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Define Insertion of a needle/catheter into an artery for the purposes of arterial blood sampling.

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Blood is drawn anaerobically from a peripheral artery (radial, brachial, femoral, or dorsalis pedis) via a single percutaneous needle puncture, or from an indwelling arterial cannula or catheter for multiple samples. Either method provides a blood specimen for direct measurement of partial pressures of carbon dioxide (PaCO2) and oxygen (PaO2), hydrogen ion activity (pH), total hemoglobin (Hbtotal), oxyhemoglobin saturation (HbO2), and the dyshemoglobins carboxyhemoglobin (COHb) and methemoglobin (MetHb).

PURPOSE: To evaluate the adequacy of ventilatory (PacO2) acid-base (pH and PaCO2), and oxygenation (PaO2 and SaO2) status, and the oxygen-carrying capacity of blood (PaO2, HbO2, Hb total, and

dyshemoglobins). The need to quantitate the patient's response to therapeutic intervention and/or diagnostic evaluation (e.g. oxygen therapy, exercise testing) The need to monitor severity and progression of a documented disease process.

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ANALYSIS The following steps are recommended to evaluate arterial blood gas values. They are based on the assumption that the average values are: pH = 7.4 PaCO2 = 40 mm Hg HCO3 = 24 mEq/L 1. First, note the pH. It can be high, low, or normal, as follows: pH > 7.4 (alkalosis) pH < 7.4 (acidosis) pH = 7.4 (normal) A normal pH may indicate perfectly normal blood gases, or it may be an indication of a compensated imbalance. A compensated imbalance is one in which the body has been able to correct the pH by either respiratory or metabolic changes (depending on the primary problem). For example, a patient with primary metabolic acidosis starts out with a low bicarbonate level but a normal CO2 level. Soon afterward, the lungs try to compensate for the imbalance by exhaling large amounts of CO2

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(hyperventilation). As another example, a patient with primary respiratory acidosis starts out with a high CO2 level; soon afterward, the kidneys attempt to compensate by retaining bicarbonate. If the compensatory mechanism is able to restore the bicarbonate to carbonic acid ratio back to 20:1, full compensation (and thus normal pH) will be achieved.

2. The next step is to determine the primary cause of the disturbance. This is done by evaluating the PaCO2 and HCO3 in relation to the pH. Example: pH > 7.4 (alkalosis) a. If the PaCO2 is < 40 mm Hg, the primary disturbance is respiratory alkalosis. (This situation occurs when a patient hyperventilates and blows off too much CO2. Recall that CO2 dissolved in water becomes carbonic acid, the acid side of the carbonic acidbicarbonate buffer system.) b. If the HCO3 is >24 mEq/L, the primary disturbance is metabolic alkalosis. (This situation occurs when the body gains too much bicarbonate, an alkaline substance. Bicarbonate

is the basic or alkaline side of the carbonic acid bicarbonate buffer system.)

Example: pH < 7.4 (acidosis) a. If the PaCO2 is >40 mm Hg, the primary disturbance is respiratory acidosis. (This situation occurs when a patient hypoventilates and thus retains too much CO2, an acidic substance.) b. If the HCO3 is <24 mEq/L, the primary disturbance is metabolic acidosis. (This situation occurs when the bodys bicarbonate level drops, either because of direct bicarbonate loss or because of gains of acids such as lactic acid or ketones.)

3. The next step involves determining if compensation has begun. This is done by looking at the value other than the primary disorder. If it is moving in the same direction as the primary value, compensation is underway. Consider the following gases: pH (1) 7.20 (2) 7.40 PaCO2 60 mm Hg 60 mm Hg HCO3 24 mEq/L 37 mEq/L

The first set (1) indicates acute respiratory acidosis without compensation (the PaCO2 is high, the HCO3 is normal). The second set (2) indicates chronic respiratory acidosis. Note that compensation has take place; that is, the HCO3 has elevated to an appropriate level to balance the high PaCO2 and produce a normal pH.

4. Two distinct acidbase disturbances may occur simultaneously. These can be identified when the pH does not explain one of the changes. Example: Metabolic and respiratory acidosis a. pH 7.21 b. PaCO2 c. HCO3 decreased acid 52 13 increased acid decreased acid

This is an example of metabolic and respiratory acidosis.

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CONTRAINDICATIONS: Contraindications are absolute unless specified otherwise. Negative results of a modified Allen test (collateral circulation test) are indicative of inadequate blood supply to the hand' and suggest the need to select another extremity as the site for puncture. Arterial puncture should not be pertormed through a lesion or through or distal to a surgical shunt (eg, as in a dialysis patient). If there is evidence of infection or peripheral vascular disease involving the selected limb, an alternate site should be selected. Agreement is lacking regarding the puncture sites associated with a lesser likelihood of complications; however, because of the need for monitoring the femoral puncture site for an extended period, femoral punctures should not be performed outside the hospital. A coagulopathy or medium-to-high-dose anticoagulation therapy (e.g. heparin or coumadin, streptokinase, and tissue plasminogen activator but not necessarily aspirin) may be a relative contraindication for arterial puncture.

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SITES OF PUNCTURE

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1. RADIAL ARTERY The radial artery is most easily accessible medial to the radial styloid process and lateral to the flexor carpi radialis tendon, 2-3 cm proximal to the ventral surface of the wrist crease

2. BRACHIAL ARTERY The brachial artery is best identified between the medial epicondyle of the humerus and the tendon of the biceps brachii in the antecubital fossa. It can be felt higher in the arm in the groove between the biceps and triceps tendons. The basilic vein and the brachial nerve are located in close proximity

3. FEMORAL ARTERY The femoral artery is best identified in the midline between the symphysis pubis and the anterior superior iliac crest, 2-4 cm distal to the inguinal ligament. The femoral artery is medial to the femoral nerve and lateral to the femoral vein

Assessment of collateral circulation (modified Allen test) If puncture of the radial artery is planned, a modified Allen test should be performed beforehand when feasible to assess the collateral circulation. Although the anatomy of the radial artery in the forearm and the hand is variable, most patients have adequate collateral flow should radial artery thrombosis occur. The modified Allen test is performed as follows. Firm occlusive pressure is held on both the radial artery and the ulnar artery (see the first image below). The patient is asked to clench the fist several times until the palmar skin is

blanched (see the second image below), then to unclench the fist. Overextension of the hand or wide spreading of the fingers should be avoided, because it may cause falsenormal results. The pressure on the ulnar artery is released while occlusion of the radial artery is maintained (see the third image below). The time required for palmar capillary refill is noted.

POSITION For radial artery blood sampling, the patient should be in the supine position, with the arm lying at his or her on a hard surface. The forearm should be supinated and the wrist dorsiflexed at 40. A gauze roll may be placed under the wrist to make the patient more comfortable and to bring the radial artery to a more superficial plane. Overextension of the wrist is discouraged, because interposition of flexor tendons may make the pulse difficult to detect. For femoral artery blood sampling, the patient is supine on a stretcher, and the patient's leg is placed in neutral anatomic position. For brachial artery blood sampling, the arm is placed on a firm surface with the shoulder slightly abducted. The elbow is extended, with the forearm in full supination.

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COMPLICATIONS: Hematoma Arteriospasm Air or clotted-blood emboli Anaphylaxis from local anesthestic Introduction of contagion at sampling site and consequent infection in patient; introduction of contagion to sampler by inadvertent needle 'stick.' Hemorrhage Trauma to the vessel Arterial occlusion Vasovagal response Pain

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Equipment Needed: A. Clean tray a. Mackintosh and towel b. Spirit c. Betadine d. Kidney tray e. Disposal syringe 2-5 ml f. Chittle forcep g. Injection heparin h. Disposable gloves i. Cup with crushed ice j. Laboratory requisition form k. Label with date, time, IPD/OPD, patients name etc.. B. Sterile tray a. Bowl b. Gauze piece c. 23 or 25 gauze needle d. Eye towel e. Arterial catheter if any

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NURSING RESPONSIBILITY 1. Check the physicians order. 2. Identify the client and explain the procedure to the client and his family including need of intervention and complications 3. Monitor vitals before and after the procedure. 4. Asses for sites of puncture 5. Obtain written consent from the patient. 6. Assure the patient that best care will be taken during the procedure. 7. Inform the physician about the patients willingness. 8. Check for the sterility of the equipments. 9. Collect all the necessary equipments near the bed of the patient

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STEPS IN PROCEDURE 1. Identify client and explain procedure to client in calm tone of voice. 2. Prepare syringe with heparin: a. Aspirate 0.5 ml sodium heparin (1000 U/ml) into syringe from vial. b. Withdraw plunger entire length of syringe and

eject all heparin out of syringe. 3. Select safest and most accessible site for ABG sample: 4. Perform Allens test. Have client make tight fist and apply direct pressure to both radial and ulnar arteries, When client opens hand, release pressure over ulnar artery and observe color of fingers, thumbs, and hand. Fingers should flush within 15 secondsa positive Allens test. If Allens test is positive, use the radial artery. 5. Wash hands and put on gloves. 6. Palpate selected radial site with fingertips and stabilize artery by slightly hyper-extending wrist. 7. Use alcohol swab to clean in a circular motion the area above the pulse. 8. Hold alcohol swab in fingers of one hand while keeping a fingertip from the other hand on the artery. 9. Insert needle with bevel up into artery at a 45 angle. 10. Hold the needle and syringe still when blood appears in the syringe. 11. Allow arterial pulsing to slowly pump 23 ml of blood into heparinized syringe.

12. When sample is collected, hold alcohol swab over the puncture site and withdraw needle. 13. Apply pressure with the alcohol swab over the puncture site for 5 minutes, or 10 minutes if the client is on anticoagulant therapy or has a bleeding disorder. 14. Inspect site for signs of complications a. Bleeding b. Change or disappearance of pulse c. Color of hand 15. Remove gloves and wash hands.

16. Prepare sample for laboratory and send it: a. Expel air bubbles from syringe. b. Label syringe with client identification. c. Place syringe in cup of crushed ice. d. Fill out requisition form,including amount of oxygen the client is receiving (e.g.,2 liters O2 by nasal cannula,room air,70% on ventilator) e. Note some laboratories also require a recent body temperature.

17. Review results of ABG sample and compare with normal values: a. pH 7.357.45, PaCO2 3545 b. PaO2 80100 c. SaO2 94%98% 18. Report ABG results to physician or qualified practitioner and perform nursing measures accordingly: a. Respiratory acidosis b. Respiratory alkalosis

DOCUMENTATION When the blood gas results are delivered to the nurse, they should be reported to the clients physician.

1. NURSES NOTES The date and time of the ABG sampling should be recorded in the narrative notes. Also record the reason for the test, the results of the Allens test, the clients response to the blood sampling, and any unusual observations. Note the route and amount of oxygen the

client is receiving and any respiratory assessment observations. Record the condition of the puncture site prior to the blood draw and after the blood draw. Be sure to note the follow-up check on the condition of the site.

2. LABORATORY REQUISTION FORM Record the date and time of the sample, the clients name and room number, the site the sample was drawn from, and the amount and route of oxygen delivery.

AFTER CARE 1. Replace all the articles 2. Send the specimen to the laboratory as early as possible 3. Check the puncture site for complications 4. Review the results and inform physician

Summary Till now we have seen the definition, purpose, contraindications, sites of withdrawal, complications, pre procedure care, steps in procedure, documentation and after care.

ASSIGNMENT WRITE 3 NURSING DIAGNOSIS FOR A PATIENT UNDERGONE ARTERIAL BLOOD GAS ANALYSIS.

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BIBLIOGRAPHY:1. Lewis, Heitkemper & Dirksen (2000) Medical Surgical Nursing Assessment and Management of Clinical Problem (7th ed) Mosby, pg no. 2552-66. 2. Black J.M. Hawk, J.H. (2005) Medical Surgical Nursing Clinical Management for Positive Outcomes. (7th ed) Elsevier, pg no. 2441-54. 3. Brunner S. B., Suddarth D.S. The Lippincott Manual of Nursing practice J.B.Lippincott. Philadelphia, pg no. 32051-59 4. Understanding medical surgical nursing, F A Davis 6th edition, elsieiver publication pg. no. 210-224. 5. www.trauma..org/systemtrauma.html

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