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1. ALI NAWAZ QADRI

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Arterial Puncture ProceduresArterial Puncture Procedures

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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

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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.

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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.

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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.

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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

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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

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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

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Personnel Who Perform ArterialPersonnel Who Perform Arterial
PuncturePuncture
 NursesNurses
 Medical technologists & techniciansMedical technologists & technicians
 Respiratory therapistsRespiratory therapists
 Emergency medical techniciansEmergency medical technicians

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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

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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

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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

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ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
• ABG equipment

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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)

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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

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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.

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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

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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

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ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
• Assess collateral circulation

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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

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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

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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

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ABG Specimen Collection (contABG Specimen Collection (cont’’d)d)
• Expel air bubbles, cap syringe, mix, & label specimen

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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

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