Obtaining an Arterial Blood

Gas Sample

C.I. Carolina Maniquiz, MAN, RN

 Arterial Blood Gas (ABG)
▪ Arterial blood gases (ABGs) are an important routine
investigation to monitor the acid-base balance of patients
▪ The most common site for sampling arterial blood is the radial
artery; other arteries may be used, but most institutions require a
physician’s order to obtain the sample from another artery.
▪ A respiratory technician or specially trained nurse can collect most
ABG samples, but a physician usually performs collection from
the femoral artery, depending on facility policy
 Purposes
1. To determine the adequacy of oxygenation.
2. To evaluate the adequacy of ventilation
3. To assess and measure the acid–base status.
4. To monitor the effectiveness of treatment.
 Indications
▪ For patients with:
✓Respiratory failure - in acute ✓Any severe illness which may
and chronic states. lead to a metabolic acidosis
such as: Cardiac failure, liver
✓Ventilated patients. failure, renal failure,
✓Sleep studies. hyperglycemic states
✓Severely unwell patients from associated with DM,
any cause - affects prognosis multiorgan failure, sepsis,
burns and poisons/toxins.
 Arterial Blood Gas: Normal Values
Parameter Normal Values
pH 7.35-7.45
PaCO2 35-45 mm Hg
HCO3 22-26 mEq/L
SaCO2 >95%
PaO2 >80-100 mm Hg
Normal value decreases with age; subtract 1 mm
Hg from 80 mm Hg for every year over 60 years of
age up to age 90 (Fischbach & Dunning, 2006)
 Materials and Equipment
• Waterproof pad or small towel • 2 pieces of 2x2 sterile gauze
• Antiseptic pad or cotton with • Secure tape
70% alcohol
• Sharps container
• Pair of sterile gloves
• Cup or bag of ice
• Lidocaine prepared in a
syringe, if indicated • Sealable plastic bag
• ABG kit, or heparinized self- • Specimen label or tag
filling 10-mL syringe with 22-
G, 1-inch needle attached
 Assessment
▪ Review the patient’s medical record and plan of care for
information about the need for an ABG specimen.
▪ Assess the patient’s cardiac status, including heart rate, blood
pressure, and auscultation of heart sounds.
▪ Assess the patient’s respiratory status, including respiratory rate,
excursion, lung sounds, and use of oxygen, including the amount
being used, if ordered.
 Assessment #2
▪ Determine the adequacy of peripheral blood flow to the extremity to be used
by performing the Allen’s test.
✓ If Allen’s test reveals no or little collateral circulation to the hand, do not
perform an arterial stick to that artery
▪ Assess the patient’s radial pulse. If unable to palpate the radial pulse, consider
using the other wrist.
▪ Assess the patient’s understanding about the need for specimen collection.
✓ Ask the patient if he or she has ever felt faint, sweaty, or nauseated when
having blood drawn.
 Implementation: Checklist
1. Verify ordered arterial blood gas (ABG) analysis in the chart. Make
sure the client has not been suctioned within the past 15 minutes.
2. Perform hand hygiene. and put on personal protective equipment
(PPE), if indicated.
3. Gather necessary supplies to the bedside stand or overbed table.
Arrange in order of sequence.
4. Check client’s identity and explain the procedure. Inform that
needlestick may cause discomfort but must remain still all throughout.
 Implementation: Checklist
5. Provide privacy. Close door or curtains around bed.
6. Position client comfortably and place a waterproof pad or small towel
under the preferred arm to be punctured.
7. Perform Allen’s test first. Ask client to clench the wrist to minimize
blood flow into the hand.
8. Press client’s radial and ulnar arteries on each side of the wrist using the
index and middle fingers of your both hands. This will occlude both
arterial and ulnar blood vessels. Hold this position for a few seconds.
 Implementation: Checklist
9. Instruct client to unclench fist and relax the hand now. Observe that
the palm will be blanched because pressure from your fingers has
impaired the normal blood flow.
10. Release pressure on the ulnar artery while maintaining pressure on the
radial artery. The hand should immediately become flushed or normal
color should return, which means that blood is now flowing. This
positive test result indicates that it is safe to puncture the radial artery
and proceed with the next steps. If the hand does not flush, perform
the test on the other arm or specimen may be taken in other sites.
 Implementation: Checklist
11. Locate the radial artery and lightly palpate for strong pulse. Take note
of this puncture site. This is after assuring that the Allen’s test is
positive.
12. Disinfect the puncture site and let it air dry.
13. Wash hands again and put on sterile gloves.
14. Administer lidocaine subcutaneously over the planned puncture site,
but give this only if indicated. Aspirate to ensure you are not in a
blood vessel. Allow to wait at least 60 seconds for full effect of the
local anesthetic.
 Implementation: Checklist
15. Get ABG syringe and remove protective cover of needle then flush
through the heparin from syringe.
16. Position needle bevel up at 45-degree angle on the puncture site, with
shaft parallel to the path of the artery vessel. Puncture the skin and
arterial wall in one motion.
17. Watch for blood backflow in the syringe. The pulsating blood will flow
on its own so do not pull back on the plunger. Fill up to the 1 ml, 2ml,
or 3 ml mark, depending on syringe or as needed.
 Implementation: Checklist
18. Withdraw needle once done and place firm pressure to the insertion
site using 2x2 sterile gauze for at least 1 minute. Then place secure
tape.
19. Check syringe for air bubbles. If any appear, remove by holding the
syringe upright and slowly ejecting some of the blood onto a 2x2
gauze pad.
20. Remove needle and throw into sharps container then cover syringe
with an airtight cap. Gently rotate syringe to ensure heparin is well
distributed, but do not shake.
 Implementation: Checklist
21. Write label on the syringe such as client’s name, specimen collected,
date and time of collection, identification of healthcare worker who
obtained the sample, and any other information required by
institution.
22. Place syringe into a cup or bag of ice then put in a sealable plastic bag
for immediate delivery to laboratory.
23. Discard materials, do aftercare, and clean bedside stand or overbed
table. Remove gloves and PPE, if used. Perform hand hygiene.
 Evaluation
▪ The expected outcome is met when an arterial blood specimen is
obtained, and the patient reports minimal pain during the
procedure.
▪ In addition, the site remains free of injury, without evidence of
hematoma formation, and the patient verbalizes the rationale for
the specimen collection
 Documentation
▪ Document results of Allen’s test, time the sample was drawn, arterial
puncture site, amount of time pressure was applied to the site to control
bleeding, type and amount of oxygen therapy that the patient was receiving,
pulse oximetry values, respiratory rate, respiratory effort, and any other
significant assessments.
➢9/22/12 1245 Allen’s test positive. ABG obtained using R radial artery.
Pressure applied to site for 5 minutes. Patient receiving 3 L/NC oxygen,
pulse oximetry 94%, respirations even/unlabored, respiratory rate 18 breaths
per minute, patient denies dyspnea. - N. Schmidt, RN
 Unexpected Situations and Interventions
▪ While you are attempting to puncture the artery, the patient complains of
severe pain: Using too much force may cause the needle to touch bone,
causing the patient pain. Too much force may also result in advancing the
needle through the opposite wall of the artery. If this happens, slowly pull
the needle back a short distance and check to see if blood returns. If blood
still fails to enter the syringe, withdraw the needle completely and restart the
procedure.
▪ You cannot obtain a specimen after two attempts from the same site: Stop.
Do not make more than two attempts from the same site. Probing the artery
may injure it and the radial nerve.
 Unexpected Situations and Interventions
▪ Blood will not flow into the syringe: Typically, this occurs as a result of arterial
spasm. Replace the needle with a smaller one and try the puncture again. A smaller-
bore needle is less likely to cause arterial spasm.
▪ After inserting the needle, you note that the syringe is filling sluggishly with dark
red/purple blood: If the patient is in critical condition, this may be arterial blood. But
if the patient is awake and alert with a pulse oximeter reading within normal
parameters, you have most likely obtained a venous sample. Discard the sample and
redraw.
▪ The patient is on warfarin (Coumadin) therapy: Expect to hold pressure on the
puncture site for at least 10 minutes. If pressure is not held sufficiently long, a
hematoma may form, place pressure on the artery, and decrease the flow of blood.
 Unexpected Situations and Interventions
▪ Blood was drawn without incident, but now, 2 hours later, the patient is
complaining of tingling in the fingers and the hand is cool and pale: Notify
the physician. An arterial thrombosis may have formed. If not treated, the
thrombosis can lead to necrosis of tissue on the extremity.
▪ Puncture site continues to ooze: If the site is not actively bleeding, consider
placing a small pressure bandage on the insertion site. This will prevent the
artery from continuing to ooze. Continually check the site for bleeding and
assess the extremity to ensure that blood flow is adequate.
▪ The Allen’s test is negative: Try the other extremity. If the other extremity
has a positive result (collateral circulation), use that extremity. If the Allen’s
test is negative in both extremities, notify the physician.
 Special Considerations
▪ Use of a particular arterial site is contraindicated for the following reasons:
✓ Absence of a palpable radial artery pulse
✓ Allen’s test showing only one artery supplying blood to the hand
✓ Allen’s test showing obstruction in the ulnar artery; cellulitis or infection at
the site
✓ Presence of arteriovenous fistula or shunt
✓ Severe thrombocytopenia (platelet count 20,000/mm3 or less, or based on
facility policy), and a prolonged prothrombin time or partial thromboplastin
time
 Special Considerations
▪ If the patient is receiving oxygen, make sure that this therapy has been
underway for at least 15 minutes before collecting an arterial blood sample.
Also be sure to indicate on the laboratory request and the specimen label the
amount and type of oxygen therapy the patient is receiving.
▪ If the patient is receiving mechanical ventilation, note the fraction of
inspired oxygen and tidal volume.
▪ If the patient is not receiving oxygen, indicate that he or she is breathing
room air.
▪ If the patient has just received a nebulizer treatment, wait about 20 minutes
before collecting the sample.
 Special Considerations
▪ If the femoral site is used for the procedure, apply pressure for a minimum
of 10 minutes.
▪ Arterial lines may be used to obtain blood samples.
▪ Keep in mind that normal pediatric values are the same above with the
following changes (Fischbach & Dunning, 2009):
✓ pH: 7.32–7.42
✓ PaCO2: 30–40 mm Hg
 Videos
• https://youtu.be/0BSv4iN8T2E
• https://youtu.be/m0yFpcqKAm4
 Reference
• Fenske, C., Watkins, K.D., Saunders, T., D'Amico, D., & Barbarito, C. (2020).
Health & Physical Assessment In Nursing, 4th edition. Pearson.
• Lynn, P., & LeBon, M. (2010). Skill Checklists for Taylor’s Clinical Nursing Skills:
A Nursing Process Approach, 3rd Edition (Workbook ed.) [E-book]. Lippincott
Williams & Wilkins.