for the poor perfusion. Have the patient place their hand under their blanket for a couple of minutes or half fill a disposable glove with lukewarm/warm-ish water (obviously not hot water!), tie a knot and let them hold it for a couple of minutes.. voilà ?

My point was that they really didn't need the rapid. The pt was not in distress and they were just doing routine vital signs. 

It is frustrating that it is so difficult to get an O2 reading on certain types of pts. I think they ended up using her nose. 

I wish they had calmed down and did some critical thinking before calling the rapid. I was laughing to myself because the pt was looking at my like "what are these people doing??" I did find out later that before the pt was transferred to our unit, there was a pretty severe hypoglycemic event (like <30) I am sure that perfusion was not great r/t to that too (mom of 2 T1s). 

I was hoping someone had a brilliant idea of an alternative site. We don't have the forehead strips to get a reading there. 

Thx!

3 hours ago, Wuzzie said:

Not at all being snarky but what's the need for an SpO2 reading on a 92 year old DNR in no distress?

it was just routine VS. Pt had been transferred from another unit and it is policy to check them upon arrival. 

Tee hee!  Just did my own reading = 76% & hr 42. I'm fine, but have chronically cold hands. I typically do the finger rubbing, but also the "Al Bundy hands-in-the-waistband" works well for me. But takes a little time.

Again, another episode of someone NOT looking at the pt, just relying on techy do-dads.

The finger rubbing often works, as does trying the ear lobe.

If you're not sure about a pulse take it manually.

If a sat looks dodgy observe the patient: skin colour, nail colour, lips, signs of palor or cyanosis, mottling, is the breathing laboured? Count a respiratory rate.

When I started training in 1983 we didn't have saturometers. We still managed to know who was in trouble and who wasn't.

The healthcare system is so ridiculous...

Of course you need an O2 Sat entered into the computer because some idiotic, clueless  Joint Commission chart auditor will be checking. She is incapable of checking nurse's notes that this wasn't accurate on the patient. 

I remember a new grad nurse working NOCs with me. We had a DNR/DNH comfort care pt who was steadily declining but with no acute distress. Despite nasal O2 for comfort, his sat was POOR. New nurse was crazy re the LOW reading level. It was very difficult to redirect him from acute, non-interventional care - he was so fixated on the O2 level. The pt was barely hanging on - but was not struggling. That oximeter was like some fascinating do-dad toy.

That was some years ago - some things never change. Her hands were so cold and it was freaking him out.

On 11/30/2021 at 11:14 AM, mmc51264 said:

My point was that they really didn't need the rapid. The pt was not in distress and they were just doing routine vital signs. 

...

I wish they had calmed down and did some critical thinking before calling the rapid.

From the perspective of a rapid response nurse in a large urban medical center:

While I get a fair number of calls that ended up being 'nothing,' I always thank them for calling and encourage them to call for anything... "call early, call often" is my refrain (and if anybody recognizes that, well... now you know who I am ?)

Here's the thing... I still get calls... or find patients through other means... on whom I should have been called much earlier ("Give me something to work with..." is another of my canned phrases) and I'd far prefer to have 10 calls that didn't amount to much than to miss 1 call where I might have been able to make a difference.

Additionally, as I tell the nurses, if it ends up going bad, it's better for all of us to have another independent, expert assessment documented...

And finally, it gives me the chance to do some education... I've been at this for awhile and I've got a fair amount of knowledge to share and tricks up my sleeve. For example, this case would have been a perfect set up to discuss the concept of perfusion index.

Oh, and one more thing: It helps build rapport with the nursing staff when we are standing at the bedside together assessing their patient.

Another of my refrains: "If you think, 'should I call rapid?' then by all means, call rapid"

Are 'rapid teams' a very common hosp thing nowadays? They didn't exist way back in the dark ages. Also I doubt there's anything even close in LTC/NH.

(I guess I should have clarified LTC/NH in my prev post.)

2 minutes ago, amoLucia said:

Are 'rapid teams' a very common hosp thing nowadays? They didn't exist way back in the dark ages. Also I doubt there's anything even close in LTC/NH.

(I guess I should have clarified LTC/NH in my prev post.)

I've been told that they are a requirement of the Joint Commission, as well they should be. Substantial data has been published on the effectiveness of RRT and early intervention to reduce poor outcomes.

I've only worked in acute care; I doubt that RRT exist in the post-acute/LTC world.

Get a nasal clip pulse ox from PACU. 

mmc51264 said:

What's been some tricks to getting an Spo2 reading on a difficult pt?

We had a 92 DNAR pt that was transferred to us and we could not get an accurate 02 reading. A nurse was freaking out because her o2 was reading 66% (the nurse also said she had a HR of 44 and called a rapid). 

It was a good lesson of looking at the pt not the #s. Pt was sitting up, not a care in the world. Looked at all of us as if we were crazy LOL.

So, if a pt has poor perfusion in all digits, ear lobe, what are some places do you all use for getting an 02 reading that is non-invasive (not going to do an ABG/VBG on an obviously not in distress pt). 

TIA

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Even if the patient is a DNR and 92 y/o, no distress, if the patient meets the criteria for a rapid, and you did all interventions, then there is nothing wrong with calling a rapid. Maybe in this case I would have spoke with the charge nurse before calling the rapid, but some patients are on a continuous pulse ox and it alarms when it's below a certain level. Maybe a respiratory therapist  could be called to the unit?

 In some facilities it is protocol to call the rapid if the vitals are below a certain level. 

Only other trick I know of is using the toe for the pulse ox and do a continuous reading. If the patient had a critical hypoglycemic episode, below 30, I would be concerned also of what can happen because she has other issues going on or potential to.