ARTERIAL BLOOD GAS (ABG) ANALYSIS The arterial oxygen tension (PaO2) indicates the degree of oxygenation of blood

, and the arterial carbon dioxide tension (PaCO2) indicates the adequacy of alveolar ventilation. Purpose: To assess ventilation and acid-base balance  Radial artery is the common site for withdrawal of blood specimen (other site includes femoral, brachial, or through an indwelling arterial catheter) Allen’s test is done to assess the adequacy of collateral circulation of the hand 10 ml pre-heparinized syringe to prevent clotting of specimen Container with ice to prevent hemolysis of the specimen


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A patient with primary metabolic acidosis starts out with a low bicarbonate level but a normal CO2 level. Soon afterward, the lungs try to compensate for the imbalance by exhaling large amounts of CO2 (hyperventilation). b. A patient with primary respiratory acidosis starts out with a high CO2 level; soon afterward, the kidneys attempt to compensate by retaining bicarbonate. If the compensatory mechanism is able to restore the bicarbonate to carbonic acid ratio back to 20:1, full compensation (and thus normal pH) will be achieved. The next step is to determine the primary cause of the disturbance. This is done by evaluating the PaCO2 and the HCO3 in relation to pH. Example: pH > 7.4 (alkalosis) Values < 40 mmHg Disturbance Respiratory alkalosis Interpretation This situation occurs when a patient hyperventilates and “blows off” too much CO2. This situation occurs when the body gains too much bicarbonate, an alkaline substance. This situation occurs when a patient hypoventilates and thus retains too much CO2, an acidic substance. This situation occurs when the body’s bicarbonate level drops, either because of direct bicarbonate loss or because of gain of acids such as lactic acid or ketones.

Normal Values: PARAMETER pH PaCO2 HCO3 VALUES 7.35 – 7.45 35 – 45 mmHg 22 – 26 mEq/L

Parameter PaCO2

DISORDER Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis

INITIAL EVENT ↑PaCO2, ↑ or normal HCO3 , ↓ pH ↓ PaCO2, ↓ or normal HCO3 , ↑ pH ↓ or normal PaCO2, ↓ HCO3 , ↓ pH ↑ or normal PaCO2, ↑ HCO3 , ↑ pH

COMPENSATION Kidneys eliminate H and retain HCO3



> 24 mEq/L

Metabolic alkalosis

Kidneys conserve H and excrete HCO3



> 40 mmHg

Respiratory acidosis

Lungs eliminate CO2, conserve HCO3 Lungs ↓ ventilation to ↑PCO2, kidneys + conserve H to excrete HCO3



< 24 mEq/L

Metabolic acidosis

the following steps are recommended to evaluate arterial blood gas values. They are based on the assumptions that the average values are: pH = 7.4 PaCO2 = 40 mmHg HCO3 = 24 mEq/L 1. First, note the pH. It can be high, low, or normal, as follows: pH > 7.4 (alkalosis) pH < 7.4 (acidosis) pH = 7.4 (normal) A normal pH may indicate perfectly normal blood gases, or it may be an indication of a compensated imbalance. A compensated balance is one in which the body has been able to correct the pH by either respiratory or metabolic changes (depending on the primary problems). Example:


The next step involves determining if compensation has begun. This is done by looking at the value other than the primary disorder. If it is moving in the same direction as the primary value, compensation is underway. Consider the following gases: pH PaCO2 HCO3 (1) 7.20 60 mmHg 24 mEq/L (2) 7.40 60 mmHg 37 mEq/L

methylene blue) or vasoconstrictor medications have been used. such as drawing blood for analysis of oxygen levels. 2. earlobe. It is an effective tool to monitor for subtle or sudden changes in oxygen saturation. persistent asthma that does not respond to conventional therapy The attack lasts longer than 24 hours. SaO2 values obtained by pulse oximetry are unreliable in cardiac arrest and shock. Oxygen saturation levels are detected by monitoring light signals generated by the oximeter and reflected by blood pulsing through the tissue at the probe. PaCO2 52 increased acid c. The second set (2) indicates chronic respiratory acidosis.e. Treatment:        bronchodilators anticholinergics corticosteroids subcutaneous epinephrine humidified oxygen mechanical ventilation relaxation exercises   Complications:    arrhythmias metabolic acidosis respiratory failure  MECHANICAL VENTILATION The use of a mechanical device to assist the respiratory muscles in the work of breathing and to improve gas exchange Invasive or non-invasive Core component of supportive therapy but may lead to numerous types of lung injury ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) Assessment:          - Nursing Management (2 components) increased RR dyspnea retractions central cyanosis dry cough fine crackles fever alteration in LOC ABG's: decreased Pa O2. Assessment:     dyspnea wheezing and tightness in the chest cough thick. Example: Metabolic and respiratory acidosis a. the HCO3 is normal). Note that compensation has taken place. that is. hygiene.21 decreased acid b. Normal SaO2 values are 95% to 100% Advantages:  Measuring blood oxygenation with pulse oximetry reduces the need for invasive procedures.. forehead. when dyes (i. management of stressors and pain and sedation management PATIENT SAFETY Equipment assessment     Verify the prescribed ventilator settings and appropriate alarm limits Properly secure the endotracheal tube Troubleshoot ventilator alarms Ensure that emergency equipment are immediately available Management:   O2 therapy semi to high fowler's position . 4. clear or yellow sputum PULSE OXIMETRY Pulse oximetry is a non-invasive method of continuously monitoring the oxygen saturation of hemoglobin (SpO2 or SaO2).   A probe or sensor is attached to the fingertip. Increased Pa CO2 1. These can be identified when the pH does not explain one of the changes. Patient Safety: patient and equipment assessment Patient comfort: patient position. the HCO3 has elevated to an appropriate level to balance the high PaCO2 and produce a normal pH. Two distinct acid-base disturbances may occur simultaneously. or when the patient has severe anemia or a high carbon monoxide level. pH 7.  The oximeter is portable.The first set (1) indicates acute respiratory acidosis without compensation (the PaCO2 is high. or bridge of the nose. HCO3 13 decreased acid      increase fluid intake meticulous eye care mechanical ventilation administer pain medication as prescribed promote comfort STATUS ASTHMATICUS severe.

Pharmacologic pain management: Patient controlled analgesia (PCA) may be used for ventilated patients who . telephones and talking). tidal volume. Personalize the ICU environment Family-focused care Closely monitor the urine output of a ventilated patient as Spiritual comfort well as serum levels of urea and creatinine to detect any Pain management renal impairment. pulse oximetry and capnometry are relatively simple and effective tools for monitoring gas exchange - Hygiene Eye care is performed every 2h to prevent corneal abrasions. stress and pain physical strength and body weight Suppresses the immune system. reducing the work of breathing and reducing myocardial workload Semi-recumbent positioning of ventilated patients. consistency and volume Watch out for hypoxemia Respiratory rate. mouthwash Helps in plaque removal and suppresses potential pathogens Washing: Encourages patient assessment and communication Urinary catheters . The common causes of sleep disturbance have been presence of bowel sounds. blood pressure. the use of accessory muscles and agitation Patients on MV have impaired cough reflex Lung secretions should be assessed for color. lighting. minute volume and airway pressures ABG analysis. sleep Deep vein thrombosis (DVT) risk is greatly increased in deprivation. Practices to prevent DVT must be loneliness done. dysynchronous chest and abdominal movement.Common practice is cleansing of the perineum and meatus twice daily with soap and water. with the head of the bed elevated from 30° to 45°. Cardiovascular system - Heart rate and rhythm. reduces the incidence of ventilated acquired pneumonia (VAP) Respiratory system Presence of dyspnea. dehydration and infection Oral care: Swabs (foam sticks) and toothbrushes. and significant impairment of non-verbal communication caused by such factors as sedation. PATIENT COMFORT Patient positioning Proper positioning optimizes oxygen transport. Patient’s muscle mass or degree of muscle wasting. gastric aspirates and frequency of bowel movement equipment. nightmares and feelings of isolation and the ventilated patient. serum electrolytes Stress management Hemoglobin levels Continuous multi-lead electrocardiography monitoring Patients experience communication difficulties.5 mL/kg/h) Skin integrity and mobility At increased risk of impairment in skin integrity chiefly through immobility associated with sedation and ventilation - Assessment and evaluation: Inability of many mechanically ventilated patients to verbalize because of endotracheal intubation. peripheral perfusion. eye contact and use of questions with a yes/no response has been reported to reduce patient Effective functioning of the gastrointestinal tract (GIT) can distress. Weakens upper airway Liver function tests and clotting times musculature Metabolic system Feelings of isolation and loneliness Monitor temperature of patient for signs of infection Increases acute confusion and distress. discomfort. (UO ≥ 0. Renal system Orientation.Patient assessment Neurological system Glasgow Coma Score (GCS) Communication scoring systems Assess pupil size and reaction - Semi-recumbent positioning rather than supine positioning has been recommended as a measure to reduce the risk of ventilator associated pneumonia. amount and characteristics of reported as environmental noise (including alarms. The nurse’s use of positive body language. be impaired as a result of a reduction in splanchnic blood Sleep disturbance flow and the use of sedative and narcotic agents Assess for abdominal discomfort and/or distension. friendly facial Gastrointestinal system expression.

- are sufficiently awake and physically able to manage the device. Nitric Oxygen (Nitric Oxide) In mammals including humans. transcutaneous electric nerve stimulation and music. Liquid Ventilation Liquid ventilation (LV) is a technique of mechanical ventilation in which the lungs are insufflated with an oxygenated perfluorochemical liquid rather than an oxygen-containing gas mixture. Nitric oxide therapy has the potential to significantly increase the quality of life and. Nitroglycerin pills used in angina react with an enzyme in the blood to produce nitric oxide. Used in critical care to promote capillary and pulmonary dilation to treat primary pulmonary hypertension in neonatal patients post-meconium aspiration and related to birth defects. rather than nitrogen. Nitric Oxide is an important cellular signaling molecule involved in many physiological and pathological processes. massage. in some cases. . Distraction. as the inert carrier of oxygen and carbon dioxide offers a number of theoretical advantages for the treatment of acute lung injury. These are often a last-resort gas mixture before the use of extracorporeal membrane oxygenation (ECMO). - Sedation prolongs mechanical ventilation time This is not to be confused with Nitrous Oxide which is an anesthetic. Recommended agents are morphine and fentanyl. NEW TRENDS VENTILATION AND EXPERIMENTAL METHODS OF Extra Corporeal Membrane Oxygenation (ECMO) A modification of the heart/lung machine which can be used for an extended period of time Originally designed for use in neonatal respiratory failure A treatment option for when conventional treatment has failed Overall goal is to optimize oxygen delivery to the tissues to meet metabolic demands Does not treat the underlying disease process Initial cannulation of a patient receiving ECMO is performed by a surgeon and maintenance of the patient is the responsibility of the ECMO Specialist who gives 24/7 monitoring care for the duration of the ECMO treatment. save the lives of infants at risk for pulmonary vascular disease. heat and cold treatments. including:     Reducing surface tension by maintaining a fluid interface with alveoli Opening of collapsed alveoli by hydraulic pressure with a lower risk of barotrauma Providing a reservoir in which oxygen and carbon dioxide can be exchanged with pulmonary capillary blood Functioning as a high efficiency heat exchanger Liquid ventilators are prototypes that may have been used for animal experimentations but experts recommend continued development of a liquid ventilator toward clinical applications. The use of perfluorochemicals. relaxation techniques. It is a powerful vasodilator with a short half-life of a few seconds in the blood.

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