‫‪Research name:‬‬

‫‪Prepared by:‬‬
‫روان عبده السيد‬
‫روان صابر ابراهيم‬
‫محمد حسام الدين محمد‬
‫‪Supervised by:‬‬
‫م‪ /‬نعمة‬
‫السابع المبني التعليمي‬

‫‪Outlines:‬‬
‫‪|Page1‬‬
 1) Definition of ABG.
2) Purpose.
3) Procedure.
− Patient preparation
− Implantation
− Nursing intervention.
− Interpretation.
Normal results.
Abnormal findings.
1) Metabolic acidosis. (Definition-
causescomplications- sign and symptoms –
assessment – diagnostic studies-treatment - nursing
intervention) 2) Metabolic alkalosis.
3) Respiratory alkalosis.
4) Respiratory acidosis.

Arterial blood gas Definition:

Arterial blood gas (ABG) analysis evaluates gas exchange in the lungs by measuring the
partial pressures of oxygen (PaO2) and carbon dioxide (Paco2) as well as the pH of an arterial
sample. Pao2 measures the pressure exerted by the oxygen dissolved in the blood and
evaluates the lungs’ ability to oxygenate the blood .

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Paco2 measures the pressure exerted by carbon dioxide dissolved in the blood and reflects
the adequacy of ventilation by the lungs. The pH measures the bloods hydrogen ion
concentration and is carbonate (HCO3-) is a measure of the bicarbonate ion concentration in
the blood, which is regulated by the kidneys. Oxygen saturation (Sa02) is the oxygen content
of the blood expressed as a percentage of the oxygen capacity which is the amount of
oxygen then blood is capable of carrying if all of the hemoglobin [Hb] were fully saturate).
Oxygen content (o2CT) measures the actual amount of oxygen in the blood and isn’t
commonly used in blood gas evaluation .

Purpose:
 To evaluate the efficiency of pulmonary gas exchange .
 To assess the integrity of the ventilatory control system .
 To determine the acid base level of the blood .  To monitor respiratory therapy .

Procedure:

Patient Preparation:
1) Explain the arterial blood gas analysis evaluates how well the lungs are delivering the
oxygen to the blood and eliminating carbon dioxide .
2) Tell the patient that the test requires a blood sample .
3) Explain to the patient, who will perform the arterial puncture, when it will occur, and
where the puncture site will be; radial, brachial, or femoral artery .
4) Inform the patient that he may not need to restrict food and fluids .
5) Instruct the patient to breathe normally during the test, and warn him that he may
experience a brief cramping or throbbing pain at the puncture site .
Implementation:
1) Use a heparinized blood gas syringe to draw the sample .
2) Perform an arterial puncture or draw blood from an arterial line .
3) Eliminate air from the sample, place it on ice immediately, and prepare to transport
for analysis .
4) Note the flow rate of oxygen therapy and method of delivery.

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 5) Note the patient’s rectal temperature .

Nursing Interventions:
1) After applying pressure to the puncture site for 3 to 5 minutes and when bleeding has
stopped, tape a gauze pad firmly over it .
2) If the puncture site is on the arm, don’t tape the entire circumference because this
may restrict circulation .
3) If the patient is receiving anticoagulants or has a coagulonopathy, apply pressure to
the puncture site longer than 5 minutes if necessary.
4) Monitor vital signs and observe for signs of circulatory impairment .

Interpretation:
Normal Results:
Normal ABG values fall within this ranges .

Pao2 – 80 to 100 mm Hg (SI, 10.6 to

13.3 kPa)
Paco2 – 35 to 45 mm Hg (SI, 4.7 to 5.3
kPa)
pH – 7.35 to 7.45 (SI, 7.35 to 7.45)
O2CT – 15% to 23% (SI, o.15 to 0.23)
Sao2 – 94% to 100% (SI, 0.94 to 1)
HCO3- -22 to 25 mEq/L (SI, 22 to 25 mmol/L)

Metabolic Acidosis:
Metabolic Acidosis is an acid-base imbalance resulting from excessive absorption or
retention of acid or excessive excretion of bicarbonate produced by an underlying pathologic
disorder. Symptoms result from the body’s attempts to correct the acidotic condition
through compensatory mechanisms in the lungs, kidneys and cells.

Causes:
• Anaerobic carbohydrate metabolism
• Renal insufficiency and failure
• Diarrhea and intestinal malabsorption
• ketoacidosis
• lactic acidosis
• prolonged fasting
• salicylate poisoning
• oliguric renal disease

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 • abnormal bicarbonate losses, which can occur in loss of fluid from the lower GI tract
from surgery, drains or severe diarrhea

Complications:
 Coma
 Arrhythmias
 Cardiac arrest

Signs and symptoms:

• headache
• drowsiness and confusion
• weakness
• increased respiratory rate and depth
• nausea and vomiting
• diminished cardiac output with pH below 7, which results in hypotension, cold clammy
skin and cardiac arrhythmias .

Assessment
ACTIVITY/REST

• May report: Lethargy, fatigue; muscle weakness

CIRCULATION:

 May exhibit: Hypotension, wide pulse pressure

 Pulse may be weak, irregular (dysrhythmias)
 Jaundiced sclera, skin, mucous membranes (liver failure)
ELIMINATION:

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 • May report: Diarrhea
• May exhibit: Dark/concentrated urine FOOD/FLUID:

• May report: Anorexia, nausea/vomiting

• May exhibit: Poor skin turgor, dry mucous membranes
NEUROSENSORY

• May report: Headache, drowsiness, decreased mental function

• May exhibit: Changes in sensorium, e.g., stupor, confusion, lethargy,
depression, delirium, coma
• Decreased deep-tendon reflexes, muscle weakness
RESPIRATION

• May report: Dyspnea on exertion

• May exhibit: Hyperventilation, Kussmaul’s respirations (deep, rapid breathing)
SAFETY

• May report: Transfusion of blood/blood products

• Exposure to hepatitis virus
• May exhibit: Fever, signs of sepsis
TEACHING/LEARNING

• History of alcohol abuse

• Use of carbonic anhydrase inhibitors or anion-exchange resins, e.g.,
cholestyramine (Questran) Diagnostic Studies:
 CONFIRMING DIAGNOSIS: Arterial pH below 7.35 confirms metabolic acidosis. In severe
acidotic states, pH may fall to 7.10 and the partial pressure of arterial carbon dioxide
may be normal or below 34 mmHg. Bicarbonate may be below 22 mEq/L .
 Urine pH: below 4.5 in the absence of renal disease.
 Serum potassium levels: above 5.5 mEq/L from chemical buffering .
 Glucose levels: above 150 mg/dl in diabetics .
 Arterial pH: Decreased, less than 7.35 .
 Bicarbonate (HCO3): Decreased, less than 22 mEq/L .
 Paco2: Less than 35 mm Hg.
 Base excess: Negative .
 Anion gap: Higher than 14 mEq/L (high anion gap) or range of 10–14 mEq/L (normal
anion gap) .
 Serum potassium: Increased (except in diarrhea, renal tubular acidosis) .
 Serum chloride: Increased .
 Serum glucose: May be decreased or increased depending on etiology .
 Serum ketones: Increased in DM, starvation, alcohol intoxication .

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  Plasma lactic acid: Elevated in lactic acidosis .
 Urine pH: Decreased, less than 4.5 (in absence of renal disease) .
 ECG: Cardiac dysrhythmias (bradycardia) and pattern changes associated with
hyperkalemia, e.g., tall T wave .

Treatment:
 Administration of sodium bicarbonate I.V. for severe cases
 Evaluation and correction of electrolyte imbalances and ultimately correction and
management of the underlying cause .

Nursing Interventions & Considerations:

 Keep sodium bicarbonate ampules handy for emergency administration .
 Monitor vital signs, laboratory results and level of consciousness frequently.
 Watch out for signs of decreasing level of consciousness .
 Record intake and output accurately to monitor renal function .
 For management of vomiting (common to metabolic acidosis), position the patient to
prevent aspiration .
 Prepare for possible seizures and administer appropriate precautions .
 Provide good oral hygiene after incidences of vomiting. Use sodium bicarbonate washes
to neutralize acid in the patient’s mouth.

Metabolic Alkalosis:
Definition
Metabolic Alkalosis is an acid-base imbalance characterized by excessive loss of acid or
excessive gain of bicarbonate produced by an underlying pathologic disorder. Metabolic
alkalosis causes metabolic, respiratory, and renal responses, producing characteristic
symptoms. This condition is always secondary to an underlying cause .

Causes:
Metabolic alkalosis results from the loss of acid, retention of base with decreased serum
levels of potassium and chloride. Other causes may include :

Vomitting
Nasogastric tube drainage or lavage without adequate electrolyte replacement
Fistulas
Steroids
Use of diuretics
Hyperadrenocorticism
Excessive intake of alkali (i.e., milk, baking soda, antacid)

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Signs and Symptoms:
Manifestations of metabolic alkalosis result from the body’s attempt to correct the acidbase
imbalance, primarily through hypoventilation. Other manifestations may include :

 Irritability
 Picking at bedclothes (carphology)
 Twitching
 Confusion
 Nausea
 Vomiting
 Diarrhea
 Cardiovascular abnormalities (i.e., atrial tachycardia).

Complications:
• Uncorrected metabolic alkalosis may progress to seizures and coma .

Laboratory Studies:
 CONFIRMING DIAGNOSIS: Blood pH level greater than 7.45 and bicarbonate levels
above 29 mEq/L confirms Metabolic Alkalosis .
 Urinalysis shows urine pH is usually about 7.0 .
 Electrocardiogram may show low T wave, merging with a U wave and atrial or sinus
tachycardia .
Related Concerns:
Plans of care specific to predisposing factors
Fluid and electrolyte imbalances

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 Renal dialysis
Respiratory acidosis (primary carbonic acid excess)
Respiratory alkalosis (primary carbonic acid deficit)

Assessment
CIRCULATION

• May exhibit: Tachycardia, irregularities/dysrhythmias

• Hypotension
• Cyanosis ELIMINATION:

• May report: Diarrhea (with high chloride content)

• Use of potassium-losing diuretics (Diuril, Hygroton, Lasix, Edecrin)
• Laxative abuse
FOOD/FLUID

• May report: Anorexia, nausea/prolonged vomiting

• High salt intake; excessive ingestion of licorice
• Recurrent indigestion/heartburn with frequent use of antacids/baking soda
NEUROSENSORY
− May report: Tingling of fingers and toes; circumoral paresthesia
− Muscle twitching, weakness
− Dizziness
− May exhibit: Hypertonicity of muscles, tetany, tremors, convulsions, loss of reflexes
− Confusion, irritability, restlessness, belligerence, apathy, coma
− Picking at bedclothes
SAFETY

• May report: Recent blood transfusions (citrated blood)

RESPIRATION

• May exhibit: Hypoventilation (increases Pco2 and conserves carbonic acid), periods of
apnea
TEACHING/LEARNING

• History of Cushing’s syndrome; corticosteroid therapy

Diagnostic Studies

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  Arterial pH: Increased, higher than 7.45 .
 Bicarbonate (HCO3): Increased, higher than 26 mEq/L (primary) .
 Paco2: Slightly increased, higher than 45 mm Hg (compensatory) .
 Base excess: Increased .
 Serum chloride: Decreased, less than 98 mEq/L, disproportionately to serum sodium
decreases (if alkalosis is hypochloremia) .
 Serum potassium: Decreased .
 Serum calcium: Usually decreased. Prolonged hypercalcemia (nonparathyroid) may
be a predisposing factor .
 Urine pH: Increased, higher than 7.0 .
 Urine chloride: Less than 10 mEq/L suggests chloride-responsive alkalosis, whereas
levels higher than 20 mEq/L suggest chloride resistance .
 ECG: May show hypokalemic changes including peaked P waves, flat T waves,
depressed ST segment, low T wave merging to P wave, and elevated U waves.

Priorities:
1) Achieve homeostasis .
2) Prevent/minimize complications .
3) Provide information about condition/prognosis and treatment needs as

appropriate . Nursing Diagnosis

The following are the possible nursing diagnosis for Respiratory Acidosis :

 Ineffective Tissue Perfusion

 Acute Confusion
 Risk for Injury

Nursing Interventions & Considerations:

• Dilute potassium when giving via I.V. containing potassium salts. Monitor the infusion
rate to prevent damage and watch out for signs of phlebitis .
• 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.

Respiratory Alkalosis:
Respiratory Alkalosis is an acid-base imbalance characterized by decreased partial pressure
of arterial carbon dioxide and increased blood pH to less than 35 mm Hg, which is due to
alveolar hyperventilation. Uncomplicated respiratory alkalosis leads to decrease in hydrogen
ion concentration, which results in elevated blood pH .

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Nursing and medical management of patients with Respiratory Alkalosis requires instituting
safety precautions, monitoring ABG levels and more .
Causes:
Pulmonary Causes: severe hypoxemia, pneumonia, interstitial lung disease,
pulmonary vascular disease and acute asthma .
Nonpulmonary Causes: anxiety, fever, aspirin toxicity, metabolic acidosis, central
nervous system disease, pregnancy.

Complications:
Cardiac arrhythmias
Seizures

Signs and Symptoms:

 Cardinal Sign: Deep Rapid Breathing (40+ bpm)
 CNS and neuromuscular disturbances: lightheadedness, agitation, circumoral and
peripheral paresthesias, carpopedal spasms, twitching and muscle weakness.
 Positive Chvostek’s sign
 Nausea and vomiting
 Muscle twitching

Assessment
CIRCULATION

May report: History/presence of anemia

Palpitations
May exhibit: Hypotension
Tachycardia, irregular pulse/dysrhythmias

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EGO INTEGRITY

• May exhibit: Extreme anxiety (most common cause of hyperventilation)

FOOD/FLUID

• May report: Dry mouth

Nausea/vomiting

• May exhibit: Abdominal distension (elevating diaphragm as with ascites, pregnancy)

• Vomiting
NEUROSENSORY
− May report: Headache, tinnitus
− Numbness/tingling of face, hands, and toes; circumoral and generalized paresthesia
− Lightheadedness, syncope, vertigo, blurred vision
− May exhibit: Confusion, restlessness, obtunded responses, coma
− Hyperactive reflexes, positive Chvostek’s sign, tetany, seizures
− Heightened sensitivity to environmental noise and activity
− Muscle weakness, unsteady gait
PAIN/DISCOMFORT

− May report: Muscle spasms/cramps, epigastric pain, precordial pain (tightness)

RESPIRATION

o May report: Dyspnea

o History of asthma, pulmonary fibrosis o Recent move/visit to location at high
altitude
o May exhibit: Tachypnea; rapid, shallow breathing; hyperventilation (often 40 or more
respirations/minute)
o Intermittent periods of apnea

SAFETY

▪ May exhibit: Fever

TEACHING/LEARNING

• May report: Use of salicylates/salicylate overdose, catecholamines, theophylline

• Discharge plan DRG projected mean length of inpatient stay: 5.4 days
• considerations: May require change in treatment/therapy of underlying disease
process/condition

Diagnostic Studies

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  CONFIRMING DIAGNOSIS: Arterial blood gas (ABG) analysis indicate PaCO2 less than
35 mmHg; pH elevated in proportion to the fall in PaCO2 (acute) or failing toward
normal (chronic) .
 Arterial blood gas (ABG) studies reveal abnormal values: pH above 7.45 and partial
pressure of carbon dioxide below 35 mmHg .
 Arterial pH: Greater than 7.45 (may be near normal in chronic stage) .
 Bicarbonate (HCO3): Normal or decreased; less than 25 mEq/L (compensatory
mechanism) .
 Paco2: Decreased, less than 35 mm Hg (primary).
 Serum potassium: Decreased .
 Serum chloride: Increased .
 Serum calcium: Decreased .
 Urine pH: Increased, greater than 7.0 .
 Screening tests as indicated to determine underlying cause, e.g: .
 CBC: May reveal severe anemia (decreasing oxygen-carrying capacity) .
 Blood cultures: May identify sepsis (usually Gram-negative) .
 Blood alcohol: Marked elevation (acute alcoholic intoxication) .
 Toxicology screen: May reveal early salicylate poisoning .
 Chest x-ray/lung scan: May reveal multiple pulmonary emboli . Nursing Diagnosis
− Impaired Gas Exchange
− Ineffective Breathing pattern
− Ineffective Tissue perfusion
− Acute confusion
− Risk for injury
Nursing Interventions & Considerations:
 Be alert for signs of changes in neurologic, neuromuscular or cardiovascular
functions .
 Institute safety measures for the patient with vertigo or the unconscious patient .
 Encourage the anxious patient to verbalize fears
 Administer sedation as ordered to relax the patient
 Keep the patient warm and dry
 Encourage the patient to take deep, slow breaths or breathe into a brown paper bag
(inspire CO2) .
 Monitor vital signs
 Monitor ABGs, primarily PaCO2; a value less than 35mmHg indicates too little co2.

Respiratory Acidosis

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Respiratory Acidosis is an acid-base imbalance characterized by increased partial pressure of
arterial carbon dioxide and decreased blood pH. The prognosis depends on the severity of
the underlying disturbance as well as the patient’s general clinical condition .
Compensatory mechanisms include (1) an increased respiratory rate; (2) hemoglobin (Hb)
buffering, forming bicarbonate ions and deoxygenated Hb; and (3) increased renal ammonia
acid excretions with reabsorption of bicarbonate .

Acute respiratory acidosis:

Associated with acute pulmonary edema, aspiration of foreign body, overdose of
sedatives/barbiturate poisoning, smoke inhalation, acute laryngospasm,
hemothorax/pneumothorax, atelectasis, adult respiratory distress syndrome (ARDS),
anesthesia/surgery, mechanical ventilators, excessive CO2 intake (e.g., use of rebreathing
mask, cerebral vascular accident [CVA] therapy), Pickwickian syndrome .

Chronic respiratory acidosis:

Associated with emphysema, asthma, bronchiectasis; neuromuscular disorders (such as
Guillain-Barré syndrome and myasthenia gravis); botulism; spinal cord injuries .

Causes:
• Chronic obstructive respiratory disorders: emphysema, chronic bronchitis
• Chest wall trauma
• Pulmonary edema
• Atelectasis
• Pneumothorax
• Drug Overdose

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 • Pneumonia
• Guillain-Barre syndrome Complications:

 Shock
 Cardiac Arrest

Signs and Symptoms:

CNS disturbances: restlessness, confusion, and apprehension to somnolence with
fine flapping tremor, or coma .
Headache
Dyspnea
Tachypnea
Increase in blood pressure
Mental cloudiness and feeling of fullness in head
Weakness

Assessment
Assessment cues are dependent on underlying cause .
ACTIVITY/REST

− May report: Fatigue, mild to profound

− May exhibit: Generalized weakness, ataxia/staggering, loss of coordination (chronic),
to stupor

CIRCULATION

− May exhibit: Low BP/hypotension with bounding pulses, pinkish color, warm skin
(reflects vasodilation of severe acidosis)
− Tachycardia, irregular pulse (other/various dysrhythmias)
− Diaphoresis, pallor, and cyanosis (late stage)
FOOD/FLUID
May report: Nausea/vomiting
NEUROSENSORY

− May report: Feeling of fullness in head (acute—associated with vasodilation)

− Headache, dizziness, visual disturbances
− May exhibit: Confusion, apprehension, agitation, restlessness, somnolence; coma
(acute)
− Tremors, decreased reflexes (severe)
RESPIRATION

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 − May report: Shortness of breath; dyspnea with exertion
− May exhibit: Respiratory rate dependent on underlying cause, i.e., decreased in
respiratory center depression /
− muscle paralysis; otherwise, rate is rapid/shallow
− Increased respiratory effort with nasal flaring/yawning, use of neck and upper body
muscles
− Decreased respiratory rate/hypoventilation (associated with decreased function of
respiratory center as in head trauma, oversedation, general anesthesia, metabolic
alkalosis)
− Adventitious breath sounds (crackles, wheezes); stridor, crowing
TEACHING/LEARNING

• Refer to specific plans of care reflecting individual predisposing/contributing factors .

Diagnostic Studies:
• CONFIRMING DIAGNOSIS: Arterial blood gas (ABG) analysis of o PaCO2 higher than
45 mm Hg o pH is below normal range of 7.35 to 7.45
o bicarbonate level is normal (acute) or elevate (in chronic stages)
• Chest X-ray, CT scan can help determine the cause
• ABGs: Pao2: Normal or may be low. Oxygen saturation (Sao2) decreased .
• Paco2: Increased, greater than 45 mm Hg (primary acidosis).
• Bicarbonate (HCO3): Normal or increased, greater than 26 mEq/L
(compensated/chronic stage).
• Arterial pH: Decreased, less than 7.35 .
• Electrolytes: Serum potassium: Typically increased .
• Serum chloride: Decreased .
• Serum calcium: Increased .
• Lactic acid: May be elevated .
• Urinalysis: Urine pH decreased .
• Other screening tests: As indicated by underlying illness/condition to determine
underlying cause .

Nursing Diagnosis:
The following are the possible nursing diagnosis for Respiratory Acidosis :

 Impaired Gas Exchange

 Ineffective Breathing Pattern
 Ineffective Tissue Perfusion
 Acute Confusion  Risk for Injury .

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Nursing Interventions & Considerations:
− Remain alert for critical changes in patient’s respiratory, CNS and cardiovascular
functions. Report such changes as well as any variations in ABG values or electrolyte
status immediately .
− Maintain adequate hydration .
− Maintain patent airway and provide humidification if acidosis requires mechanical
ventilation. Perform tracheal suctioning frequently and vigorous chest
physiotherapy, if ordered .
− Institute safety measures and assist patient with positioning.
− Continuously monitor arterial blood gases.

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