3. ALI NAWAZ QADRI
Ali Nawaz Qadri
(RN, DCHN, BSCN 1ST
SEMESTER)
Subject: Advanced Concept Nursing
Topic: Arterial Puncture Procedure
Faculty: Sir Sarfaraz Masih
Collage: KKCON (LUMHS)
Dated: 14-06-2013
Email: alinawazqri@hotmail.com
4. ALI NAWAZ QADRI
ObjectivesObjectives
1.1. Define the key terms and abbreviations listed at theDefine the key terms and abbreviations listed at the
beginning of this chapter.beginning of this chapter.
2.2. State the primary reason for performing arterialState the primary reason for performing arterial
punctures and identify the personnel who may bepunctures and identify the personnel who may be
required to perform them.required to perform them.
3.3. Explain the purpose of collecting arterial blood gasExplain the purpose of collecting arterial blood gas
(ABG) specimens and identify and describe commonly(ABG) specimens and identify and describe commonly
measured ABG parameters.measured ABG parameters.
4.4. Identify the sites that can be used for arterial puncture,Identify the sites that can be used for arterial puncture,
the criteria used for selection of the site, and thethe criteria used for selection of the site, and the
advantages and disadvantages of each site.advantages and disadvantages of each site.
5. ALI NAWAZ QADRI
Objectives (contObjectives (cont’’d)d)
5.5. List equipment and supplies needed for arterialList equipment and supplies needed for arterial
puncture.puncture.
6.6. Identify typical required and supplemental requisitionIdentify typical required and supplemental requisition
information and describe patient assessment andinformation and describe patient assessment and
preparation procedures, including the administration ofpreparation procedures, including the administration of
local anesthetic, prior to performing arterial blood gases.local anesthetic, prior to performing arterial blood gases.
7.7. Explain the purpose of the modified Allen test, describeExplain the purpose of the modified Allen test, describe
how it is performed, define what constitutes a positivehow it is performed, define what constitutes a positive
or negative result, and give the procedure to follow foror negative result, and give the procedure to follow for
either result.either result.
6. ALI NAWAZ QADRI
Objectives (contObjectives (cont’’d)d)
8.8. Describe the procedure for collecting radialDescribe the procedure for collecting radial
arterial blood gases and the role of thearterial blood gases and the role of the
phlebotomist in other site collections.phlebotomist in other site collections.
9.9. List hazards and complications of arterialList hazards and complications of arterial
puncture, identify sampling errors that maypuncture, identify sampling errors that may
affect the integrity of an arterial sample, andaffect the integrity of an arterial sample, and
describe the criteria for specimen rejection.describe the criteria for specimen rejection.
7. ALI NAWAZ QADRI
OverviewOverview
Disadvantages of Arterial PunctureDisadvantages of Arterial Puncture
Technically difficultTechnically difficult
Potentially more painful & hazardous than venipuncturePotentially more painful & hazardous than venipuncture
Thus, not normally used for routine blood testsThus, not normally used for routine blood tests
Reason for Arterial PunctureReason for Arterial Puncture
To obtain blood for arterial blood gas (ABG) testsTo obtain blood for arterial blood gas (ABG) tests
Arterial blood:Arterial blood:
Best specimen for evaluating respiratory functionBest specimen for evaluating respiratory function
Has high oxygen content & consistency of compositionHas high oxygen content & consistency of composition
8. ALI NAWAZ QADRI
ABGsABGs
Used in diagnosis & management of respiratoryUsed in diagnosis & management of respiratory
disordersdisorders
Provide valuable info. about patientProvide valuable info. about patient’’s:s:
OxygenationOxygenation
VentilationVentilation
Acid-base balanceAcid-base balance
Used in management of electrolyte & acid-base balanceUsed in management of electrolyte & acid-base balance
in patients w. diabetes & other metabolic disordersin patients w. diabetes & other metabolic disorders
9. ALI NAWAZ QADRI
Commonly Measured ABG AnalytesCommonly Measured ABG Analytes
AnalyteAnalyte NormalNormal
RangeRange
DescriptionDescription
pHpH 7.35–7.35–
7.457.45
A measure of acidity or alkalinity ofA measure of acidity or alkalinity of
blood (acidosis or alkalosis)blood (acidosis or alkalosis)
PaOPaO22 80–10080–100
mm Hgmm Hg
Partial pressure of OPartial pressure of O22 dissolved indissolved in
arterial bloodarterial blood
PaCOPaCO22 35–4535–45
mm Hgmm Hg
Partial pressure of COPartial pressure of CO22 dissolved indissolved in
arterial bloodarterial blood
HCOHCO22 22–2622–26
mEq/LmEq/L
A measure of bicarbonate in bloodA measure of bicarbonate in blood
OO22 satsat 97%–97%–
100%100%
Percent OPercent O22 bound to hemoglobinbound to hemoglobin
BaseBase
excessexcess
-2–+2-2–+2
mEq/LmEq/L
A calculation of non respiratoryA calculation of non respiratory
part of acid-base balancepart of acid-base balance
10. ALI NAWAZ QADRI
Personnel Who Perform ArterialPersonnel Who Perform Arterial
PuncturePuncture
NursesNurses
Medical technologists & techniciansMedical technologists & technicians
Respiratory therapistsRespiratory therapists
Emergency medical techniciansEmergency medical technicians
11. ALI NAWAZ QADRI
Site-Selection CriteriaSite-Selection Criteria
Presence of collateral circulationPresence of collateral circulation
Blood supply from more than one arteryBlood supply from more than one artery
Artery accessibility & sizeArtery accessibility & size
Type of tissue surrounding puncture siteType of tissue surrounding puncture site
Low risk of injuring adjacent structures or tissue during punctureLow risk of injuring adjacent structures or tissue during puncture
Ability to fix or secure artery to prevent rollingAbility to fix or secure artery to prevent rolling
Adequate pressure can be applied to artery after collectionAdequate pressure can be applied to artery after collection
Absence of inflammation, irritation, edema, hematoma, lesion,Absence of inflammation, irritation, edema, hematoma, lesion,
wound, AV shunt in close proximity, or recent arterial puncturewound, AV shunt in close proximity, or recent arterial puncture
12. ALI NAWAZ QADRI
Arterial Puncture SitesArterial Puncture Sites
The Radial ArteryThe Radial Artery
AdvantagesAdvantages
Good collateral circulation (radial & ulnar arteries)Good collateral circulation (radial & ulnar arteries)
Easy to palpate (close to surface of skin)Easy to palpate (close to surface of skin)
Less chance of hematoma formation after collectionLess chance of hematoma formation after collection
DisadvantagesDisadvantages
Requires considerable skill to puncture it successfully due to smallRequires considerable skill to puncture it successfully due to small
sizesize
Difficult to locate on patients w. hypovolemia or low cardiac outputDifficult to locate on patients w. hypovolemia or low cardiac output
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Arterial Puncture Sites (contArterial Puncture Sites (cont’’d)d)
• Arteries of the arm and hand
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Arterial Puncture Sites (contArterial Puncture Sites (cont’’d)d)
The Brachial ArteryThe Brachial Artery
AdvantagesAdvantages
Large & relatively easy to palpate & punctureLarge & relatively easy to palpate & puncture
Sometimes the preferred artery for a large volume of bloodSometimes the preferred artery for a large volume of blood
Adequate collateral circulation (but not as good as radial)Adequate collateral circulation (but not as good as radial)
DisadvantagesDisadvantages
Deeper & can be harder to palpate than radial arteryDeeper & can be harder to palpate than radial artery
Lies close to basilic vein; risk of mistakenly puncturing itLies close to basilic vein; risk of mistakenly puncturing it
Lies close to median nerve; risk of pain & nerve damageLies close to median nerve; risk of pain & nerve damage
Increased risk of hematoma formationIncreased risk of hematoma formation
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Arterial Puncture Sites (contArterial Puncture Sites (cont’’d)d)
The Femoral ArteryThe Femoral Artery
Largest artery used for arterial punctureLargest artery used for arterial puncture
Located superficially in groin, lateral to pubis boneLocated superficially in groin, lateral to pubis bone
Performed primarily by physicians & specially trainedPerformed primarily by physicians & specially trained
emergency room personnelemergency room personnel
Generally used only in emergency situations or when noGenerally used only in emergency situations or when no
other site is availableother site is available
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Arterial Puncture Sites (contArterial Puncture Sites (cont’’d)d)
• Arteries of the leg
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Arterial Puncture Sites (contArterial Puncture Sites (cont’’d)d)
Other SitesOther Sites
In infants:In infants:
ScalpScalp
Umbilical arteriesUmbilical arteries
In adults:In adults:
Dorsalis Pedis ArteriesDorsalis Pedis Arteries
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ABG Specimen CollectionABG Specimen Collection
Test RequisitionTest Requisition
Info. concerning conditions at time of collectionInfo. concerning conditions at time of collection
is needed:is needed:
Current body temperatureCurrent body temperature
Respiratory rateRespiratory rate
Ventilation statusVentilation status
Fraction of inspired oxygen (FIOFraction of inspired oxygen (FIO22))
Prescribed flow rate in liters per minutePrescribed flow rate in liters per minute
19. ALI NAWAZ QADRI
ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
Equipment and SuppliesEquipment and Supplies
Personal protective equipmentPersonal protective equipment
Fluid-resistant lab coat, gown, or apronFluid-resistant lab coat, gown, or apron
GlovesGloves
Face protectionFace protection
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ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
Equipment & SuppliesEquipment & Supplies
AntisepticAntiseptic
Local anesthetic (optional)Local anesthetic (optional)
Sharp, short-bevelSharp, short-bevel
hypodermic needlehypodermic needle
1- to 5-mL self-filling syringe1- to 5-mL self-filling syringe
Luer-tip normal or bubbleLuer-tip normal or bubble
removal capremoval cap
CoolantCoolant
2- by 2-in. gauze squares2- by 2-in. gauze squares
Self-adhering gauze bandageSelf-adhering gauze bandage
ID & labeling materialsID & labeling materials
Puncture-resistant sharpsPuncture-resistant sharps
containercontainer
22. ALI NAWAZ QADRI
ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
Patient PreparationPatient Preparation
Identification & explanation of proceduresIdentification & explanation of procedures
Patient preparation & assessmentPatient preparation & assessment
Modified Allen testModified Allen test
Administration of local anesthetic (optional)Administration of local anesthetic (optional)
23. ALI NAWAZ QADRI
ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
Modified Allen test procedureModified Allen test procedure
1.1. Have patient make a tight fistHave patient make a tight fist
2.2. Compress patientCompress patient’’s radial & ulnar arteries at same times radial & ulnar arteries at same time
3.3. Maintaining pressure, have patient open hand slowlyMaintaining pressure, have patient open hand slowly
4.4. Lower patientLower patient’’s hand & release pressure on ulnar arterys hand & release pressure on ulnar artery
onlyonly
5.5. Assess results: +hand flushes pink; -hand does notAssess results: +hand flushes pink; -hand does not
flush pinkflush pink
6.6. Record results on requisitionRecord results on requisition
24. ALI NAWAZ QADRI
ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
• Left: using middle & index fingers to apply pressure to
patient’s wrist. Middle: patient opens hand. Right:
positive result—hand flushes pink within 15 seconds.
25. ALI NAWAZ QADRI
ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
Preparing and Administering Local AnestheticPreparing and Administering Local Anesthetic
1.1. Verify absence of allergy to anesthetic or its derivativesVerify absence of allergy to anesthetic or its derivatives
2.2. Sanitize hands & don glovesSanitize hands & don gloves
3.3. Attach needle to syringeAttach needle to syringe
4.4. Clean stopper of anesthetic bottle w. alcohol wipeClean stopper of anesthetic bottle w. alcohol wipe
5.5. Insert needle through bottle stopper & withdrawInsert needle through bottle stopper & withdraw
anestheticanesthetic
6.6. Carefully replace needle cap & put syringe in horizontalCarefully replace needle cap & put syringe in horizontal
positionposition
7.7. Clean & air-dry siteClean & air-dry site
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ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
Preparing and Administering Local AnestheticPreparing and Administering Local Anesthetic
8.8. Insert needle into skin at site at angle of 10 degreesInsert needle into skin at site at angle of 10 degrees
9.9. Pull back slightly on plungerPull back slightly on plunger
10.10. Slowly expel contents into skin, forming a raised whealSlowly expel contents into skin, forming a raised wheal
11.11. Wait 1 to 2 min. before proceeding w. arterial punctureWait 1 to 2 min. before proceeding w. arterial puncture
12.12. Note anesthetic application on requisitionNote anesthetic application on requisition
27. ALI NAWAZ QADRI
ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
Radial ABG ProcedureRadial ABG Procedure
1.1. Review & accession test requestReview & accession test request
2.2. Approach, identify, & prepare patientApproach, identify, & prepare patient
3.3. Check for sensitivities to latex & other substancesCheck for sensitivities to latex & other substances
4.4. Access steady state, verify collection requirements, & recordAccess steady state, verify collection requirements, & record
infoinfo
5.5. Sanitize hands & don glovesSanitize hands & don gloves
6.6. Assess collateral circulationAssess collateral circulation
7.7. Position arm & ask patient to extend wristPosition arm & ask patient to extend wrist
8.8. Locate radial artery & clean siteLocate radial artery & clean site
29. ALI NAWAZ QADRI
ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
Radial ABG ProcedureRadial ABG Procedure
9.9. Administer local anesthetic (optional)Administer local anesthetic (optional)
10.10. Prepare equipment & clean gloved nondominant fingerPrepare equipment & clean gloved nondominant finger
11.11. Pick up equipment & uncap & inspect needlePick up equipment & uncap & inspect needle
12.12. Relocate radial artery & warn patient of imminentRelocate radial artery & warn patient of imminent
puncturepuncture
13.13. Insert needle at a 30- to 45-degree angle, slowly direct itInsert needle at a 30- to 45-degree angle, slowly direct it
toward pulse, & stop when a flash of blood appearstoward pulse, & stop when a flash of blood appears
14.14. Allow syringe to fill to proper levelAllow syringe to fill to proper level
15.15. Place gauze, remove needle, activate safety feature, &Place gauze, remove needle, activate safety feature, &
apply pressureapply pressure
30. ALI NAWAZ QADRI
ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
• Insert needle at a 30- to 45-degree angle, slowly direct
it toward pulse, & stop when a flash of blood appears
31. ALI NAWAZ QADRI
ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
Radial ABG ProcedureRadial ABG Procedure
16.16. Remove & discard syringeRemove & discard syringe
17.17. Expel air bubbles, cap syringe, mix, & label specimenExpel air bubbles, cap syringe, mix, & label specimen
18.18. Check patientCheck patient’’s arm & apply bandages arm & apply bandage
19.19. Dispose of used & contaminated materials, removeDispose of used & contaminated materials, remove
gloves, & sanitize handsgloves, & sanitize hands
20.20. Thank patient & transport specimen to lab ASAPThank patient & transport specimen to lab ASAP
32. ALI NAWAZ QADRI
ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
• Expel air bubbles, cap syringe, mix, & label specimen
33. ALI NAWAZ QADRI
Hazards and Complications of ArterialHazards and Complications of Arterial
Puncture and Sampling ErrorsPuncture and Sampling Errors
Hazards &Hazards &
ComplicationsComplications
ArteriospasmArteriospasm
Artery damageArtery damage
DiscomfortDiscomfort
InfectionInfection
NumbnessNumbness
Thrombus formationThrombus formation
Vasovagal responseVasovagal response
Sampling ErrorsSampling Errors
Air bubblesAir bubbles
Delay in analysisDelay in analysis
Improper mixingImproper mixing
Improper syringeImproper syringe
Obtaining venous blood byObtaining venous blood by
mistakemistake
Use of improperUse of improper
anticoagulantanticoagulant
Use of too much or too littleUse of too much or too little
heparinheparin