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Cardiovascular nursing practitioner Arterial gas analysis

1. St. Paul’s Hospital Millennium Medical College Arterial Blood Gas Analysis and Interpretation Prepared by : Sr Tigist Tsegaye ( MSc,CVNP ) Department of Medical Surgical Nursing Postgraduates Cardiovascular Nursing Programme AUGUST ,2022 1 (Sr Tigist Tsegaye ,MSc CVNP)

2. Arterial Blood Gas Analysis(ABG) And Interpretation   An arterial blood gas (ABG) tests explicitly blood taken from an artery. ABG analysis assesses a patient's partial pressure of oxygen (PaO2) , carbon dioxide (PaCO2 ) as well blood's pH balance. An acceptable normal range of ABG values of ABG components are the following: pH (7.35-7.45)  PaO2 (75-100 mmHg)  PaCO2 (35-45 mmHg) Bicarbonate (HCO3): 22 to 26 milliequivalents per liter ( mEq /L) 2 (Sr Tigist Tsegaye ,MSc CVNP)

3. Arterial Blood Gas Analysis... Interpreting an arterial blood gas (ABG) is a crucial skill for physicians, nurses, respiratory therapists, and other health care personnels . ABG interpretation is especially important in critically ill patients . Steps in ABG Analysis Step 1:   Is there alkalemia or acidemia present? pH < 7.35  acidemia pH > 7.45  alkalemia This is  usually  the primary disorder Remember:  an acidosis or alkalosis may be present even if the pH is in the normal range (7.35 – 7.45) You will need to check the PaCO 2 , HCO 3 3 (Sr Tigist Tsegaye ,MSc CVNP)

4. Arterial Blood Gas Analysis ... Step2: Is the disturbance respiratory or metabolic?  What is the relationship between the direction of change in the pH and the direction of change in the PaCO 2 ? In primary respiratory disorders, the pH and PaCO2 change in  opposite  directions; in metabolic disorders the pH and HCO 3  change in the same direction. Acidosis Respiratory pH ↓ PaCO 2      ↑ Acidosis Metabolic pH ↓ in HCO 3 ↓ Alkalosis Respiratory pH ↑ PaCO 2     ↑ Alkalosis Metabolic pH ↑ HCO 3 ↑ 4 (Sr Tigist Tsegaye ,MSc CVNP)

5. Arterial Blood Gas Analysis... Step 3 is it partially or fully compensated, uncompensated ? The body will compensate for pH imbalances until all reserve is lost and it can no longer do so. The older patients are, the more co-morbidities they may be likely to have, thus making compensation more difficult . Similarly, the more serious their condition, the less likely it is that they will be able to compensate . 5 (Sr Tigist Tsegaye ,MSc CVNP)

6. Arterial Blood Gas Analysis... Compensation involves trying to create a state of ‘opposites ’ A patient suffering from respiratory acidosis will try to create the opposite state of metabolic alkalosis in order to compensate . A patient in respiratory alkalosis will try to move to a state of metabolic acidosis. The principle of compensation is easy to remember as follows – the opposite of respiratory is metabolic and the opposite of acidosis is alkalosis . 6 (Sr Tigist Tsegaye ,MSc CVNP)

7. Arterial Blood Gas Analysis... Etiologies of respiratory acidosis Airway obstruction - Upper - Lower COPD asthma other obstructive lung disease CNS depression 7 (Sr Tigist Tsegaye ,MSc CVNP)

8. Arterial Blood Gas Analysis... 8 (Sr Tigist Tsegaye ,MSc CVNP)

9. Arterial Blood Gas Analysis... etiologies of respratory acidosis intake of carbohydrates Incorrect mechanical ventilation settings Neuromuscular impairment Ventilatory restriction Increased CO2  production: shivering, rigors, seizures, malignant hyperthermia, hypermetabolism Treatment :O2,suction,Physiotherapy,Nebulizer,CPAP 9 (Sr Tigist Tsegaye ,MSc CVNP)

10. Arterial Blood Gas Analysis... Nursing Diagnosis The following are the possible  Nursing diagnosis  for Respiratory Acidosis: Impaired Gas Exchange Ineffective breathing Ineffective Tissue Perfusion Acute Confusion Risk for Injury Nursing Priorities Achieve homeostasis. Prevent/minimize complications. Provide information about condition/prognosis and treatment needs as appropriate. 10 (Sr Tigist Tsegaye ,MSc CVNP)

11. Arterial Blood Gas Analysis... Nursing Interventions for Respiratory Acidosis Administer oxygen. encourage coughing and deep breathing. suction (pneumonia) may need respiratory treatment (asthma) hold respiratory depression drugs (know the category of drugs used sedatives etc) Watch potassium levels that are >5.1… 11 (Sr Tigist Tsegaye ,MSc CVNP)

12. Arterial Blood Gas Analysis... Etiologies of respiratory alkalosis CNS stimulation: fever, pain, fear, anxiety, CVA, cerebral edema, brain trauma, brain tumor, CNS infection Hypoxemia or hypoxia: lung disease, profound anemia, low FiO2 Stimulation of chest receptors: pulmonary edema, pleural effusion, pneumonia, pneumothorax , pulmonary embolus 12 (Sr Tigist Tsegaye ,MSc CVNP)

13. Arterial Blood Gas Analysis Etiologies of respiratory alkalosis… Drugs, hormones: salicylates , catecholamines , Pregnancy, liver disease, sepsis, hyperthyroidism Incorrect mechanical ventilation settings Treatment :Adjust of ventilator reduce the risk of hyperventilation. Bronchodilators 13 (Sr Tigist Tsegaye ,MSc CVNP)

14. Arterial Blood Gas Analysis … Nursing Interventions for Respiratory Alkalosis Teach patient breathing techniques to slow down breathing, holding breath…” rebreathing into a paper bag or re-breather mask. Watch potassium levels ( hypokalemia ) Closely watch patients on mechanical ventilation to ensure breaths are not hyperventilating the patient 14 (Sr Tigist Tsegaye ,MSc CVNP)

15. Arterial Blood Gas Analysis... Etiologies of metabolic alkalosis Hypovolemia GI loss of H+ -Vomiting, gastric suction, diarrhea with chloride-rich fluid Renal loss H+ -Loop and thiazide diuretics, post- hypercapnia (especially after institution of mechanical ventilation) -edematous states (heart failure, cirrhosis, nephrotic syndrome), 15 (Sr Tigist Tsegaye ,MSc CVNP)

16. Arterial Blood Gas Analysis... Etiologies of metabolic alkalosis hyperaldosteronism , hypercortisolism , excess ACTH, exogenous steroids, hyperreninemia , severe hypokalemia , renal artery stenosis , bicarbonate administration Treatment: Oxygen infusion. Potassium replacement. Magnesium replacement. Chloride infusion. Hydrochloric acid infusion. Stopping the medications that caused the condition Hydrochloric acid infusion. 16 (Sr Tigist Tsegaye ,MSc CVNP)

17. Arterial Blood Gas Analysis... Nursing Interventions & Considerations of metabolic alkalosis Dilute potassium when giving via I.V. containing potassium salts. ... Watch for signs of muscle weakness, tetany or decreased activity. Monitor vital signs frequently and record intake and output to evaluate respiratory, fluid and electrolyte status. Observe seizure precautions 17 (Sr Tigist Tsegaye ,MSc CVNP)

18. Arterial Blood Gas Analysis... Etiologies of metabolic acidosis Uremia Diabetic ketoacidosis , alcoholic ketoacidosis , starvation ketoacidosis Lactic acidosis -Type A:  tissue ischemia -Type B:  Altered cellular metabolism Ethanol intoxication Salicylate intoxication 18 (Sr Tigist Tsegaye ,MSc CVNP)

19. Arterial Blood Gas Analysis... Treatment of metabolic acidosis injectable bicarbonate Nursing Interventions & Considerations of metabolic acidosis Monitor BP Assess LOC and note progressive changes in neuromuscular status. Note neuromuscular strength, tone, movement. Provide seizure or    coma precautions and bed in low position, use of side rails , frequent observation 19 (Sr Tigist Tsegaye ,MSc CVNP)

20. Arterial Blood Gas Analysis... Disorders Characteristics Situations Respiratory acidosis with metabolic acidosis ↓in pH ↓ in HCO 3 ↑ in PaCO 2 Cardiac arrest Intoxications Multi-organ failure Respiratory alkalosis with metabolic alkalosis ↑in pH ↑ in  HCO 3   ↓ in PaCO 2     Cirrhosis with diuretics Pregnancy with vomiting Over ventilation of COPD Respiratory acidosis with metabolic alkalosis pH in normal range ↑ in PaCO 2 , ↑ in  HCO 3 - COPD with diuretics, vomiting, NG suction Severe hypokalemia mixed and complex acid-base disturbances 20 (Sr Tigist Tsegaye ,MSc CVNP)

21. Arterial Blood Gas Analysis... Disorders Characteristics Situations Respiratory alkalosis with metabolic acidosis pH in normal range ↓ in PaCO 2 ↓ in HCO 3            Sepsis Salicylate toxicity Renal failure with CHF or pneumonia Advanced liver disease Metabolic acidosis with metabolic alkalosis pH in normal range HCO 3 - normal   Uremia or ketoacidosis with vomiting, NG suction, diuretics,  treatment Spontaneous Breathing. Mechanical Ventilation. Sodium Bicarbonate Administration. 21 (Sr Tigist Tsegaye ,MSc CVNP)

22. Reference Pinson R. Revisiting respiratory failure, part 1.  ACP Hosp . 2013;Oct:56   www.acphospitalist org/ archices . Accessed August 23, 2014. Schraufnagel D.  Breathing in America: Diseases, Progress, and Hope . American Thoracic Society; 2010 . 22 (Sr Tigist Tsegaye ,MSc CVNP)

23. Thank you 23 (Sr Tigist Tsegaye ,MSc CVNP)