ARTERIAL BLOOD GAS
LEARNING PACKAGE
Sampling of Arterial Blood Gases in Critical Care Areas
Adapted for Armidale Rural Referral Hospital
December 2011 Megan Hay CNS
(from a package by Central Gippsland Health Service November 2006)
To the Learner:
Self Directed Learning Packages are useful tools to enable guidance from
teaching resources to provide a basic understanding of the topic presented.
They allow autonomy in basic learning to learn at your own pace and at your
own level.
Self Directed Learning Packages should not be used as a stand alone
learning tool; many resources are available to you to fulfil your learning needs.
The clinical educators, facilitators, liaison and senior staff, in your clinical area
are your central source to assist in clarification, enhancement or further
direction of your learning needs.
The information in this competency package is intended to be a guide
only and Nurses should be aware of the policies and procedures of their
employing organisation. However, it should be noted that acting within
a guideline or policy statement of an employer, any other organisation
or professional group does not relieve them of responsibility for their
own acts and may not provide immunity in case of negligence.
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Table of Contents:
Aim
4
Objectives
4
Assessment criteria
4
Indications for arterial blood sampling
5
Contraindications / Concerns for arterial puncture
5
Complications of arterial puncture
6
Site Selection
7
Radial artery anatomy
7
Brachial artery anatomy
8
Femoral artery anatomy
9
Testing collateral circulation
10
History
10
Research
10
Allen’s Test
11-12
Plethysmography & Pulse Oximetry (POX)
12-13
Sampling from an arterial puncture
14
Sampling from arterial lines
17-18
References
19-20
Arterial Blood Sampling Short Answer Questions
21
Arterial Blood Sampling Multi-choice Quiz
21-22
Arterial Blood Sampling Competency
23
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AIM:
The aim of this module is to assist the Registered Nurse to acquire the knowledge and
proficiency required for performing arterial punctures and collecting arterial blood samples.
OBJECTIVES:
On completion of this module the RN should be able to:
• List the indications for arterial puncture
• Discuss the contra-indications for arterial puncture
• List complications which may occur
• Identify the sites which may be used for the arterial puncture
• Describe the steps taken in performance of an Plethysmography test
• Describe the steps taken in performance of an Allen’s test
• Explain why the Allen’s or Plethysmography test is performed prior to a radial
artery puncture
• Explain how to perform an arterial puncture of the radial, brachial, and
femoral artery
• Discuss the care of the puncture site
• Explain the handling of the blood sample obtained.
ASSESSMENT CRITERIA:
Upon completion of the theory module, revision questions and quiz the
participant is required to perform two radial puncture procedures under the supervision of a
medical officer or a Registered Nurse with current ABG sampling competency.
The completed chart should be presented to the ABG co-ordinator or Clinical Educator and a
certificate of proficiency will be awarded.
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INDICATIONS FOR ARTERIAL BLOOD SAMPLING:
The sampling of arterial blood for analysis of the respiratory and acid-base status of
patients is a common practice in acute care medicine.
Arterial Blood Gas (ABG) samples are performed to assist in the diagnosis of
respiratory insufficiency, hypoxaemia, metabolic disorders and unstable
cardiopulmonary status.
Blood gas measurement provides “end-effect” data on oxygenation and CO2
elimination.
They also assess the affinity state of haemoglobin, as reflected by the percentage of
saturation by oxygen and by the levels of carboxyhemoglobin and methemoglobin.
Because results obtained will identify changes in pH, PaCO2 and PaO2 prior to the
development of clinical symptoms clinicians are able to initiate required therapies
rapidly, and monitor the patient’s response to therapy.
CONTRAINDICATIONS / CONCERNS FOR ARTERIAL PUNCTURE:
Contraindications are relative and should be considered in terms of the risks to the
patient under the circumstances and the importance of obtaining the sample.
• Vascular surgery in the area to which an arterial sample is to be taken. Eg,
dacron grafts increase the risk of contamination and bleeding problems. It is
also difficult to apply pressure in such areas
• A fractured wrist as the circulation to the hand maybe compromised
• A coagulopathy or medium-to-high dose anticoagulation therapy (eg, heparin
or warfarin, streptokinase, and tissue plasminogen activator but not
necessarily aspirin) may be a relative contraindication for arterial puncture
• History of a clotting disorder (haemophilia)
• History of arterial spasms following previous punctures
• Severe peripheral vascular disease
• The presence of an AV fistula shunt for haemodialysis
• Cellulitis or other infection over the arteries
• Absence of palpable pulse
• Positive Allen’s test – indicative of inadequate collateral blood supply to the
hand and suggest the need to select another extremity as the site of puncture
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COMPLICATIONS OF ARTERIAL PUNCTURE:
COMPLICATION
CAUSE
ACTION
Arteriospasm
May occur secondary to pain
Reassure patient; explain
or anxiety
procedure and purpose.
Leakage of blood into tissue
Ensure using small diameter
due to lack of sufficient
needle. Ensure proper
elastic tissue to seal
technique in holding sitex5-
puncture site, especially in
10 minutes post puncture
Haematoma
the elderly
Haemorrhage
Patient receiving
Two minutes after pressure
anticoagulant therapy or
is released inspect site for
patients with known blood
bleeding oozing or seepage
coagulation disorders
of blood; continue pressure
until bleeding ceases. A
longer compression time is
necessary
Infection of health care
Contact with virus,
Universal blood and body
provider
infectionscontained in blood
fluid precautions should be
of infected patients
implemented. All blood
samples from all patients
must be treated with full
precautions
Nosocomial bacteraemia
Distal ischaemia
Inadequate cleansing prior to
Ensure appropriate cleansing
puncture
technique
No collateral circulation
DO NOT proceed with
puncture after patient has
had positive
Allen’s/plethysmography
Numbness of hand
Nerve damage
Ensure proper technique.
Palpate artery well, do not
redirect when needle lies
deep within tissue
Sepsis
Infection/inflammation
Avoid sites indicating
adjacent to puncture site
presence of infection of
inflammation
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SITE SELECTION:
Arterial blood usually is obtained by percutaneous needle puncture of a palpable
artery. ARRH Local Procedure dictates that accredited RN’s may only access the
radial artery.
The radial, brachial, and femoral arteries are used most commonly.
The posterior tibial and dorsalis pedis arteries also are used in children (these areas
are discussed in Part 3 arterial catheterization), and the umbilical artery frequently is
cannulated in neonates.
The approach and anatomic landmarks for the various sites are described below
RADIAL ARTERY ANATOMY • The anatomy of the radial artery is shown below.
• The radial artery is palpable between the distal radius and the tendon
of the flexor carpi radialis and usually can be more easily accessed
with the wrist extended.
• The modified Allen test or plethysmography with pulse oximetry
(POX) should be used to demonstrate collateral flow through the
superficial palmar arch prior to cannulation. The incidence of
thrombosis of the radial artery is high (up to 50 percent), but the
incidence of actual ischemic complications is low.
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BRACHIAL ARTERY ANATOMY The brachial artery is palpable in the antecubital fossa just medial to the biceps tendon.
Although somecollateral flow into the lower arm occurs,thrombosis of the brachial artery can
lead to loss of limb, and other sites of catheter placement are preferable.
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FEMORAL ARTERY ANATOMY The femoral artery can be palpated just below the midpoint of the inguinal ligament. The
needle should be inserted just below the inguinal ligament, at a90º angle toward the
pulsation .Arterial catheterization via the femoral route may lead to thrombosis and distal
embolization to the foot and should be accompanied by close monitoring of distal pulses.
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TESTING COLLATERAL CIRCULATION:
End arteries, such as the radial, ulnar, posterior tibial and dorsalis pedis arteries are
small and distal, avoiding the problem in disrupting a major artery. All end arteries
have surrounding collateral circulation.
The Allen's test is used to confirm redundant collateral circulation.
History:
In 1929, Edgar V. Allen described a noninvasive evaluation of the patency of the
arterial supply to the hand of patients with thromboangitis obliterans (Am J Med Sci
1929;178:237). In the early 1950s, Allen's test was modified (Wright I. Vascular
diseases in clinical practice. Chicago: Year Book Medical Publishers, 1952) for use
as a test of collateral circulation prior to arterial cannulation. The modified Allen's test
can be performed quickly and easily, but it is susceptible to error. (With Allen's
original test, both hands were tested simultaneously. The patient clenched both fists
tightly for 1 minute while the examiner compressed one artery of each hand. This
method helps diagnose complete occlusion, just as Allen intended. The test was later
modified, however, to evaluate the adequacy of collateral circulation. To perform the
modified Allen's test, the examiner compresses both arteries while the patient's fists
are clenched. The patient then opens the hand, and the adequacy of circulation is
evaluated when the examiner releases one of the arteries.)
Research:
The Gold Standard in detecting perfusion defects has still been proven to be
the Allen’s test (Ronald & Patel, 2005) however clinical practice has required
modification of this test.
Plethysmography together with Pulse oximeter recording (POX) is often used
as a modified test in the detection of perfusion defect in the arterial tracing.
Reviewed studies (Glavin & Jones, 1989, Fuhrman et. al, 1990, Cheng et. al, 1988,
Barbeau et. al, 2004, Richey, 2004) have shown that pulse oximetry used in
conjunction with plethysmography have a high degree of reliability, however the
modified Allen’s test still provides greater sensitivity for low flow state to the hand.
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In Brief - To perform the Allens test:
• Occlude the radial and ulnar arteries by applying firm pressure to the
inner and outer aspects of the wrist.
• Maintain the pressure until the hand turns pale;
• Release the pressure on the ulnar artery.
• The hand should “pink up” within 6 secs – (although this is argued
within the literature 6 secs appears to be the general consensus).
• If the hand remains pale, insufficient redundant circulation is present
and damage to the radial artery could result in ischemia of the hand –
• Another site should be considered to draw an ABG sample.
See over for greater detail.
Postive Allen’s Test = Don’t use!! Insufficient circulation
Negative Allen’s Test = Good circulation
Modified Allen’s Test
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Plethysmography & Pulse Oximetry (POX)
• The patient is instructed to hold the hand in a neutral position with the palm up.
• The pulse oximeter probe is placed on the thumb when assessing the ulnar artery
and placed on the fifth finger when assessing the radial artery
• The monitor is then viewed for a plethysmographic waveform.
• The pulse oximeter probe is placed on the thumb when assessing the ulnar artery
and placed on the fifth finger when assessing the radial artery.
• The monitor is then viewed for a plethysmographic waveform.
• The radial and ulnar arteries are then occluded until the waveform becomes flat
or decreased by greater than 50 percent.
• After that, the artery being assessed is released.
• The plethysmographic waveform reappearing within fifteen seconds or less
indicates a satisfactory test result.
• Greater than 15 seconds is abnormal and another site should be selected
http://snhs.georgetown.edu/gujhs/vol1no3/richey.html
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Limitations of using Pulse Oximetry:
1. Motion
2. Abnormal Haemoglobin level
3. Sensor exposure to ambient light
4. Skin pigmentation
5. Nail polish
6. Intravascular dyes
Never use pulse oximetry on its own as a test – it has a much poorer outcome for
indication of collateral circulation than the Allen’s test or plethysmography used in
conjunction with pulse oximetry
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SAMPLING FROM AN ARTERIAL PUNCTURE:
Explain the procedure to the patient and emphasise the importance of remaining calm
to prevent hyperventilation and thus interfere with the results. Tell the patient there
may be discomfort and sudden movements should be avoided. Ensure adequate
explanations are provided regarding the reasons for obtaining an arterial blood
sample and the method.
EQUIPMENT:

Cotton swabs

23 gauge needle

Alcohol Swab
 Gloves & glasses
 Ice pack or bag and ice to pack syringe (if delay to analysis anticipated)
 Patient label

Pre-heparinised arterial blood gas syringe. (Check the expiry date. A heparinised
syringe is used as unclotted blood is needed for analysis)
 Air tight cap for syringe
 Bluey
 Request slip if available
 Wash hands prior to preparing equipment, gloving and putting on glasses.
 Select arterial site to be used and locate pulse. Take into consideration all
contraindications when choosing puncture site. (See ‘contraindications’)
Avoid using the same sample site on consecutive punctures to prevent infection.
 If the patient is ventilated, and has been suctioned recently, changes to ventilator
settings, or given a nebuliser, ABG’s should be avoided for 20 minutes as this will
interfere with true results. If patient is requiring oxygen therapy, consideration
should be given to taking arterial blood gas on room air. In this situation, oxygen
supplement should be turned off for 20 minutes prior to the arterial blood gas
sampling.
 If the radial artery is chosen for an arterial puncture, the Allen’s test or POX
must be performed to test collateral circulation. The Allen’s test or POX can only
be performed on the radial artery.
(See ‘Testing collateral circulation’)
 Position client supine with arm at side, palm up. Before stab you may use a small
towel rolled under wrist to hyperextend wrist.
 Clean the skin thoroughly using an alcohol swab, remembering to use gloves and
glasses at all times. Allow approximately 40 seconds for the alcohol to evaporate.
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For Radial artery puncture palpate pulse with two fingers and insert the needle at
a 30 –40o angle to wrist, pointing towards the elbow.
For Brachial artery puncture insert needle closer to a 60o angle: ensure arm is
extended and palm is up. The needle should enter just above the elbow crease.
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For Femoral artery puncture insert needle at a 90 degree angle
 When blood appears in the syringe allow the pressure of the artery to fill the
syringe. 1.5 –2.5ml of blood is a sufficient amount.
 Withdraw needle and apply pressure immediately for no less than five full
minutes. Apply pressure for ten full minutes of the patient is fully heparinised
or has had thrombolytic therapy within the past 24hrs. Do not bandage site.
Bandaging only compresses venous or capillary ooze. Therefore it is
unnecessary to apply after an arterial stab and conceals the site. Bandaging
is not to be used in place of digital pressure to the site. It is important that the
site is visualised and assessed for no visible signs of bleeding ensuring
haemostasis has occurred.
 Remove and discard sharps into container.
 Expel air from tip of syringe of blood and apply airtight seal – air bubbles may
introduce error leading to an artificially high arterial PaO2.
 Label the sample with the patient’s name. Store blood syringe in ice pack till
delivered to pathology for analysis or analyse immediately in the Intensive Care Unit
 Ensure you dispose of sharps appropriately
*NB.
An arterial blood sample held at room temperature has to be analysed within 15
minutes of obtaining the sample
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An arterial blood sample packed in ice has to be analysed within 2hours of obtaining
the sample
The patients’ temperature and amount of inspired oxygen is important as it determines how
much oxygen is bound to the patients’ haemoglobin molecules and is delivered to the tissues
It is important to realise that some health facilities require FiO2 and temperature to be
recorded on the label when sent for testing and some don’t – Please check with your facility
It is important to record these on the chart at the time the sample is taken
SAMPLING FROM ARTERIAL LINES
Blood for arterial blood gases and other pathology may be obtained from an
arterial line that is already insitu. A three way tap near the indwelling arterial
catheter lumen facilitates the process.
EQUIPMENT

Personal protective equipment - Disposable gloves & eye protection must
be worn.

2 x 5 ml syringe (or gold sample tubes and vacutainer barrel &
blue multi-sample device luer)

ABG syringe & patient addressograph

Clean arterial line red cap

Request slip

Patient temperature & FiO2
 Bluey
• Explain the procedure to the patient prior to procedure.
Lay out necessary equipment on over bed table next to patient bed and within
easy reach.
Lay blue protective sheeting under limb with arterial line to protect patient and
bed clothing from accidental back flow of blood from pressure line.
Open sterile gauze package on bedside table.
• If using vacutainer method: Attach blue multi sample device luer adaptor to
vacutainer barrel by removing top protector from adaptor and screwing
adaptor into the barrel.
• Hit three minutes silence alarm on overhead monitor.
Place on gloves and eye protection.
• Ensure three way stop cock is turned off to sample port.
Remove red cap from pressure line transducer and place on sterile gauze to
protect from contamination or discard and replace with a new one.
Wipe down sample port with alcohol swab before starting procedure.
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Place either syringe or vacutainer barrel securely onto sample port.
Turn stop cock off to pressure bag and withdraw blood into syringe (or orange
blood tube from arterial line).
• Withdraw 3mls from radial line and 5mls from femoral line.
• Turn stop cock 45 degrees back towards sample port and remove blood filled
syringe and discard appropriately (or orange blood tube + vacutainer).
• Place ABG syringe on sample port then turn stop cock off to pressure bag.
Draw 1ml to 1.5mls into syringe (arterial pressure should fill syringe).
• Turn stop cock 45 degrees towards patient.
• Remove ABG syringe.
• Remove any air from syringe and place black cap on syringe.
• Place either syringe or vacutainer barrel securely onto sample port.
Turn stop cock off to the patient and flush sample port into syringe (or orange
blood tube from arterial line).
• Turn stop cock off to the sample port. Place red arterial cap back onto the
sample port.
• Flush the pressure line for 2 – 3 seconds to clear all blood in the line.
• Ensure your line is accurately zeroed
• Label the sample with the patient’s name. Analyse immediately in the Intensive Care
Unit
� An arterial blood sample held at room temperature has to be analysed
within 15 minutes of obtaining the sample
� An arterial blood sample packed in ice has to be analysed within 2
hours of obtaining the sample
• The patients’ temperature and amount of inspired oxygen is important as it
determines how much oxygen is bound to the patients’ haemoglobin
molecules and is delivered to the tissues
• it is important to realize that some health facilities require FiO2 and
temperature to be recorded on the label when sent for testing and
some don’t – Please check with your facility
• it is important to record these on the chart at the time the sample is
taken
• Ensure you dispose of all sharps and blood appropriately
• NB:
If blood cultures are to be taken, only one set should ever come from the line.
Any repeated cultures should be obtained via a peripheral venipuncture.
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References:
Williams, A 1998, ABC of oxygen - Assessing and interpreting arterial blood gases and acid-base
balance, British Medical Journal, vol. 317 pp1213.
Mueller, R, Lang, G & Beam, J 1976, Bubbles in samples for blood gas determinations: A potential
source of error, American Journal of Clinical Pathology, vol. 65 p 242.
Gammon, B 2006, Measurement of arterial blood gases and arterial catheterization in adults accessed
at UpToDate14.2 at www.uptodate.com at CGHS Library Services.
Richey, K 2004, Inter-user reliability of assessing collateral circulation by the modified allen’s test versus
pulse oximetry with plethysmography, Georgetown Journal of Health Science, vol.1, no.3, accessed at
http://snhs.georgetown.edu/gujhs/vol1no3/richey.html
Kaye, W 1994, Invasive monitoring techniques. In: Textbook of Advanced Cardiac Life Support,
American Heart Association, Dallas.
Barker, W 1998, In: Clinical Procedures in Emergency Medicine, 3rd Ed, Roberts (Ed), WB Saunders.
Jones, R, et al., 1981, The effect of method of radial artery cannulation on postcannulation blood flow
and thrombus formation, Anesthesiology vol. 55 p.76.
Gammon, B & Bajaj, L 2006, Measurement of arterial blood gases and arterial catheterization in children
accessed at UpToDate14.2 at www.uptodate.com at CGHS Library Services.
King, C & Henretig, F 2000, In: Pocket Atlas of Pediatric Emergency Procedures, Lippincott, Williams
and Wilkins, Philadelphia.
O’Mara, K, 1996, Use of Pulse Oximetry for Assessing Ulnar Collateral Flow, Annals of Internal
Medicine, vol 125, no. 6, p 522.
Glavin R & Jones H 1989, Assessing collateral circulation in the hand—four methods compared,
Anaesthesia, vol.44, pp594-595.
Williams, T & Schenken J 1987, Radial artery puncture and the Allen test, Annals of Intern Medicine,
vol. 106, pp. 164-165.
Fuhrman, T, Pippin, W, Talmage, L & Reilly, T 1992, Evaluation of collateral circulation of the hand,
Journal of Clinical Monitoring and Computing, vol.8, no.1, pp 28-32, accessed at
http://www.springerlink.com/content/qk718135222671x6/
Cheng, E, Lauer, K, Stommel, K & Guenther, N 1988, Evaluation of the palmar circulation by pulse
oximetry, Journal of Clinical Monitoring and Computing, vol.5, no.1, pp1-3, accessed at
http://www.springerlink.com/content/qx104515w842m647/
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Shapiro B, Harrison R, Cane R & Templin R 1989, Clinical application of blood gases, 4th ed., Year
Book Medical Publishers Inc., St Louis.
Module 2: IV Access Arterial Blood Gas Sampling http://meds.queensu.ca/~pmsp/iv/ABGmod2.htm
Hemodynamics Arterial Puncture Checklist. http://rnbob.tripod.com/artstick.htm
Barbeau, G, Arsenault, F, Dugas, L, Simard, S, Mai, M & Lariviere, M 2004, Evaluation of the
ulnopalmar arterial arches with pulse oximetry and plethysmography: Comparison with the Allen’s test in
1010 patients, American Heart Journal, vol. 147, no.3, pp 489-493.
For interest sake only I am unsure wether you can obtain this original article as I could not but the
reference for you is:
Allen EV 1929, Thromboangitis obliterans: methods of diagnosis of chronic occlusive arterial lesions
distal to the wrist with illustrative cases, American Journal of Medical Science, 1929; vol.178, pp 237-44.
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Name:
Date:
ARTERIAL BLOOD SAMPLING SHORT ANSWER QUESTIONS:
1. Describe how you would perform the Allen’s test and discuss its importance
2. Describe how you would perform Plethysmography & Pulse oximetry (POX)
3. Identify the three sites used for arterial punctures
4. Evaluate the vascular implications associated with arterial puncture from each
site.
5. Discuss care of the puncture site
6. List the indications for an arterial puncture
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ARTERIAL BLOOD SAMPLING MULTI-CHOICE QUIZ:
You may need to consult other resources to answer some of the questions.
1. Arterial blood sampling is used:
a) instead of phlebotomy in young patients with strong pulses
b) only in patients with pulmonary disease
c) only in patients with renal disease
d) to assess lung ventilation, tissue oxygenation, and acid base status.
2. The radial artery is:
a) found in the deep tissues under the flexor carpi radialis tendon
b) in the superficial subcutaneous tissues on the radial site of the wrist
c) antecubital fossa just medial to the biceps
d) below the midline of the inguinal ligament
3. The most common complication of arterial blood gas sampling is:
a) obstructing thrombus in the artery
b) infection
c) haemotoma
d) radial nerve injury
4. The syringe is filled during sampling by:
a) drawing up on the plunger once in the artery
b) allowing arterial pressure to fill the syringe to about 1ml
c) squeezing the forearm
d) applying pressure to the artery
5. The most common reason for a difficult or painful arterial puncture is:
a) anatomic variability
b) faulty equipment
c) airlock in the syringe
d) missing the artery on the initial puncture and then probing deeper.
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6. When using the Allen test following release of pressure on the ulna artery
vascular ‘refill’ in health takes approximately 15 seconds.
True
False
7. When using the Allen test following release of pressure on the ulna artery, a
vascular ‘refill’ completion in excess of 4 seconds would require that the other
arm be considered as a potential sampling site.
True
False
8. When using the POX method a decrease in the plethysmographic waveform
must be greater than 50% when the radial and ulnar arteries are occluded
True
False
9. The alcohol skin preparation applied to the sample site takes approximately
40 seconds to evaporate.
True
False
10. Following sample collection pressure need only be applied to the sample site
for a minimum of 30 seconds
True
False
11. Following sample collection, a premature release of pressure on the sample
site can lead to a haematoma formation
True
False
12. Under no circumstances should a dressing be directly applied to the sampling
puncture site
True
False
13. The arterial blood gas result is only a physiological reflection of the patient’s
condition in respect of the time that the sample was acquired
True
False
14. An arterial blood sample packed in ice has to be analysed within 2 hours of
obtaining the sample
True
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ARTERIAL BLOOD SAMPLING COMPETENCY
ARTERIAL PUNCTURE
Name ________________________ Position_______________________
Date _____/______/______ Ward ______________
C - Competent, NC – Not Competent, NO – Not Observed, NA – Not
Assessed
Performance Criteria
Achievement
C/NC &
NO/NA
1. Identifies the indications for obtaining arterial blood samples
2. Checks patient coagulation status
3. Selects site - Performs Allen Test or POX & interprets findings
4. Demonstrates appropriate use of personal protective attire
5. Preps site and palpate site
6. States the angle at which the blood sample should be taken
7. Obtains arterial blood sample from radial artery:
a) Performs puncture and allows syringe to fill
b) Expels air from syringe, caps tightly
c) Applies pressure for at least 5 min radially
8.Demonstrates appropriate labelling and handling of sample
9. States maximum time lapses for iced and un-iced testing of samples
10. Reassess patient, and puncture site for haematoma
11. States precautions and nursing measures aimed at reducing the
risk of complications
Assessed by: __________________________________________________
Assessors Signature: ____________________________________________
Assesses signature: _____________________________________________
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