15 Ifc, Abg

IFC, ABG
Dr. Javate
PRIME 2
November 29, 2022
Submitted by:
PRIME 2 JUNIOR INTERNS

Fule, Sofia Gabrielle B.
Animas, Archie J.
Gabriel, Mark Joseph D.
Aquino, Janjer Bon M. *
Gaceta, Chelsea Denise T. *
Aquino, Trisha Mae V.
Arzaga, John Joel C. Gaite, Summer Marionne *
Ascano, John Christian Gamilde, Lourdes Gayle R.
Garcia, Jan Rossana S.

Aslam, Areej D. *
Garcia, Marc Wilhelm M.

Asprer, Calman Jan M.
Garong, Maria Ana Therese D.

Atienza, Marielle M.
Gille, Genree Ann B.

Bartolome, Nimrod Ramil II C. *
Gonzales, Jan Chloe C.
Fortes, Hannah Selina V.
Francisco, Jenica Vianca Loren

G.
Francisco, Krizza Mae A.
*F2F Duty
X= DONE
JI Animas, Archie J.
Prime 2 (Written Output under Dr. Javate)
ABG and IFC
November 29, 2022
INDWELLING FOLEY CATHETER

Urethral catheterization is insertion of a flexible catheter through the urethra into the
urinary bladder.
AGE AND APPROPRIATE CATHETER SIZE
Age Weight (kg) Foley (Fr)
0-6 months 3.5-7 6
1 year 10 6-8
2 years 12 8
3 years 14 8-10
5 years 18 10
6 years 21 12
8 years 27 12
12 years varies 12-14
INDICATIONS
● To drain the bladder prior to, during, or after surgery
● For investigations
● To accurately measure the urine output
● To relieve retention of urine
● To relieve urinary incontinence when no other means is practical
PROCEDURE FOR INSERTION OF URINARY CATHETER

Female child
● Perform hand hygiene
● Place child in supine position with knees bent and hips flexed
● If soiling evident, clean genital area with soap and water first
● Open dressing pack (aseptic field) and prepare equipment needed using aseptic
technique
● Pour sterile normal saline onto tray
● Perform aseptic hand wash and don sterile gloves
● Apply sterile drapes/towel
● Separate labia with one hand and expose urethral opening. In neonates, the
urethral meatus is immediately above the hymeneal fringes.
● Using swabs held in forceps in the other hand clean the labial folds and the
urethral opening. Move swab from above the urethral opening down towards the
rectum. Discard swab after each urethral stroke into waste bag or designated
waste area.
● Remove catheter wire if a 6Fr catheter is used
● Lubricate catheter
● Insert catheter into the urethral opening, upward at approximately 30 degree
angle until urine begins to flow.
● Inflate the balloon slowly using sterile water to the volume recommended on the
catheter. Check that child feels no pain. If there is pain, it could indicate the
catheter is not in the bladder. Deflate the balloon and insert the catheter further
into the bladder. ALWAYS ensure urine is flowing before inflating the balloon.
Note that in a child under 6 months a balloon is not typically used. In this case be
especially mindful that strapping is secure.
● Withdraw the catheter slightly until resistance is felt and attach to drainage
system
● Remove gloves and perform hand hygiene
● Secure the catheter to the thigh with either a catheter securement device or tape
● Clean trolley and dispose of used articles into yellow biohazard bag
Male child
● Place child in supine position
● If soiling evident, clean genital area with soap and water first
● Open catheter pack (aseptic field) and prepare equipment needed using aseptic
technique
● Pour sterile saline onto tray
● Perform aseptic hand wash and don sterile gloves
● Lift the penis and retract the foreskin if non-circumcised. Do not force the foreskin
back, especially in infants. A sterile gauze swab can be used to hold the penis.
● Using other hand, clean the urethral opening with swabs held in forceps. Use a
circular motion from the urethral opening to the base of the penis. Discard swab
into waste bag or designated waste area.
● For boys older than 3 years insert the Xylocaine gel into the urethra. Gently hold
the urethra opening closed and wait 2 - 3 minutes to give the gel time to work.
For infants apply sterile lubricant to catheter before insertion. Post urology
surgery consider using two syringes of xylocaine gel to increase lubrication of the
urethra and decrease risk of trauma.
● Remove the wire if using a 6Fr catheter
● Hold the penis with slight upward tension and perpendicular to the child's body.
Insert the catheter.
● When the first sphincter is reached (at level of pelvic floor muscles) gently bring
the penis down to face the child's toes, apply constant gentle pressure. If
resistance is felt the following strategies should be considered:
● Remove the catheter and utilise a 2nd tube of lubricant
● Increase traction on penis and apply gentle pressure on the catheter
● Ask the child to take a deep breath
● Ask the child to cough and bear down e.g. try to pass urine
● Gently rotate the catheter.
ARTERIAL BLOOD GAS

An arterial blood gas (ABG) test measures the levels of oxygen and carbon dioxide in
the blood to find out how well the lungs are working. An ABG test checks how well the
lungs can move oxygen into the blood and remove carbon dioxide from the blood.
Equipment
● 23 or 25 gauge butterfly with long needle
● Pre-heparinized blood gas syringe
● Iodine swab
● Dry cotton ball/gauze
PROCEDURE
Procedure General: Step Action

1 Gather required equipment
2 Select an appropriate site for the arterial

puncture. Site selection should be based on:
• Availability of collateral circulation
• Accessibility
• Presence of other surrounding anatomical structures
such as nerves,
• Accompanying veins or bone.
• Condition of the site.
The sites to be used in order of preference are:
• Radial artery (RCS only)
• Brachial artery
• Dorsalis pedis
• Posterior tibial
3 Check the FIO2 prior to initiation of the puncture.
4 Locate the radial artery. Hold the arm supine and slightly extend
the wrist. Severe extension of the wrist may obscure the pulse. Palpate the radial artery
pulse in the distal bone notch of the radius below the base of the thumb and lateral to
the tendon.
5 Determine that collateral circulation is adequate by using the

Modified Allen Test as follows: Hold patient's hand overhead with fist clenched to drain
blood while compressing both radial and ulnar arteries. Lower the hand and open the
fist. Release pressure over ulnar artery. Check to see if color returns within six (6)
seconds, indicating a patent ulnar artery and intact superficial palmar arch.
6 Scrub the site with iodine solution on cotton swab.
7 Palpate the artery for the site of the strongest arterial impulse.
8 Enter the skin at 30 to 45 angle. The skin is entered just proximal to
the wrist at about the level of the proximal skin crease. Insert the needle gently but
firmly in the area where maximum impulse is felt.
9 Advance the needle slowly until arterial blood is obtained or

resistance is felt. If resistance is felt while advancing the needle deeper, the needle is
slowly withdrawn, advancement is changed slightly to one side and then to the other. If
the artery has not been punctured after redirecting the needle several times, withdraw
the needle and obtain a new setup if puncture is to be attempted again.
10 When the artery has been punctured, attach pre-heparinized

tuberculin syringe to the hub of the butterfly. Aspirate slowly and gently. Collect a
minimum of 0.2 ml in the tuberculin syringe.
11 After obtaining the sample, withdraw the needle and apply direct
constant pressure for a minimum of five (5) minutes by the clock using a dry cotton ball
or gauze. Even if an attempt is unsuccessful or results in an inadequate sample,
pressure must be applied. If bleeding has not stopped after five (5) minutes of
continuous pressure on the site, continue to apply pressure.
12 Check sample for presence of small bubbles. If a small bubble gets

into the sample, point the top of the syringe up and expel the air bubbles immediately
and cap the syringe. KEY POINT: An air bubble in the sample can change the blood gas
values.
13 Label the syringe.
14 Take the sample to the unit based blood gas lab as soon as
possible and run immediately.
NORMAL VALUES
pH 7.35-7.45
PAO2 75-100 mmHg
PaCO2 35-45 mmHg
HCO3 22-26 mEq/L
SPO2 94-100
INTERPRETATION OF ABG RESULTS
● A low pH and high PCO2 suggests an acute respiratory acidosis (too much
acidity of the blood caused by a respiratory issue), such as from not breathing
adequately
● A low pH with a low HCO3 and normal PCO2 suggests an acute metabolic
acidosis (too much acidity of the blood caused by a metabolic issue), such as
severe dehydration
● A high pH and a low PCO2 suggests an acute respiratory alkalosis (too little
acidity of the blood caused by a respiratory issue), such as in hyperventilation
from asthma
● A high pH with a high HCO3 and normal PCO2 suggests an acute metabolic
alkalosis (too little acidity of the blood caused by a metabolic issue), such as with
vomiting
JI Aquino, Trisha Mae V.
ABG and IFC
November 29, 2022
AGE AND APPROPRIATE CATHETER SIZE
★ Infant male: 6 to 8 french

★ Infant female:8 to 10 french
★ Toddler 8 to 10 french
★ Older children: 12 to 14 french
ANATOMY OF THE MALE URINARY TRACT
★ Urinary tract begins with the urethra that extends backward towards the prostate
and then reaches the bladder.
★ Urethra is not straight, it curves at approximately 90 degree angle at a junction
we call the bulbourethral
CATHETER INSERTION IN UNCIRCUMCISED MALE
★ Fully retract foreskin. Phimotic foreskin cannot be fully retracted over the glans
penis.
★ Place the catheter at the 6 o'clock position then aim the catheter straight back.
★ It is important to insert the catheter all the way through the bladder before the
balloon is inflated.
Inflammation of the balloon too early can damage the prostatic urethra, bulbar
urethra, or membranous urethra.
★ If urine does not flow from the catheter, flush the catheter to see if it draws back.
This also allows for confirmation of placement and safely blowing up the balloon.
★ Ensure proper placement - visualize urine return, easy flushing of the catheter; If
neither is observed, remove catheter and begin insertion again.
MALE INFANT CATHETER INSERTION

★ Drape the patient to maintain a sterile field
★ Apply betadine to the head of the penis.
★ Apply in a circular motion, starting from the center moving outward.
★ For uncircumcised males, retract the foreskin up until the urethral meatus is
visualized. Be careful not to retract skin so much to prevent bleeding and surgery.
★ In case of phimosis, apply the betadine around the area of catheter insertion.
★ Lubricate Foley Catheter
★ Insert the catheter by holding the penis straight with the left hand and the
catheter on the right. Insert the catheter into the urethral meatus and push until the
end of the catheter to make sure that the bladder has been reached. If any
resistance is felt, stop and evaluate.
★ Once the catheter reaches the bladder, urine should flow freely out of the
catheter or easy flushing of water is observed.
★ Inflate the balloon. Usually around 3-5cc of sterile water is adequate.
★ Gently pull back in order to remove excess catheter in the bladder
★ If blood is observed, keep the catheter in place and ask an expert for assistance.
ANATOMY OF THE FEMALE URINARY TRACT
★ Urethra is located at the 6 o’clock position of the clitoris.

★ Urethra is typically short and angles directly upward so the catheter should be
aimed towards the head, upward toward the bladder.
★ If inserted in the vagina, a catheter should be left in place so that a second
catheter can be used to probe on an area superior to the vaginal insertion. Urine
should easily flow back from the catheter, if not flushing of the catheter should be
done. Inflate the balloon after and follow the steps as indicated in the male
insertion.
FEMALE CHILD CATHETER INSERTION

★ Create a sterile field around the perineum.
★ Place females in a frog-leg position to help open the introitus.
★ Apply betadine to the introitus, both in the vagina and urethral area.
★ Inspection of the introitus allows for expedient catheter placement and minimizes
trauma. Identify the vaginal opening and the urethral opening.
★ Insert the urethral catheter in the urethral opening found at 6’oclock of the
clitoris. In case of obstruction, inspect the introitus again
★ Once the catheter is in the bladder, urine should freely flow out of the catheter or
you can flush the catheter.
★ Do not inflate the catheter balloon until you have confirmation of catheter
placement.
ARTERIAL BLOOD GAS
★ Arterial blood gas monitoring is the standard for assessing a patient’s

oxygenation, ventilation, and acid-base status. Although ABG monitoring has been
replaced mainly by non-invasive monitoring, it is still useful in confirming and
calibrating non-invasive monitoring techniques
★ A "blood gas analysis" can be performed on blood obtained from anywhere in the
circulatory system (artery, vein, or capillary).
★ An arterial blood gas (ABG) tests explicitly blood taken from an artery.
★ ABG analysis assesses a patient's partial pressure of oxygen (PaO2) and carbon
dioxide (PaCO2).
★ PaO2 provides information on the oxygenation status, and PaCO2 offers
information on the ventilation status (chronic or acute respiratory failure).
★ PaCO2 is affected by hyperventilation (rapid or deep breathing), hypoventilation
(slow or shallow breathing), and acid-base status.
PARAMETERS AND NORMAL VALUES AND INDICATIONS
★ pH 7.35-7.45
★ PAO2 75-100 mmHg
★ PaCO2 35-45 mmHg
★ HCO3 22-26 mEq/L
★ SPO2 94-100
★ Patient’s response to treatment strategies such as mechanical ventilation
★ Patient’s oxygen carrying capacity
★ To determine the need for supplemental oxygen
★ Diagnosis of respiratory, metabolic, and mixed acid-base disorders
★ Patient’s acid-base status
★ For the quantification of hemoglobin level
CONTRAINDICATIONS
★ Abnormal modified Allen test

★ Clotting problems
★ Local infection or damage at the injection site
★ Anticoagulation therapy
★ Thrombolytic agents
★ Disease affecting the blood vessels
★ Arteriovenous fistulas or vascular grafts
MODIFIED ALLEN TEST
★ Used to check for collateral circulation of the radial and ulnar arteries in the wrist.
★ Measures the competency and quality of the artery and should be performed
prior to performing an arterial puncture.
COLLECTION OF ABG
★ The radial artery is most easily accessible medial to the radial styloid process
and lateral to the flexor
carpi radialis tendon, 2-3 cm proximal to the ventral surface of the wrist crease.
★ The femoral artery is best identified in the midline between the symphysis pubis
and the anterior superior
iliac crest, 2-4 cm distal to the inguinal ligament. The femoral artery is medial to the
femoral nerve and
lateral to the femoral vein
★ The brachial artery is best identified between the medial epicondyle of the
humerus and the tendon of the
biceps brachii in the antecubital fossa. It can be felt higher in the arm in the groove
between the biceps and triceps tendons. The basilic vein and the brachial nerve are
located in close proximity.
RESULTS OF ABG
★ The first step is to look at the pH and assess for the presence of acidemia (pH <
7.35) or alkalemia (pH >
7.45). If the pH is in the normal range (7.35-7.45), use a pH of 7.40 as a cutoff
point.
★ In other words, a pH of 7.37 would be categorized as acidosis, and a pH of 7.42
would be categorized as
alkalemia.
★ Next, evaluate the respiratory and metabolic components of the ABG results, the
PaCO2 and HCO3,
respectively. The PaCO2 indicates whether the acidosis or alkalemia is primarily
from a respiratory or
metabolic acidosis/alkalosis.
★ PaCO2 > 40 with a pH < 7.4 indicates a respiratory acidosis, while PaCO2 < 40
and pH > 7.4 indicates a
respiratory alkalosis (but is often from hyperventilation from anxiety or
compensation for a metabolic
acidosis).
★ Next, assess for evidence of compensation for the primary acidosis or alkalosis
by looking for the value
(PaCO2 or HCO3) that is not consistent with the pH. Lastly, assess the PaO2 for
any abnormalities in
oxygenation.
JI Arzaga, John Joel C..
ABG and IFC
November 29, 2022
Normal ABG values

It is important to know the definition of all the normal values
● pH: this is used to measure the acidity or basicity of the blood in the body
o 7.35-7.45
● Partial Pressure of Oxygen (PAO2): this refers to the amount of oxygen in
arterial blood and it shows how efficiently oxygen is transported from the lungs to
the blood
o 75-100mmHg
● Partial Pressure of Carbon Dioxide (PACO2): this measures how efficiently
carbon dioxide is transported to the lungs to be removed from the body
o 35-45mmHg
● Bicarbonate (HCO3): this measures the amount of a form of carbon dioxide
known as bicarbonate or bicarb that is in the blood. Normally, bicarb is
transported into your lungs through your blood, and then eliminate upon
exhalation in the form of carbon dioxide
o 22-26mEq/L
● Oxygen Saturation (SPO2): this measures the degree to which the hemoglobin
contained in your red blood cells is saturated with oxygen
o 94-100%
Indications for ABG

● For the assessment of the patient’s response to treatment strategies such as
mechanical ventilation
● To determine the patient’s oxygen carrying capacity
● To determine the need for supplemental oxygen
● For the diagnosis of respiratory, metabolic, and mixed acid-base disorders
● To monitor the patient’s acid-base status
● For the procurement of a blood sample in emergency situations when access to
the vein is not possible
● For the quantification of hemoglobin levels
Contraindications for ABG

● The patient had an abnormal modified Allen test
● The patient had clotting problems
● The patient has a local infection or damage at the injection site
● The patient is on anticoagulation therapy
● The patient is taking thrombolytic agents
● The patient has a disease affecting the blood vessels
● The patient has arteriovenous fistulas or vascular grafts
Steps in performing Modified Allen test

1. Have the patient make a fist: ask the patient to clench the fist in order to
enhance circulation within the arteries. If the patient lacks the ability to do so,
close his or her hand tightly
2. Locate the radial and ulnar artery: face the patient and locate the radial and
ulnar artery. The radial artery is located in the thumb side of the wrist and the
other side of the forearms, while the ulnar artery is on the pinky side of the wrist.
Make sure to locate the radial and ulnar pulses
3. Grab the patient’s hand: using your right hand, slowly grab your patient’s left
hand. You can also use your left hand to grab the patients right hand depending
on your preference.
4. Locate the pulse: place your middle finger on top of the radial pulse and your
pointer finger on the ulnar pulse of the patient
5. Apply pressure to both arteries: when the pulses can be felt, apply occlusive
pressure to both the ulnar and radial arteries to temporarily stop blood circulation
of the hand. Be sure to tell the patient to relax his or her hand while doing this.
6. Have the patient open their hand: this is done to check if palms and fingers
have blanched. Blanching means that you have completely occluded the ulnar
and radial arteries with your fingers. The hands should have a whitish
appearance in color.
7. Slowly release the pressure on the ulnar artery: you can release the pressure
on the ulnar artery while keeping the radial artery occluded. If the patient’s hand
flushes, meaning it turned pink, within 5-15 seconds, this means that the ulnar
artery is patent or has a good blood flow. This is considered a positive modified
Allen test and you can proceed to stick the ABG at this site.
However, if flushing is not observed within 5-15 seconds, this result suggests that
the ulnar artery does not have collateral circulation and this is considered as a
negative modified Allen test. It is not recommended not to puncture the radial
artery at this site. You should try to do the modified Allen Test to the other arm or
move on to the brachial artery.
Sticking an ABG
An ABG test requires collecting a small sample of blood from an artery the sample must
be obtained by either the respiratory therapist, doctor, or a qualified technician
Before sticking the patient, you must determine the best site for collecting the blood
sample. Possible ABG sample site
● Wrist (radial artery)
● Upper arm (brachial artery)
● Groin (femoral artery)
In addition, a blood sample can also be obtained in a pre-existing arterial line
An ABG blood sample cannot be obtained from a vein
Sterilize the injection site using and antiseptic or antimicrobial solution. Radial artery is
the preferred site for ABG because it has a good collateral circulation, it is superficial
and easy to palpate, it is not near large veins and the stick is relatively pain free.
Position the patient either lying down or sitting with the arm well supported. You may
use a rolled towel positioned under the patient’s wrist in order to provide comfort for the
patient and to hyper extend the site of the injection. This position makes it easier to
palpate the pulse and stick the artery
After the radial artery is located, the practitioner will insert a sterile needle into the artery
and draw blood. In some cases, the needle needs to be repositioned in order to locate
and puncture the artery, when doing this, you will withdraw the needle into the
subcutaneous tissue to prevent severing the artery or tendons and avoiding damage to
the nearby tissues. It is also extremely painful for the patient to fish for the artery.
Once the blood sample is obtained, a sterile gauze and bandage will be placed on the
puncture wound in order to stop bleeding and prevent infection. The lab sample will
immediately be sent to the laboratory for analysis. The specimen must be analyzed
within 15 minutes after extraction in order to ensure that accurate ABG results were
obtained. It is important to keep in mind that an ABG stick may be difficult to perform in
uncooperative patients, those with hard to find pulses, patients with cognitive
impairment, patients with tremors and patients with a significant amount of body fat. In
some cases multiple attempts are needed in order to draw the sample, however
repeated puncture of a sing site increases the prevalence of hematoma which is welling
of clotted blood within the tissue and also scarring. In severe cases, it can also cut the
artery and cause a significant amount of bleeding. You might need to use an alternative
site in order to draw sample if too many unsuccessful attempts is done in the same
spot.
Potential errors in ABG
1. Drawing the blood sample from the incorrect patient
a. Obviously, this can significantly alter the course of treatment of a critical
patient. This can be caused by posting the ABG results on the incorrect
patient record, or mislabeling the blood sample
2. Obtaining a blood sample from a vein instead of an artery
a. In some cases, inexperienced healthcare provider might stick the vein
instead of the artery. In this case, the sample will be filled with venous
blood instead of arterial blood, which will show vastly different results
3. Blood clotting
a. It is highly recommended to analyze the blood sample 10 minutes after
extraction in order to avoid clotting. Analyzing a blood sample that has
already clotted will yield inaccurate results and will basically render the
specimen useless
4. Obtaining a blood sample on incorrect settings or support
a. This can significantly affect the course of the treatment of the patient and
the medical team’s assessment of the patient’s needs. For instance, if a
blood sample was obtained when the patient is still of supplemental
oxygen instead of room air, the results can be misleading and can yield
falsely elevated PaO2 levels
5. Air contamination of the blood sample
a. Air contamination can alter the results of an ABG sample by causing the
measured PaO2 to read inaccurately
6. Contamination caused by too much heparin
a. Too much liquid heparin dilutes the blood sample and cause changes in
pH levels and can significantly affect the oxygen and carbon dioxide
values
7. Inappropriate mixing of the blood sample
a. Depending on hospital or laboratory protocol, healthcare providers
thoroughly mix the blood sample with heparin immediately upon collection
in order to avoid clotting. It is also remixed before it goes into the analyzer.
The best way to mix the sample is to roll it in between our palms. The
most common mistake is vigorously shaking the vial or container. Another
error is not mixing iced samples for a long amount of time, it is advisable
to mix iced samples longer in order to mobilize the blood and mix the
blood components
8. Prolonged delays in blood sample analysis
a. The blood sample must be sent to the laboratory for analysis no longer
than 10-15 minutes after the blood was drawn. Any delay in blood sample
analysis cause changes in the PaO2 and PaCO2 levels due to continuous
red blood cell metabolism
ABG Interpretation
Being able to interpret the results of an ABG sample is extremely important; this will
help determine the best course of action to take when it comes to treating the patient
1. Obtain and run the ABG sample:
2. Determine if the pH is alkalosis or acidosis
a. Acidosis: <7.35
b. Alkalosis: >7.45
3. Determine if the issue is respiratory or metabolic
a. Carbon dioxide (PaCO2) is being regulated by the lungs, it is acidic
b. Bicarbonate (HCO3) is being regulated by the kidneys, it is alkalotic
c. PaCo2 is abnormal and bicarbonate is normal: respiratory issue
d. PaCO2 normal, bicarbonate abnormal: metabolic issue
4. Determine if its compensated or uncompensated
a. Respiratory problem, body will compensate with bicarbonate
b. Metabolic problem, body will compensate with carbon dioxide
c. Respiratory acidosis: compensation is increase bicarbonate in our system
d. Respiratory alkalosis: compensation is decrease amount of bicarbonate
e. Bicarbonate is still within normal limits, no compensation going on
f. Metabolic acidosis: compensation is decrease the amount of carbon dioxide
g. Metabolic alkalosis: compensate by increasing carbon dioxide
h. Partially compensated if the pH is not yet back to normal, complete if pH is
normal.
5. Oxygen Saturation and Hypoxemia
a. Look at the PaO2 value
PaO2 SaO2
Normal 80-100 mmHg >95%
oxygenation
Mild 60-79 mmHg 90-94%
hypoxemia
Moderate 40-59 mmHg 75-89%
hypoxemia
Severe <40 mmHg <75%
hypoxemia
CATHETER INSERTION
Selection of catheter size
Age range Catheter size
Infant male 6 or 8 French
Infant female 8-10 French
toddler 8-10 French
Older children 12-14 French
A lot of variability in practice, but largest catheter that will be accommodated easily
should be selected
Anatomy of the male urinary tract

Urinary tract begins with the urethra that extends backward towards the prostate and
then reaching the bladder. Urethra is not straight, it curves at approximately 90 degree
angle at a junction we called the bulbourethral.
Catheter insertion in uncircumcised male

1. Fully retract foreskin.
a. Phimotic foreskin cannot be fully retracted over the glans penis. Place
catheter at 6 o’clock position then aim catheter straight back
2. It is important to insert the catheter all the way through the bladder before the
balloon is inflated. Inflammation of the balloon too early can damage the prostatic
urethra, bulbar urethra, or membranous urethra
3. If urine does not flow from catheter
a. Flush the catheter to see if it draws back
b. This also allows for confirmation of placement and safely blowing up the
balloon
4. Ensure proper placement
a. Visualize urine return
b. Easy flushing of the catheter
c. If neither is observed, remove catheter and begin insertion again
Male infant catheter insertion

● before beginning: verify the patient identity and explain procedure to patient
and/or their parents
● sterile field should be set up beside the patient since catheter insertion is a sterile
procedure
● gather equipment and materials: betadine (povidone-iodine), water-soluble
lubricant, drapes, catheter, sterile water
1. drape the patient to maintain a sterile field

2. apply betadine to the head of the penis. Apply in a circular motion, starting from
the center moving outward. For uncircumcised males, retract the foreskin up until
the urethral meatus is visualized. Be careful not to retract skin so much to
prevent bleeding and surgery. In case of phimosis, apply the betadine around the
area of catheter insertion
3. Lubricate Foley Catheter
Some clinicians recommend inflating the balloon prior to insertion of catheter to ensure
the balloon will inflate and not leak, and potentially fall out
Others do not practice this as it could enlarge the diameter of the catheter and make it
more difficult to insert
4. Insert the catheter by holding the penis straight with the left hand and the
catheter on the right. Insert the catheter into the urethral meatus and push until
the end of the catheter to make sure that the bladder has been reached. If any
resistance id felt, stop and evaluate. Once catheter reached the bladder, urine
should flow freely out of the catheter or easy flushing of water is observed
5. Inflate the balloon. Usually around 3-5cc of sterile water is adequate
6. Gently pull back in order to remove excess catheter in the bladder
7. If blood is observed, keep the catheter in place and ask an expert for assistance
Anatomy of the female urinary tract

Difficulty in identifying the urethra located at the 6 o’clock position of the clitoris.
Urethra is typically short and angles directly upward so catheter should be aimed
towards the head, upward toward the bladder. If inserted in the vagina, catheter should
be left in place so that a second catheter can be used to probe on an area superior to
the vaginal insertion. Urine should easily flow back from the catheter, if not flushing of
the catheter should be done. Inflate the balloon after and follow the steps as indicated in
the male insertion
Female child catheter insertion

1. Create a sterile field around the perineum. Place females in a frog-leg position to
help open the introitus
2. Apply betadine to the introitus, both in the vagina and urethral area
3. Inspection of the introitus allows for expedient catheter placement and minimize
trauma. Identify the vaginal opening, the urethral opening
4. Insert the urethral catheter in the urethral opening. Found at 6’oclock of the
clitoris
5. In case of obstruction, inspect the introitus again
6. Once bladder is in the bladder, urine should freely flow out of the catheter or you
can flush the catheter
Helpful tips to identify the urethra:
● Use extra light to illuminate the perineum
● Elevate the hips with small towel or blanket in order to bring the perineum into
better view
● Identify landmarks, such as the clitoris and vaginal introitus, to locate the urethral
meatus
7. Do not inflate the catheter balloon until you have confirmation of catheter
placement
Conclusion
Seek urological help if the following occur
● Catheter does not irrigate freely or urine does not flow from the catheter
● Bleeding
● Catheter does not advance easily
● Abnormal anatomy is encountered
● 2 or 3 unsuccessful attempts have been made
JI Ascaño, John Christian V..
ABG and IFC
November 29, 2022

SELECTION OF CATHETER SIZE
AGE RANGE CATHETER SIZE
Infant Male 6-8 French
Infant Female 8-10 French
Toddler 8-10 French
Older Children 12-14 French
URINARY CATHETER SUPPLIES

● Betadine (povidone – iodine) - provide sterility to the field catheter to be inserted
● KY jelly as a lubricant (water soluble) - ensure that the catheter easily go through
the urinary tract
● Sterile water - to instantly inflate the foley balloon
● Drapes - to maintain sterility around the area of interest
MALE INFANT CATHETER INSERTION

● Verify patient identity
● Ensure the procedure is explained to the patient and/or their parents
● Set up a sterile field next to the patient since the catheter is inserted on a
sterile condition possible
Procedure
1. Provide drapes around the patient to maintain a sterile field
2. Betadine should be amply applied to the head of the penis in order to sterilize
the field.
a. How to apply Betadine:
i. In a circular motion starting from the center moving outward
ii. In uncircumcised boys, it is advisable to just gently retract the foreskin
to the point where the urethral meatus is exposed.
iii. Careful attention to not retracting so much to cause bleeding or injury.
iv. If there is physiologic phimosis
3. Foreskin cannot be retracted back to visualize the urethral meatus
4. Betadine should just be applied generously around the area of catheter
insertion
5. Lubricate the foley with KY jelly
a. Some clinicians recommend inflating the balloon prior to insertion of the
catheter to ensure the balloon will inflate and not leak, and potentially fall out
b. Others do not routinely practice it since it could enlarge the diameter of the
catheter due to the stretching of the balloon making it more difficult to insert the
catheter
6. With the left hand holding the penis straight, a foley catheter is inserted into the
urethral meatus.
7. If any resistance occurs
a. Stop
b. Reevaluate your situation before attempting pass of urethral catheter
8. The catheter can be gently pulled back in order to remove all the excess
catheter from the bladder and allowing the foley to rest securely at the bladder
neck
FEMALE CHILD CATHETER INSERTION

1. Create a sterile field around the perineum
2. Importance of putting them in a frog leg position
a. a. Helps open up the introitus
b. b. Allow better visualization of the vaginal opening and the urethral
opening
3. Apply betadine generously to the introitus, both around the vagina and urethral
area
4. Inspect the introitus to allow the catheter to be placed expediently and
minimize trauma
5. It is important to identify the vaginal opening, the urethral opening
6. The urethral catheter should be inserted in the urethral opening which is
typically found at the 6 o’clock position to the clitoris
7. The female urethra is rather short and angles upward, therefore the catheter
should be similarly placed
8. If there is any resistance, then the catheter is in an inappropriate place.
9. Inspection of the introitus should be performed again to see where the potential
urethral meatus could be.
10. It is not uncommon to accidently place the catheter into the vaginal introitus,
instead of removing it, leaving it in place. This will allow you to place the
catheter above that and more likely reach the bladder
11. If it does not, irrigation should be placed through the foley catheter to confirm
proper placement
ARTERIAL BLOOD GAS ANALYSIS
A test that measures the blood levels of oxygen and carbon dioxide as well as
the levels of acid-base in the body. It is used to test how well the lungs are moving
oxygen to different body parts and how efficiently they are able to eliminate carbon
dioxide. Normally, healthy lungs move oxygen into the blood and push carbon dioxide
out efficiently during inhalation & exhalation. With this process, the body receives
energy making sure to eliminate waste. However, if the patient has breathing problems
or has disease that affects their lung function the ABG results can be abnormal.
● This test is routinely done to diagnose and monitor patients suffering from critical
conditions
● Provides a precise measurement of the levels of oxygens and carbon dioxide in
the body, it can help the doctor in determining the lung and kidney function.
● In most cases, the doctor may order an ABG if the patient has the following
symptoms:
○ Breathing difficulty
○ Changes in mental status
○ Nausea and vomiting
○ ABG can help the doctor to assess whether treatments for lung conditions
are effective, check acid-base balances in patients with kidney disease,
diabetes and those recovering from drug overdoses, determine the
presence of ruptured blood vessels or metabolic disease and check for
chemical poisoning.
Normal Values
pH 7.35-7.45 Use to measure the
alkalinity or the acidity of
the blood in the body
PaO2 75-100 mmHg Refers to the amount of

oxygen in the arterial
blood and it shows how
efficiently oxygen is
transported from the
lungs to the blood.
PaCO2 35-45 mmHg Measures how efficiently

carbon dioxide is
transported to the lungs
to be removed from the
body.
Bicarbonate 22-26 mEq/L Measures the amount of

a form of carbon dioxide
known as bicarbonate
that is in the blood.
Normally, bicarbonate is
transported into your
lungs through your blood
and then eliminated upon
exhalation in the form of
carbon dioxide
O2 Saturation 94-100% Measures the degree to

which hemoglobin
contained in your red
blood cells is saturated
with oxygen.
ABG Procedure
● ABG requires collecting a sample of blood from an artery.
● Sample must be obtained by either the respiratory therapist, doctor or a
qualified technician
● determine the best site for collecting the blood sample
Possible ABG sample sites:
➔ Wrist (Radial artery)
➔ Arm (Brachial Artery)
➔ Groin (Femoral artery)
➔ Pre-existing arterial line
1. Blood samples cannot be obtained from a vein - once the site is determined,
the respiratory therapist will sterilize the injection site using an antiseptic or an
antimicrobial solution.
1.1. The radial artery is the preferred site because it has good collateral
circulation and it is superficial, easy to palpate, not near any large vein
and the stick is relatively pain free
2. Position the patient in lying down or sitting with the hand properly supported.
May use a rolled towel to put under the patient’s wrist in order to provide
comfort and to hyperextend the site of injection that makes the palpation of the
pulse easier and stick the artery.
2.1. After locating the radial artery, the RT will insert a sterile needle to draw
blood. In some cases, the syringe is needed to be repositioned in order
to locate the artery. When doing this, you will withdraw the tip of the
syringe to the subcutaneous tissue to prevent severing the arteries or
tendons or damage to the nearby tissues as this may also be extremely
painful for the patient while you’re digging around to look for the artery.
3. Once the blood sample is obtained, a sterile band aid or gauze is placed to the
puncture wound in order to stop bleeding and avoid infection
4. Blood sample will immediately be sent to the laboratory for analysis
5. Specimen must be analyzed within 15 minutes after extraction in order to
ensure accurate ABG results obtained
Note:
● ABG sticks may be difficult to perform in an uncooperative patient, patients with
hard to find pulses, patients with cognitive impairment, with tremors and those
with significant amounts of body fat.
● Repeated puncture of a single site increases the prevalence of hematoma which
is swelling of blood in the clotted tissue and scarring.
● In severe cases, it can also cut the arteries and cause a significant amount of
bleeding so you may need to use an alternate site in order to draw the blood
sample if too many unsuccessful attempts are made in the same spot.
Potential errors
➔ Drawing the blood sample from the incorrect patient. This can alter the treatment
of a critical patient and can be caused by posting the ABG result on the incorrect
patient record or mislabeling the blood sample.
➔ Obtaining a blood sample from a vein instead of an artery. This will show vastly
different blood results
➔ Blood clotting - it is highly recommended to analyze the blood sample 10 mins
after the extraction in order to avoid clotting. Failure to analyze within this time
frame will yield inaccurate results and will basically render the specimen useless.
➔ Obtaining a blood sample on incorrect setting or support
◆ This can significantly affect the course of treatment and the medical
team’s assessment of the patient’s needs. For instance, if a blood sample
was obtained when the patient is still on supplemental oxygen instead of
room air, the results can be misleading and can yield falsely elevated
PaO2 levels.
➔ Air contamination of the sample can cause the measured PaO2 to read
inaccurately.
➔ Contamination caused by too much heparin
◆ Too much heparin dilutes the blood sample and causes changes in pH
levels and can significantly affect the oxygen and carbon dioxide values
➔ Inappropriate mixing of the blood sample
◆ Depending on the hospital/ laboratory protocol, healthcare providers
thoroughly mix the blood sample with Heparin immediately upon collection
The best way to mix It is to roll the sample in your palm and not to
vigorously shake it.
➔ Not mixing iced samples for a long time
◆ It is recommended to mix iced samples longer in order to promote
mobilization and mixing up all the components of blood samples.
➔ Prolonged delays in the blood sample analysis - sample must be sent to the
laboratories for analysis no longer than 10-15 mins after the blood was drawn.
Any delay will cause changes in the PaO2 and PaCO2 levels due to continuous
red blood cell metabolism.
ARTERIAL BLOOD GAS INTERPRETATION

This serves as one of the most accurate ways to assess a patient’s clinical condition,
which will help the doctor and the respiratory therapist make important decisions on
how to best treat the patient.
1. Obtain and run ABG sample
2. Determine if the pH is Alkalosis or Acidosis
a. If the pH is <7.35 = acidosis
b. If the pH is >7.45 = alkalosis
3. Identify if the issue is respiratory or Metabolic related ± look at the PaCO2
(carbon dioxide) & the HCO3 (bicarbonate) to determine the cause.
a. Carbon dioxide is regulated by the lungs, and Bicarbonate by the
kidneys.
b. PaCO2 is ABNORMAL if it falls outside the normal range (35-45mmHg)
that would mean a respiratory issue is present.
c. HCO3 is ABNORMAL, falling out of the normal range would mean a
metabolic issue is present.
d. Carbon Dioxide (PaCO2) equals Acidosis & Bicarbonate (HCO3) equals
alkalinic.
4. Identify if it’s compensated or uncompensated. to do this remember these two
things:
a. When there is a respiratory problem, the body will compensate with
bicarbonate.
b. When there is a metabolic problem, our body will compensate with
Carbon Dioxide
JI Asprer, Calman Jan M.
ABG and IFC
November 29, 2022
COMPLETE GUIDE TO ABGs
Arterial Blood Gas is a test that measures the blood levels of oxygen and carbon
dioxide, as well as the level of acid-base in the body
Gas exchange occurs when our lungs move oxygen into the blood and push carbon
dioxide out efficiently during inhalation and exhalation. In this process the body receives
energy while making sure to eliminate waste. If the person presents with breathing
problems or any pathologic disease that affects their lung function, the ABG can have
an abnormal result.
Importance of ABG
● ABG test is routinely used in the diagnosis and monitoring of patients
suffering from critical conditions.
● This test provides precise measurements of the levels of oxygen and carbon
dioxide in the body.
● It helps the doctor determine the patient’s lung and kidney function.
In most cases, the doctor may order an ABG if the patient has the following symptoms
● Changes in mental status
● Assessing Breathing difficulties
● Nausea and vomiting
● Monitor if treatments are effective
● Check the acid-base balances status of patients with kidney disease,
diabetes, and those recovering from drug overdoses
● Determine the presence of a ruptured blood vessel or metabolic disease and
chemical poisoning
Normal ABG values
arterial blood and it shows how efficiently oxygen is transported from the
lungs to the blood
● Oxygen Saturation (SPO2): this measures the degree to which the
hemoglobin contained in your red blood cells is saturated with oxygen
Parameters Normal Values
pH 7.35 - 7.45
PaO2 75 - 100 mmHg
PaCO2 35 - 45 mmHg
HCO3 22 - 26 mEq/L
SpO2 >94%
Indications Contraindications
● For the assessment of the ● The patient had an abnormal

patient’s response to treatment modified Allen test
strategies such as mechanical ● The patient had clotting
ventilation problems
● To determine the patient’s ● The patient has a local
oxygen carrying capacity infection or damage at the
● To determine the need for injection site
supplemental oxygen ● The patient is on
● For the diagnosis of respiratory, anticoagulation therapy
metabolic, and mixed ● The patient is taking
acid-base disorders thrombolytic agents
● To monitor the patient’s ● The patient has a disease
acid-base status affecting the blood vessels
● For the procurement of a blood ● The patient has arteriovenous
sample in emergency situations fistulas or vascular grafts
when access to the vein is not
possible
● For the quantification of
hemoglobin levels
Modified Allen Test

The Allen test was created in 1929 by Edgar V. Allen as a non-invasive means of testing
the patency of a patient's arteries. It has been adopted as the Modified Allen Test, and is
used to check for collateral circulation of the radial and ulnar arteries in the wrist. The
test measures the competency and quality of the artery and should always be
performed prior to performing an arterial puncture or an Arterial Blood Gas extraction
(ABG).

other side of the forearms, while the ulnar artery is on the pinky side of the
wrist. Make sure to locate the radial and ulnar pulses
hand. You can also use your left hand to grab the patients right hand
depending on your preference.
5. Apply pressure to both arteries: when the pulses can be felt, apply
occlusive pressure to both the ulnar and radial arteries to temporarily stop
blood circulation of the hand. Be sure to tell the patient to relax his or her
hand while doing this.
have blanched. Blanching means that you have completely occluded the
ulnar and radial arteries with your fingers. The hands should have a whitish
7. Slowly release the pressure on the ulnar artery: you can release the
pressure on the ulnar artery while keeping the radial artery occluded. If the
patient’s hand flushes, meaning it turned pink, within 5-15 seconds, this
means that the ulnar artery is patent or has a good blood flow. This is
considered a positive modified Allen test and you can proceed to stick the
ABG at this site.
ABG Extraction
An ABG extraction requires collecting a small sample of blood from an artery. The
sample must be obtained by either the respiratory therapist, doctor, or a qualified
technician.
Before sticking the patient, you must determine the best site for collecting the blood
sample. Possible ABG sample site
● Foot (Popliteal artery)
In addition, a blood sample can also be obtained in a pre-existing arterial line
It is important to note that an ABG blood sample cannot be obtained from a vein.
Sterilize the injection site using an antiseptic or antimicrobial solution. Radial artery is
the preferred site for ABG because it has a good collateral circulation, it is superficial
and easy to palpate, it is not near large veins and the stick is relatively pain free.
Position the patient either lying down or sitting with the arm well supported. You may
use a rolled towel positioned under the patient’s wrist in order to provide comfort for the
patient and to hyper extend the site of the injection. This position makes it easier to
palpate the pulse and stick the artery
After the radial artery is located, the practitioner will insert a sterile needle into the artery
and draw blood. In some cases, the needle needs to be repositioned in order to locate
and puncture the artery, when doing this, you will withdraw the needle into the
subcutaneous tissue to prevent severing the artery or tendons and avoiding damage to
the nearby tissues. It is also extremely painful for the patient to fish for the artery.
Once the blood sample is obtained, a sterile gauze and bandage will be placed on the
puncture wound in order to stop bleeding and prevent infection. The lab sample will
immediately be sent to the laboratory for analysis. The specimen must be analyzed
within 15 minutes after extraction in order to ensure that accurate ABG results were
obtained. It is important to keep in mind that an ABG stick may be difficult to perform in
uncooperative patients, those with hard to find pulses, patients with cognitive
impairment, patients with tremors and patients with a significant amount of body fat. In
some cases multiple attempts are needed in order to draw the sample, however
repeated puncture of a sing site increases the prevalence of hematoma which is
swelling of clotted blood within the tissue and also scarring. In severe cases, it can also
cut the artery and cause a significant amount of bleeding. You might need to use an
alternative site in order to draw a sample if too many unsuccessful attempts are done in
the same spot.

1. Drawing the blood sample from the incorrect patient - This can
significantly alter the course of treatment of a critical patient. This can be
caused by posting the ABG results on the incorrect patient record, or
mislabeling the blood sample
2. Obtaining a blood sample from a vein instead of an artery - In some
cases, inexperienced healthcare provider might stick the vein instead of the
artery. In this case, the sample will be filled with venous blood instead of
arterial blood, which will show vastly different results
3. Blood clotting - It is highly recommended to analyze the blood sample 10
minutes after extraction in order to avoid clotting. Analyzing a blood sample
that has already clotted will yield inaccurate results and will basically render
the specimen useless
4. Obtaining a blood sample on incorrect settings or support - This can
significantly affect the course of the treatment of the patient and the medical
team’s assessment of the patient’s needs. For instance, if a blood sample
was obtained when the patient is still of supplemental oxygen instead of room
air, the results can be misleading and can yield falsely elevated PaO2 levels
5. Air contamination of the blood sample - Air contamination can alter the
results of an ABG sample by causing the measured PaO2 to read
inaccurately
6. Contamination caused by too much heparin - Too much liquid heparin
dilutes the blood sample and cause changes in pH levels and can significantly
affect the oxygen and carbon dioxide values
7. Inappropriate mixing of the blood sample - Depending on hospital or
laboratory protocol, healthcare providers thoroughly mix the blood sample
with heparin immediately upon collection in order to avoid clotting. It is also
remixed before it goes into the analyzer. The best way to mix the sample is to
roll it in between our palms. The most common mistake is vigorously shaking
the vial or container. Another error is not mixing iced samples for a long
amount of time, it is advisable to mix iced samples longer in order to mobilize
the blood and mix the blood components
8. Prolonged delays in blood sample analysis - The blood sample must be
sent to the laboratory for analysis no longer than 10-15 minutes after the
blood was drawn. Any delay in blood sample analysis cause changes in the
PaO2 and PaCO2 levels due to continuous red blood cell metabolism
ABG Interpretation
An ABG can serve as one of the most accurate ways to assess a patient’s clinical
condition, which will help the doctor and respiratory therapist make important decisions
on how to best treat the patient.
ABG interpretation is especially important in critically ill patients because it helps the
health care team to determine the best course of action in deciding how to treat the
patient.
○ Obtain and run the ABG sample: in order to be able to interpret an ABG,
you must collect the actual arterial blood sample from the patient. Run the
blood sample through a blood analyzer and obtain the results.
○ Determine if the pH is alkalosis or acidosis
■ Acidosis: <7.35
■ Alkalosis: >7.45
○ Determine if the issue is respiratory or metabolic
■ Carbon dioxide (PaCO2) is being regulated by the lungs, it is
acidic
■ Bicarbonate (HCO3) is being regulated by the kidneys, it is
alkalotic
■ PaCo2 is abnormal and bicarbonate is normal: respiratory issue
■ PaCO2 normal, bicarbonate abnormal: metabolic issue
○ Determine if its compensated or uncompensated
■ Respiratory problem, body will compensate with bicarbonate
■ Metabolic problem, body will compensate with carbon dioxide
■ Respiratory acidosis: compensation is increase bicarbonate in
our system
■ Respiratory alkalosis: compensation is decrease amount of
bicarbonate
■ Bicarbonate is still within normal limits, no compensation going
on
■ Metabolic acidosis: compensation is decrease the amount of
carbon dioxide
■ Metabolic alkalosis: compensate by increasing carbon dioxide
■ Partially compensated if the pH is not yet back to normal,
complete if pH is normal.
○ Oxygen Saturation and Hypoxemia
■ Look at the PaO2 value
PaO2 Levels SaO2 Levels
Normal 80 - 100 mmHg > 94%
Mild hypoxemia 60 - 79 mmHg 90 - 94%
Moderate hypoxemia 40 - 59 mmHg 75 - 89%
Severe hypoxemia < 40 mmHg < 75%
CATHETER INSERTION
The use of a catheter is based on the age and gender

Age Size of Catheter
Infant female 8 - 10 French
Toddler 8 - 10 French
Older children 12 - 14 French

Male urinary tract begins with the urethra that extends backward towards the prostate
and then reaching the bladder. Urethra is not straight, it curves at approximately 90
degree angle at the bulbourethral junction.

1. Fully retract foreskin - Phimotic foreskin cannot be fully retracted over the
glans penis. Place catheter at 6 o’clock position then aim catheter straight
back
balloon is inflated. Inflammation of the balloon too early can damage the
prostatic urethra, bulbar urethra, or membranous urethra
b. This also allows for confirmation of placement and safely blowing up
the balloon

Before performing the procedure:
● Verify the patient identity and explain procedure to patient and/or their parents
● Sterile field should be set up beside the patient since catheter insertion is a
sterile procedure
● Gather equipment and materials: betadine (povidone-iodine), water-soluble
1. Properly drape the patient to maintain a sterile field

2. Apply betadine to the head of the penis in a circular motion, starting from the
center moving outward. For uncircumcised males, retract the foreskin up until
prevent bleeding and surgery. In case of phimosis, apply the betadine around
the area of catheter insertion
catheter on the right. Insert the catheter into the urethral meatus and push
until the end of the catheter to make sure that the bladder has been reached.
If any resistance is felt, stop and evaluate. Once catheter reached the
bladder, urine should flow freely out of the catheter or easy flushing of water
is observed
7. If blood is observed, keep the catheter in place and ask an expert for
assistance

There is always a challenge in identifying the urethra which is located at the 6 o’clock
position of the clitoris. Urethra is typically short and angles directly upward so the
catheter should be aimed towards the head, upward toward the bladder. If inserted in
the vagina, the catheter should be left in place so that a second catheter can be used to
probe on an area superior to the vaginal insertion. Urine should easily flow back from
the catheter, if not flushing of the catheter should be done. Inflate the balloon after and
follow the steps as indicated in the male insertion

1. Create a sterile field around the perineum. Place females in a frog-leg
position to help open the introitus
3. Inspection of the introitus allows for expedient catheter placement and
minimizes trauma. Identify the vaginal opening, the urethral opening
clitoris
6. Once bladder is in the bladder, urine should freely flow out of the catheter or
you can flush the catheter
placement
Conclusion
Seek urological consult in cases such as;
● Presence of blood
● Abnormal anatomy
JI Atienza, Marielle M.
ABG and IFC
November 29, 2022
Intrafolley Catheter
Catheter size will be selected based on the age range of the patient. Remember that
this may be variable in practice.
● Infant male = 6 or 8 french
● Infant female = 8-10 french
● Toddler = 8-10 french
● Older children = 12-14 french
Supplies Needed:
1. Catheter
2. Betadine (povidone-iodine) - to provide sterility of the field
3. KY jelly (water-soluble lubricant) - to ensure the catheter can go easily through
the urinary tract
4. Sterile water - to inflate the balloon
5. Drapes - to maintain sterility around the area of interest
How to insert IFC?

● Male Urinary Tract
○ First verify patient identity and explain the procedure to the patient and/or
the parents.
○ A sterile field should be set up next to the patient since the catheter should
be inserted in the most sterile condition possible.
○ Betadine should be applied in ample amounts on the head of the penis to
sterilize the field. Apply it in a circular motion starting from the center
moving outward.
■ In uncircumcised patients, gently retract the foreskin until the
urethral meatus is exposed before application. Careful attention
should be paid to not retract the foreskin so much as to cause
bleeding or other injury.
■ However, if there is physiologic phimosis and the foreskin cannot
be retracted to visualize the urethral meatus, the betadine should
just be applied generously over the area of catheter insertion.
○ Next, the foley catheter should be lubricated with KY jelly.
■ Some clinicians recommend that the balloon be inflated before
inserting the catheter to ensure that the balloon inflates and does
not leak, since leakage could cause the catheter to accidentally fall
out.
■ Other clinicians do not routinely practice this, as stretching of the
balloon could enlarge the diameter of the catheter, making it difficult
to insert.
○ With the left hand holding the penis straight, the foley catheter is inserted
into the urethral meatus.
■ In uncircumcised patients with tight foreskin, aiming at the 6 o’clock
position allows for catheter insertion into the urethral meatus,
oftentimes without actually visualizing the meatus itself.
■ If any resistance occurs, stop the insertion and reevaluate the
situation before attempting another pass of the catheter.
○ Once the catheter has been inserted, urine should flow out freely.
■ It is not uncommon for the lubricant to plug up the opening and
prevent urine from flowing.
■ Sometimes, flushing the catheter with a little water can help begin
the process to ensure the catheter is in.
■ If there is inadequate urine flow from the catheter, then it should be
flushed with water to confirm that it is indeed in the bladder.
○ Once it has been confirmed to be in the bladder, the balloon should be
inflated (if it has not been already). For most pediatric Foley procedures,
3-5 cc of fluid is adequate.
○ Once this has been done, the catheter can be gently pulled back to
remove all excess catheter from the bladder and to allow the Foley to rest
securely at the bladder neck.
■ If blood is seen in the Foley, the catheter should be left in position
and ask for assistance.
● Female Urinary Tract

○ Identify the female urethra by looking for the clitors (slit-like orifice at 6
o’clock position)
○ Sterile field must first be created around the perineum. The female patient
must be placed in a frog leg position to help open the introitus, allowing for
better visualization of both the vaginal and urethral openings.
■ Betadine will be applied to the introitus, around the vaginal and
urethral areas.
■ It is important to inspect the introitus. This will allow for the catheter
to be placed expediently as well as minimize trauma.
○ Once ready, the catheter should be inserted into the urethral opening, the
catheter should be similarly placed - aiming towards the head. If there is
any resistance, this means the catheter is in an inappropriate place.
■ In this case, inspection should be done again to see where the
urethral meatus could be. Again, if the catheter is placed into the
vaginal opening, it can be left there while a second catheter is used
to probe for a urethral opening above the landmark created by the
vaginal insertion.
■ If urine is freely flowing from the catheter, this means it has already
entered the bladder.
■ If not, irrigation should be placed through the Foley catheter to
confirm proper placement.
Some helpful tips to identify the urethra include:

● Use of extra lighting to illuminate the perineum
● Elevating the hips using a small towel or blanket to bring the perineum into better
view
● Identifying landmarks such as the clitoris and vaginal introitus, in order to locate
the urethral meatus.
Urological help should be sought if the following occur:

● Catheter does not irrigate freely or urine does not flow from the catheter.
● Bleeding
● Catheter does not advance easily.
● Abnormal anatomy is encountered.
● 2 or 3 unsuccessful attempts have been made.
Arterial Blood Gas (ABG)
ABG: stands for arterial blood gas and is a test that measures the blood levels of
oxygen and carbon dioxide, as well as the level of acid-base in the body.
Normally, healthy lungs move oxygen into the blood and push carbon dioxide out
efficiently during inhalation and exhalation. This is what is called gas exchange. With
this process the body receives energy while making sure to eliminate waste. If the
patient has breathing problems or a disease that affects their lung function, the ABG
results can be abnormal.
Importance of ABG
ABG test is routinely used in the diagnosis and monitoring of patients suffering from
critical conditions. This test provides precise measurements of the levels of oxygen and
carbon dioxide in the body. It helps the doctor determine the patient’s lung and kidney
function.
● Breathing difficulties
In addition, an ABG can help the doctor to:

● Assess whether treatments for lung conditions are effective
● Check the acid-base balances in patients with kidney disease, diabetes, and
those recovering from drug overdoses
● Determine the presence of a ruptured blood vessel or metabolic disease
● Check for chemical poisoning
Indications for ABG


Normal ABG values

It is important to know the definition of all the normal values.
Parameter Normal Values
pH Measurement of acidity or basicity of blood in 7.35-7.45

the body
PaO2 Amount of O2 in arterial blood, reflects how 75 - 100 mmHg

(Partial efficiently O2 is being transported from the
pressure of O2) lungs to the blood.
PaCO2 Measures how efficiently CO2 is being 35 - 45 mmHg

(Partial transported to the lungs to be removed from
pressure of the body.
CO2)
HCO3 Measurement of the amount of bicarbonate in 22 - 26 mEq/L

blood.
SPO2 Measures the degree to which Hgb in the 94 - 100%

RBC are saturated with O2.
JI Fortes, Hannah Selina V.
ABG and IFC
November 29, 2022
ARTERIAL BLOOD GAS AND CATHETER INSERTION
ARTERIAL BLOOD GAS
oxygen and carbon dioxide, as well as the level of acid-base in the body
results can be abnormal
Importance of ABG
function.

Normal ABG values

o 7.35-7.45
the blood
o 75-100mmHg
o 35-45mmHg
o 22-26mEq/L
o 94-100%
*Normal values may very slightly vary in different publications
Indications for ABG


Modified Allen Test

● The Allen test for assessment of blood flow was originally developed by Edgar V.
Allen in 1929 as a non-invasive method of assessing the patency of a patient’s
arteries
● Since then, it has been adopted as the modified Allen Test, and is used to check
for collateral circulation of the radial and ulnar arteries in the wrist
● The difference between the Modified Allen test and the original Allen Test is that
Modified Allen test efficiently evaluates the adequacy of blood circulation at one
hand at a time.
● The Modified Allen test measures the competency and quality of the artery and
should be performed prior to performing an arterial puncture

● Have the patient make a fist: ask the patient to clench the fist in order to
● Locate the radial and ulnar artery: face the patient and locate the radial and
● Grab the patient’s hand: using your right hand, slowly grab your patient’s left
on your preference.
● Locate the pulse: place your middle finger on top of the radial pulse and your
● Apply pressure to both arteries: when the pulses can be felt, apply occlusive
● Have the patient open their hand: this is done to check if palms and fingers
● Slowly release the pressure on the ulnar artery: you can release the pressure
*However, if flushing is not observed within 5-15 seconds, this result suggests that the
ulnar artery does not have collateral circulation and this is considered as a negative
modified Allen test. It is not recommended not to puncture the radial artery at this site.
You should try to do the modified Allen Test to the other arm or move on to the brachial
artery.
Sticking an ABG
● An ABG test requires collecting a small sample of blood from an artery the
technician
● Before sticking the patient, you must determine the best site for collecting the
blood sample. Possible ABG sample site
○ Wrist (radial artery)
○ Upper arm (brachial artery)
○ Groin (femoral artery)
● In addition, a blood sample can also be obtained in a pre-existing arterial line
● An ABG blood sample cannot be obtained from a vein
● Sterilize the injection site using and antiseptic or antimicrobial solution. Radial
artery is the preferred site for ABG because it has a good collateral circulation, it
is superficial and easy to palpate, it is not near large veins and the stick is
relatively pain free.
● Position the patient either lying down or sitting with the arm well supported. You
may use a rolled towel positioned under the patient’s wrist in order to provide
comfort for the patient and to hyper extend the site of the injection. This position
makes it easier to palpate the pulse and stick the artery
● After the radial artery is located, the practitioner will insert a sterile needle into
the artery and draw blood. In some cases, the needle needs to be repositioned in
order to locate and puncture the artery, when doing this, you will withdraw the
needle into the subcutaneous tissue to prevent severing the artery or tendons
and avoiding damage to the nearby tissues. It is also extremely painful for the
patient to fish for the artery.
● Once the blood sample is obtained, a sterile gauze and bandage will be placed
on the puncture wound in order to stop bleeding and prevent infection. The lab
sample will immediately be sent to the laboratory for analysis. The specimen
must be analyzed within 15 minutes after extraction in order to ensure that
accurate ABG results were obtained. It is important to keep in mind that an ABG
stick may be difficult to perform in uncooperative patients, those with hard to find
pulses, patients with cognitive impairment, patients with tremors and patients
with a significant amount of body fat. In some cases multiple attempts are
needed in order to draw the sample, however repeated puncture of a sing site
increases the prevalence of hematoma which is welling of clotted blood within the
tissue and also scarring. In severe cases, it can also cut the artery and cause a
significant amount of bleeding. You might need to use an alternative site in order
to draw sample if too many unsuccessful attempts is done in the same spot.

3. Blood clotting
specimen useless
values
blood components
ABG Interpretation
● Obtain and run the ABG sample:
● Determine if the pH is alkalosis or acidosis
○ Acidosis: <7.35
○ Alkalosis: >7.45
● Determine if the issue is respiratory or metabolic
○ Carbon dioxide (PaCO2) is being regulated by the lungs, it is acidic
○ Bicarbonate (HCO3) is being regulated by the kidneys, it is alkalotic
○ PaCo2 is abnormal and bicarbonate is normal: respiratory issue
○ PaCO2 normal, bicarbonate abnormal: metabolic issue
● Determine if its compensated or uncompensated
○ Respiratory problem, body will compensate with bicarbonate
○ Metabolic problem, body will compensate with carbon dioxide
○ Respiratory acidosis: compensation is increase bicarbonate in our system
○ Respiratory alkalosis: compensation is decrease amount of bicarbonate
○ Bicarbonate is still within normal limits, no compensation going on
○ Metabolic acidosis: compensation is decrease the amount of carbon dioxide
○ Metabolic alkalosis: compensate by increasing carbon dioxide
○ Partially compensated if the pH is not yet back to normal, complete if pH is
normal.
● Oxygen Saturation and Hypoxemia
○ Look at the PaO2 value
PaO2 SaO2
oxygenation
Mild 60-79 mmHg 90-94%
hypoxemia
hypoxemia
hypoxemia
CATHETER INSERTION
toddler 8-10 French
*A lot of variability in practice, but largest catheter that will be accommodated easily
should be selected

then reaches the bladder. Urethra is not straight, it curves at approximately 90 degree
angle at a junction we call the bulbourethral.

● Fully retract foreskin.
○ Phimotic foreskin cannot be fully retracted over the glans penis. Place
● It is important to insert the catheter all the way through the bladder before the
● If urine does not flow from catheter
○ Flush the catheter to see if it draws back
○ This also allows for confirmation of placement and safely blowing up the
balloon
● Ensure proper placement
○ Visualize urine return
○ Easy flushing of the catheter
○ If neither is observed, remove catheter and begin insertion again

procedure


● Difficulty in identifying the urethra located at the 6 o’clock position of the clitoris.
towards the head, upward toward the bladder. If inserted in the vagina, catheter
should be left in place so that a second catheter can be used to probe on an area
superior to the vaginal insertion. Urine should easily flow back from the catheter,
if not flushing of the catheter should be done. Inflate the balloon after and follow
the steps as indicated in the male insertion

● Create a sterile field around the perineum. Place females in a frog-leg position to
● Apply betadine to the introitus, both in the vagina and urethral area
● Inspection of the introitus allows for expedient catheter placement and minimize
● Insert the urethral catheter in the urethral opening. Found at 6’oclock of the
clitoris
● In case of obstruction, inspect the introitus again
● Once bladder is in the bladder, urine should freely flow out of the catheter or you

better view
meatus
● Do not inflate the catheter balloon until you have confirmation of catheter
placement
Conclusion
● Bleeding
JI Francisco, Jenica Vianca Loren G.
ABG and IFC
November 29, 2022
ARTERIAL BLOOD GAS/CATHETER INSERTION
ABG
- stands for arterial blood gas and is a test that measures the blood levels of
- healthy lungs move oxygen into the blood and push carbon dioxide out efficiently
during inhalation and exhalation. This is what is called gas exchange. With this
process the body receives energy while making sure to eliminate waste. If the
patient has breathing problems or a disease that affects their lung function, the
ABG results can be abnormal
- Importance of ABG
- ABG test is routinely used in the diagnosis and monitoring of patients
suffering from critical conditions. This test provides precise measurements
of the levels of oxygen and carbon dioxide in the body. It helps the doctor
determine the patient’s lung and kidney function.
- In most cases, the doctor may order an ABG if the patient has the
following symptoms
- Breathing difficulties
- Changes in mental status
- Nausea and vomiting
- In addition, an ABG can help the doctor to:
- Assess whether treatments for lung conditions are effective
- Check the acid-base balances in patients with kidney disease,
diabetes, and those recovering from drug overdoses
- Determine the presence of a ruptured blood vessel or metabolic
disease
- Check for chemical poisoning
Normal ABG values

o 7.35-7.45
the blood
o 75-100mmHg
o 35-45mmHg
o 22-26mEq/L
o 94-100%
INDICATIONS CONTRAINDICATION
- Assessment of the patient - Abnormal modified Allen test

response to treatment strategies - Clotting problems
(mechanical ventilation) - Infection or damage at the injection
- Determine oxygen carrying site
capacity - Anticoagulation therapy
- Determine need for supplemental - Taking thrombolytic agents
oxygen - Disease affecting the blood
- Diagnosis of respiratory, metabolic, vessels
and mixed acid-base disorders - Arteriovenous fistulas or vascular
- Monitor the patient’s acid-base grafts
status
- Procurement of a blood sample in
emergency situations when access
to the vein is not possible
- Quantification of hemoglobin levels
Modified Allen Test

- for assessment of blood flow was originally developed by Edgar V. Allen in 1929
as a non-invasive method of assessing the patency of a patient’s arteries. Used
to check for collateral circulation of the radial and ulnar arteries in the wrist
- The difference between the Modified Allen test and the original Allen Test is that
hand at a time.
- The Modified Allen test measures the competency and quality of the artery and

on your preference.
Sticking an ABG
- An ABG test requires collecting a small sample of blood from an artery the
technician
- Before sticking the patient, you must determine the best site for collecting the
- Wrist (radial artery)
- Upper arm (brachial artery)
- Groin (femoral artery)
- In addition, a blood sample can also be obtained in a pre-existing arterial line
- An ABG blood sample cannot be obtained from a vein
- Sterilize the injection site using and antiseptic or antimicrobial solution. Radial
- Position the patient either lying down or sitting with the arm well supported. You
- After the radial artery is located, the practitioner will insert a sterile needle into
- Once the blood sample is obtained, a sterile gauze and bandage will be placed
needed in
- order to draw the sample, however repeated puncture of a sing site increases the
prevalence of hematoma which is welling of clotted blood within the tissue and
also scarring. In severe cases, it can also cut the artery and cause a significant
amount of bleeding. You might need to use an alternative site in order to draw
sample if too many unsuccessful attempts is done in the same spot.

3. Blood clotting
specimen useless
values
blood components
ABG Interpretation
- Being able to interpret the results of an ABG sample is extremely important; this
will help determine the best course of action to take when it comes to treating the
patient
a. Acidosis: <7.35
b. Alkalosis: >7.45
d.
Respiratory alkalosis: compensation is decrease amount of bicarbonate
e.
Bicarbonate is still within normal limits, no compensation going on
f.
Metabolic acidosis: compensation is decrease the amount of carbon dioxide
g.
Metabolic alkalosis: compensate by increasing carbon dioxide
h.
Partially compensated if the pH is not yet back to normal, complete if pH is
normal.
PaO2 SaO2

oxygenation
Mild 60-79 mmHg 90-94%
hypoxemia
hypoxemia
hypoxemia
CATHETER INSERTION
● Selection of catheter size
toddler 8-10 French
should be selected
A. Anatomy of the male urinary tract

- Urinary tract begins with the urethra that extends backward towards the prostate
and then reaching the bladder. Urethra is not straight, it curves at approximately
90 degree angle at a junction we called the bulbourethral.
● Catheter insertion in uncircumcised male

a. Phimotic foreskin cannot be fully retracted over the glans penis.
Place catheter at 6 o’clock position then aim catheter straight back
2. It is important to insert the catheter all the way through the bladder before
the balloon is inflated. Inflammation of the balloon too early can damage
the prostatic urethra, bulbar urethra, or membranous urethra
b. This also allows for confirmation of placement and safely blowing
up the balloon
● Male infant catheter insertion

- before beginning: verify the patient identity and explain procedure to patient
- sterile field should be set up beside the patient since catheter insertion is a sterile
procedure
- gather equipment and materials: betadine (povidone-iodine), water-soluble

2. apply betadine to the head of the penis. Apply in a circular motion, starting
from the center moving outward. For uncircumcised males, retract the
foreskin up until the urethral meatus is visualized. Be careful not to retract
skin so much to prevent bleeding and surgery. In case of phimosis, apply
the betadine around the area of catheter insertion
i. Some clinicians recommend inflating the balloon prior to insertion of
catheter to ensure the balloon will inflate and not leak, and
potentially fall out
ii. Others do not practice this as it could enlarge the diameter of the
catheter and make it more difficult to insert
catheter on the right. Insert the catheter into the urethral meatus and push
until the end of the catheter to make sure that the bladder has been
reached. If any resistance id felt, stop and evaluate. Once catheter
reached the bladder, urine should flow freely out of the catheter or easy
flushing of water is observed
assistance
B. Anatomy of the female urinary tract

- Difficulty in identifying the urethra located at the 6 o’clock position of the clitoris.
- Urethra is typically short and angles directly upward so catheter should be aimed
towards the head, upward toward the bladder.
- If inserted in the vagina, catheter should be left in place so that a second catheter
can be used to probe on an area superior to the vaginal insertion.
- Urine should easily flow back from the catheter, if not flushing of the catheter
should be done.
- Inflate the balloon after and follow the steps as indicated in the male insertion
● Female child catheter insertion

1. Create a sterile field around the perineum. Place females in a frog-leg
position to help open the introitus
minimize trauma.
i. Identify the vaginal opening, the urethral opening
4. Insert the urethral catheter in the urethral opening. Found at 6’oclock of
the clitoris
6. Once catheter is in the bladder, urine should freely flow out of the catheter
or you can flush the catheter
i. Helpful tips to identify the urethra:
1. Use extra light to illuminate the perineum
2. Elevate the hips with small towel or blanket in order to bring
the perineum into better view
3. Identify landmarks, such as the clitoris and vaginal introitus,
to locate the urethral meatus
placement
● Conclusion
○ Seek urological help if the following occur
■ Catheter does not irrigate freely or urine does not flow from the
catheter
■ Bleeding
■ Catheter does not advance easily
■ Abnormal anatomy is encountered
■ 2 or 3 unsuccessful attempts have been made
JI Francisco, Krizza Mae A.
ABG and IFC
Nov 29, 2022
ARTERIAL BLOOD GAS

- stands for arterial blood gas and is a test that measures the blood levels of
- Normally, healthy lungs move oxygen into the blood and push carbon dioxide out
efficiently during inhalation and exhalation. This is what is called gas exchange.
With this process the body receives energy while making sure to eliminate waste.
If the patient has breathing problems or a disease that affects their lung function,
the ABG results can be abnormal
Importance of ABG
- In most cases, the doctor may order an ABG if the patient has the following
symptoms
- In addition, an ABG can help the doctor to:

Normal ABG values
o 7.35-7.45
the blood
o 75-100mmHg
o 35-45mmHg
o 22-26mEq/L
o 94-100%
Indications for ABG


Modified Allen Test

The Allen test for assessment of blood flow was originally developed by Edgar V. Allen
in 1929 as a non-invasive method of assessing the patency of a patient’s arteries
Since then, it has been adopted as the modified Allen Test, and is used to check for
collateral circulation of the radial and ulnar arteries in the wrist
The difference between the Modified Allen test and the original Allen Test is that
Modified Allen test efficiently evaluates the adequacy of blood circulation at one hand at
a time.
The Modified Allen test measures the competency and quality of the artery and should
be performed prior to performing an arterial puncture

on your preference.
Sticking an ABG
- An ABG test requires collecting a small sample of blood from an artery. The
technician. Before sticking the patient, you must determine the best site for
collecting the blood sample. Possible ABG sample site
- Sterilize the injection site using and antiseptic or antimicrobial solution. Radial
- Position the patient either lying down or sitting with the arm well supported. You
- After the radial artery is located, the practitioner will insert a sterile needle into
patient to fish for the artery. Once the blood sample is obtained, a sterile gauze
and bandage will be placed on the puncture wound in order to stop bleeding and
prevent infection. The lab sample will immediately be sent to the laboratory for
analysis. The specimen must be analyzed within 15 minutes after extraction in
order to ensure that accurate ABG results were obtained. It is important to keep
in mind that an ABG stick may be difficult to perform in uncooperative patients,
those with hard to find pulses, patients with cognitive impairment, patients with
tremors and patients with a significant amount of body fat. In some cases
multiple attempts are needed in order to draw the sample, however repeated
puncture of a sing site increases the prevalence of hematoma which is welling of
clotted blood within the tissue and also scarring. In severe cases, it can also cut
the artery and cause a significant amount of bleeding. You might need to use an
alternative site in order to draw sample if too many unsuccessful attempts is
done in the same spot.

3. Blood clotting
specimen useless
values
blood components
ABG Interpretation
a. Acidosis: <7.35
b. Alkalosis: >7.45
normal.
PaO2 SaO2
oxygenation
Mild 60-79 mmHg 90-94%
hypoxemia
hypoxemia
hypoxemia
CATHETER INSERTION

toddler 8-10 French


b. This also allows for confirmation of placement and safely blowing up the
balloon
procedure


- Difficulty in identifying the urethra located at the 6 o’clock position of the clitoris.

1. Create a sterile field around the perineum. Place females in a frog-leg position to
3. Inspection of the introitus allows for expedient catheter placement and minimize
clitoris
6. Once bladder is in the bladder, urine should freely flow out of the catheter or you
better view
meatus
placement
JI Fule, Sofia Gabrielle B.
ABG and IFC
November 29, 2022
ABG
Importance of ABG
critical conditions. This test provides precise measurements of the levels of oxygen
and carbon dioxide in the body. It helps the doctor determine the patient’s lung and
kidney function.
pH 7.35-7.45
PaO2 75 - 100 mmHg

(Partial pressure of O2)
PaCO2 35 - 45 mmHg
(Partial pressure of CO2)
HCO3 22 - 26 mEq/L
SPO2 94 - 100%
Indications for ABG

● For the procurement of a blood sample in emergency situations when access
to the vein is not possible

ABG Interpretation
a. Acidosis: <7.35
b. Alkalosis: >7.45
f. Metabolic acidosis: compensation is decrease the amount of carbon
dioxide
normal.
PaO2 SaO2

oxygenation
Mild hypoxemia 60-79 mmHg 90-94%

hypoxemia
Severe hypoxemia <40 mmHg <75%
CATHETER INSERTION

toddler 8-10 French
should be selected

balloon is inflated. Inflammation of the balloon too early can damage the
prostatic urethra, bulbar urethra, or membranous urethra
i. This also allows for confirmation of placement and safely blowing
up the balloon
b. Ensure proper placement
i. Visualize urine return
ii. Easy flushing of the catheter
iii. If neither is observed, remove catheter and begin insertion again

● sterile field should be set up beside the patient since catheter insertion is a
sterile procedure

the center moving outward. For uncircumcised males, retract the foreskin up
until the urethral meatus is visualized. Be careful not to retract skin so much to
prevent bleeding and surgery. In case of phimosis, apply the betadine around
the area of catheter insertion
Some clinicians recommend inflating the balloon prior to insertion of catheter to
ensure the balloon will inflate and not leak, and potentially fall out
assistance
Difficulty in identifying the urethra located at the 6 o’clock position of the clitoris.
superior to the vaginal insertion. Urine should easily flow back from the catheter, if not
flushing of the catheter should be done. Inflate the balloon after and follow the steps
as indicated in the male insertion

1. Create a sterile field around the perineum. Place females in a frog-leg position
to help open the introitus
minimize trauma. Identify the vaginal opening, the urethral opening
clitoris
6. Once bladder is in the bladder, urine should freely flow out of the catheter or
you can flush the catheter
better view
● Identify landmarks, such as the clitoris and vaginal introitus, to locate the
urethral meatus
placement
JI Gabriel, Mark Joseph D.
ABG and IFC
November 29, 2022
Arterial Blood Gas

● Measures the blood levels of oxygen and carbon dioxide, as well as the level of
acid-base in the body
● Importance of ABG
❖ Assess whether treatments for lung conditions are effective
❖ Check the acid-base balances in patients with kidney disease, diabetes,
and those recovering from drug overdoses
❖ Determine the presence of a ruptured blood vessel or metabolic disease
❖ Check for chemical poisoning
Normal ABG Values

Parameter Definition Normal Values
pH Used to measure the acidity or basicity of the 7.35-7.45

blood in the body
PaO2 Refers to the amount of oxygen in arterial 70-100 mmHg

blood and it shows how efficiently oxygen is
transported from the lungs to the blood
PaCO2 Measures how efficiently carbon dioxide is 35-45 mmHg

transported to the lungs to be removed from
the body
HCO3 Measures the amount of a form of carbon 22-26 mEq/L

dioxide known as bicarbonate or bicarb that is
in the blood.
SpO2 Measures the degree to which the hemoglobin 94-100%

contained in your red blood cells is saturated
with oxygen
Indications for ABG



● Have the patient make a fist
● Locate the radial and ulnar artery
● Grab the patient’s hand
● Locate the pulse
● Apply pressure to both arteries
● Have the patient open their hand
● Slowly release the pressure on the ulnar artery
ABG Interpretation
❖ Acidosis: <7.35
❖ Alkalosis: >7.45
Catheter Insertion

toddler 8-10 French

● Before beginning: verify the patient identity and explain procedure to patient
procedure
● drape the patient to maintain a sterile field
● apply betadine to the head of the penis. Apply in a circular motion, starting from
● Lubricate Foley Catheter

clitoris
placement
JI Gamilde, Lourdes Gayle R.
ABG and IFC
November 29, 2022
CATHETER INSERTION
toddler 8-10 French
should be selected


balloon

procedure



clitoris

better view
meatus
placement
Conclusion
● Bleeding
Stands for arterial blood gas and is a test that measures the blood levels of oxygen and
carbon dioxide, as well as the level of acid-base in the body. Normally, healthy lungs move
oxygen into the blood and push carbon dioxide out efficiently during inhalation and exhalation.
This is what is called gas exchange. With this process the body receives energy while making
sure to eliminate waste. If the patient has breathing problems or a disease that affects their lung
function, the ABG results can be abnormal.
Importance of ABG
ABG test is routinely used in the diagnosis and monitoring of patients suffering from critical
conditions. This test provides precise measurements of the levels of oxygen and carbon dioxide
in the body. It helps the doctor determine the patient’s lung and kidney function.

● Check the acid-base balances in patients with kidney disease, diabetes, and those
recovering from drug overdoses
● For the assessment of the patient’s response to ● The patient had an abnormal modified Allen test
treatment strategies such as mechanical ventilation ● The patient had clotting problems
● To determine the patient’s oxygen carrying capacity ● The patient has a local infection or damage at the
● To determine the need for supplemental oxygen injection site
● For the diagnosis of respiratory, metabolic, and mixed ● The patient is on anticoagulation therapy
acid-base disorders ● The patient is taking thrombolytic agents
● To monitor the patient’s acid-base status ● The patient has a disease affecting the blood vessels
● For the procurement of a blood sample in emergency ● The patient has arteriovenous fistulas or vascular
situations when access to the vein is not possible grafts
Arterial Blood Gas Values
Parameter Normal Values Description
pH 7.35-7.45 Measurement of acidity or basicity of blood in the body
PaO2 75 - 100 mmHg Amount of O2 in arterial blood, reflects how efficiently O2 is being
(Partial pressure of O2) transported from the lungs to the blood.
PaCO2 35 - 45 mmHg Measures how efficiently CO2 is being transported to the lungs to
(Partial pressure of CO2) be removed from the body.
HCO3 22 - 26 mEq/L Measurement of the amount of bicarbonate in blood.
SPO2 94 - 100% Measures the degree to which Hgb in the RBC are saturated with
O2.
JI Gille, Genree Ann B.

ABG and IFC
November 29, 2022
Intrafolley Catheter
Catheter size will be selected based on the age range of the patient. Remember that
this may be variable in practice.
● Infant male = 6 or 8 french
● Infant female = 8-10 french
● Toddler = 8-10 french
● Older children = 12-14 french
Supplies Needed:
1. Catheter
2. Betadine (povidone-iodine) - to provide sterility of the field
3. KY jelly (water-soluble lubricant) - to ensure the catheter can go easily through
the urinary tract
4. Sterile water - to inflate the balloon
5. Drapes - to maintain sterility around the area of interest
How to insert IFC?

● Male Urinary Tract
○ First verify patient identity and explain the procedure to the patient and/or
the parents.
○ A sterile field should be set up next to the patient since the catheter should
be inserted in the most sterile condition possible.
○ Betadine should be applied in ample amounts on the head of the penis to
sterilize the field. Apply it in a circular motion starting from the center
moving outward.
■ In uncircumcised patients, gently retract the foreskin until the
urethral meatus is exposed before application. Careful attention
should be paid to not retract the foreskin so much as to cause
bleeding or other injury.
■ However, if there is physiologic phimosis and the foreskin cannot
be retracted to visualize the urethral meatus, the betadine should
just be applied generously over the area of catheter insertion.
○ Next, the foley catheter should be lubricated with KY jelly.
■ Some clinicians recommend that the balloon be inflated before
inserting the catheter to ensure that the balloon inflates and does
not leak, since leakage could cause the catheter to accidentally fall
out.
■ Other clinicians do not routinely practice this, as stretching of the
balloon could enlarge the diameter of the catheter, making it difficult
to insert.
○ With the left hand holding the penis straight, the foley catheter is inserted
into the urethral meatus.
■ In uncircumcised patients with tight foreskin, aiming at the 6 o’clock
position allows for catheter insertion into the urethral meatus,
oftentimes without actually visualizing the meatus itself.
■ If any resistance occurs, stop the insertion and reevaluate the
situation before attempting another pass of the catheter.
○ Once the catheter has been inserted, urine should flow out freely.
■ It is not uncommon for the lubricant to plug up the opening and
prevent urine from flowing.
■ Sometimes, flushing the catheter with a little water can help begin
the process to ensure the catheter is in.
■ If there is inadequate urine flow from the catheter, then it should be
flushed with water to confirm that it is indeed in the bladder.
○ Once it has been confirmed to be in the bladder, the balloon should be
inflated (if it has not been already). For most pediatric Foley procedures,
3-5 cc of fluid is adequate.
○ Once this has been done, the catheter can be gently pulled back to
remove all excess catheter from the bladder and to allow the Foley to rest
securely at the bladder neck.
■ If blood is seen in the Foley, the catheter should be left in position
and ask for assistance.
● Female Urinary Tract

○ Identify the female urethra by looking for the clitors (slit-like orifice at 6
o’clock position)
○ Sterile field must first be created around the perineum. The female patient
must be placed in a frog leg position to help open the introitus, allowing for
better visualization of both the vaginal and urethral openings.
■ Betadine will be applied to the introitus, around the vaginal and
urethral areas.
■ It is important to inspect the introitus. This will allow for the catheter
to be placed expediently as well as minimize trauma.
○ Once ready, the catheter should be inserted into the urethral opening, the
catheter should be similarly placed - aiming towards the head. If there is
any resistance, this means the catheter is in an inappropriate place.
■ In this case, inspection should be done again to see where the
urethral meatus could be. Again, if the catheter is placed into the
vaginal opening, it can be left there while a second catheter is used
to probe for a urethral opening above the landmark created by the
vaginal insertion.
■ If not, irrigation should be placed through the Foley catheter to
confirm proper placement.

● Elevating the hips using a small towel or blanket to bring the perineum into better
view
● Identifying landmarks such as the clitoris and vaginal introitus, in order to locate
the urethral meatus.

● Bleeding
oxygen and carbon dioxide, as well as the level of acid-base in the body.
results can be abnormal.
Importance of ABG
function.

Indications for ABG


Normal ABG values
It is important to know the definition of all the normal values.
pH Measurement of acidity or basicity of blood in 7.35-7.45

the body
PaO2 Amount of O2 in arterial blood, reflects how 75 - 100 mmHg

(Partial efficiently O2 is being transported from the
pressure of O2) lungs to the blood.
PaCO2 Measures how efficiently CO2 is being 35 - 45 mmHg

(Partial transported to the lungs to be removed from
pressure of the body.
CO2)
HCO3 Measurement of the amount of bicarbonate in 22 - 26 mEq/L

blood.
SPO2 Measures the degree to which Hgb in the 94 - 100%

RBC are saturated with O2.
JI Garcia, Jan Rossanna
ABG and IFC
November 29, 2022
WHAT IS ABG?
ABG stands for arterial blood gas and is a test that measures the blood levels of oxygen
and carbon dioxide, as well as the level of acid-base in the body. Normally, healthy lungs move
function, the ABG results can be abnormal
WHAT IS THE IMPORTANCE OF ABG?

critical conditions. This test provides precise measurements of the levels of oxygen and carbon
dioxide in the body. It helps the doctor determine the patient’s lung and kidney function. In most
cases, the doctor may order an ABG if the patient has the following symptoms like breathing
difficulties, changes in mental status, nausea and vomiting. In addition, an ABG can help the
doctor to: assess whether treatments for lung conditions are effective, check the acid-base
balances in patients with kidney disease, diabetes, and those recovering from drug overdoses,
determine the presence of a ruptured blood vessel or metabolic disease, check for chemical
poisoning.
WHAT ARE THE NORMAL ABG VALUES?
★ pH: this is used to measure the acidity or basicity of the blood in the body
○ 7.35-7.45
★ Partial Pressure of Oxygen (PAO2): this refers to the amount of oxygen in arterial
blood and it shows how efficiently oxygen is transported from the lungs to the blood
○ 75-100mmHg
★ Partial Pressure of Carbon Dioxide (PACO2): this measures how efficiently carbon
dioxide is transported to the lungs to be removed from the body
○ 35-45mmHg
★ Bicarbonate (HCO3): this measures the amount of a form of carbon dioxide known as
bicarbonate or bicarb that is in the blood. Normally, bicarb is transported into your lungs
through your blood, and then eliminate upon exhalation in the form of carbon dioxide
○ 22-26mEq/L
★ Oxygen Saturation (SPO2): this measures the degree to which the hemoglobin
WHEN SHOULD ABG BE REQUESTED?

● For the assessment of the patient’s response to treatment strategies such as mechanical
ventilation
● For the procurement of a blood sample in emergency situations when access to the vein
is not possible
WHAT ARE THE CONTRAINDICATIONS FOR ABG?

WHAT IS “MODIFIED ALLEN TEST”?

The Allen test for assessment of blood flow was originally developed by Edgar V. Allen in
1929 as a non-invasive method of assessing the patency of a patient’s arteries. The difference
between the Modified Allen test and the original Allen Test is that Modified Allen test efficiently
evaluates the adequacy of blood circulation at one hand at a time. The Modified Allen test
measures the competency and quality of the artery and should be performed prior to performing
an arterial puncture
HOW TO DO THE MODIFIED ALLEN TEST?

A. Have the patient make a fist: ask the patient to clench the fist in order to enhance
circulation within the arteries. If the patient lacks the ability to do so, close his or her
hand tightly
B. Locate the radial and ulnar artery: face the patient and locate the radial and ulnar
artery. The radial artery is located in the thumb side of the wrist and the other side of the
forearms, while the ulnar artery is on the pinky side of the wrist. Make sure to locate the
radial and ulnar pulses
C. Grab the patient’s hand: using your right hand, slowly grab your patient’s left hand. You
can also use your left hand to grab the patients right hand depending on your
preference.
D. Locate the pulse: place your middle finger on top of the radial pulse and your pointer
finger on the ulnar pulse of the patient
E. Apply pressure to both arteries: when the pulses can be felt, apply occlusive pressure
to both the ulnar and radial arteries to temporarily stop blood circulation of the hand. Be
sure to tell the patient to relax his or her hand while doing this.
F. Have the patient open their hand: this is done to check if palms and fingers have
blanched. Blanching means that you have completely occluded the ulnar and radial
arteries with your fingers. The hands should have a whitish appearance in color.
G. Slowly release the pressure on the ulnar artery: you can release the pressure on the
ulnar artery while keeping the radial artery occluded. If the patient’s hand flushes,
meaning it turned pink, within 5-15 seconds, this means that the ulnar artery is patent or
has a good blood flow. This is considered a positive modified Allen test and you can
proceed to stick the ABG at this site.
However, if flushing is not observed within 5-15 seconds, this result suggests that the
artery.
Sticking an ABG
An ABG test requires collecting a small sample of blood from an artery the sample must be
obtained by either the respiratory therapist, doctor, or a qualified technician
Before sticking the patient, you must determine the best site for collecting the blood sample.
Possible ABG sample site
WHAT ARE THE POTENTIAL ERRORS IN ABG?

a. Obviously, this can significantly alter the course of treatment of a critical patient.
This can be caused by posting the ABG results on the incorrect patient record, or
mislabeling the blood sample
a. In some cases, inexperienced healthcare provider might stick the vein instead of
the artery. In this case, the sample will be filled with venous blood instead of
arterial blood, which will show vastly different results
3. Blood clotting
a. It is highly recommended to analyze the blood sample 10 minutes after extraction
in order to avoid clotting. Analyzing a blood sample that has already clotted will
yield inaccurate results and will basically render the specimen useless
a. This can significantly affect the course of the treatment of the patient and the
medical team’s assessment of the patient’s needs. For instance, if a blood
sample was obtained when the patient is still of supplemental oxygen instead of
room air, the results can be misleading and can yield falsely elevated PaO2
levels
a. Too much liquid heparin dilutes the blood sample and cause changes in pH levels
and can significantly affect the oxygen and carbon dioxide values
a. Depending on hospital or laboratory protocol, healthcare providers thoroughly
mix the blood sample with heparin immediately upon collection in order to avoid
clotting. It is also remixed before it goes into the analyzer. The best way to mix
the sample is to roll it in between our palms. The most common mistake is
vigorously shaking the vial or container. Another error is not mixing iced samples
for a long amount of time, it is advisable to mix iced samples longer in order to
mobilize the blood and mix the blood components
a. The blood sample must be sent to the laboratory for analysis no longer than
10-15 minutes after the blood was drawn. Any delay in blood sample analysis
cause changes in the PaO2 and PaCO2 levels due to continuous red blood cell
metabolism
\HOW TO INTERPRET ABG?

Being able to interpret the results of an ABG sample is extremely important; this will help
determine the best course of action to take when it comes to treating the patient
a. Acidosis: <7.35
b. Alkalosis: >7.45
h. Partially compensated if the pH is not yet back to normal, complete if pH is normal.
PaO2 SaO2
oxygenation
Mild hypoxemia 60-79 mmHg 90-94%
hypoxemia
hypoxemia
CATHETER INSERTION
toddler 8-10 French
A lot of variability in practice, but largest catheter that will be accommodated easily should be
selected

Urinary tract begins with the urethra that extends backward towards the prostate and then
reaching the bladder. Urethra is not straight, it curves at approximately 90 degree angle at a
junction we called the bulbourethral.
HOW TO INSERT CATHETER IN AN UNCIRCUMCISED MALE?

a. Phimotic foreskin cannot be fully retracted over the glans penis. Place catheter at
6 o’clock position then aim catheter straight back
2. It is important to insert the catheter all the way through the bladder before the balloon is
inflated. Inflammation of the balloon too early can damage the prostatic urethra, bulbar
urethra, or membranous urethra
b. This also allows for confirmation of placement and safely blowing up the balloon
● before beginning: verify the patient identity and explain procedure to patient and/or their
parents
procedure
● gather equipment and materials: betadine (povidone-iodine), water-soluble lubricant,
drapes, catheter, sterile water

2. apply betadine to the head of the penis. Apply in a circular motion, starting from the
center moving outward. For uncircumcised males, retract the foreskin up until the
urethral meatus is visualized. Be careful not to retract skin so much to prevent bleeding
and surgery. In case of phimosis, apply the betadine around the area of catheter
insertion
Some clinicians recommend inflating the balloon prior to insertion of catheter to ensure the
balloon will inflate and not leak, and potentially fall out
Others do not practice this as it could enlarge the diameter of the catheter and make it more
difficult to insert
4. Insert the catheter by holding the penis straight with the left hand and the catheter on the
right. Insert the catheter into the urethral meatus and push until the end of the catheter to
make sure that the bladder has been reached. If any resistance id felt, stop and
evaluate. Once catheter reached the bladder, urine should flow freely out of the catheter
or easy flushing of water is observed

Difficulty in identifying the urethra located at the 6 o’clock position of the clitoris. Urethra
is typically short and angles directly upward so catheter should be aimed towards the head,
upward toward the bladder. If inserted in the vagina, catheter should be left in place so that a
second catheter can be used to probe on an area superior to the vaginal insertion. Urine should
easily flow back from the catheter, if not flushing of the catheter should be done. Inflate the
balloon after and follow the steps as indicated in the male insertion
HOW TO INSERT CATHETER IN A FEMALE?

1. Create a sterile field around the perineum. Place females in a frog-leg position to help
open the introitus
3. Inspection of the introitus allows for expedient catheter placement and minimize trauma.
Identify the vaginal opening, the urethral opening
4. Insert the urethral catheter in the urethral opening. Found at 6’oclock of the clitoris
6. Once bladder is in the bladder, urine should freely flow out of the catheter or you can
flush the catheter
● Elevate the hips with small towel or blanket in order to bring the perineum into better
view
● Identify landmarks, such as the clitoris and vaginal introitus, to locate the urethral meatus
7. Do not inflate the catheter balloon until you have confirmation of catheter placement
Conclusion
Seek urological help if the following occur: Catheter does not irrigate freely or urine does
not flow from the catheter, beeding, catheter does not advance easily, abnormal anatomy is
encountered, 2 or 3 unsuccessful attempts have been made
JI Garcia, Marc Wilhelm M
ABG and IFC
November 29, 2022
Intrafolley Catheter (IFC)

Catheter size will be selected based on the age range of the patient. Remember that this may
be variable in practice.
Supplies Needed:
● Catheter
● Betadine (povidone-iodine) - to provide
sterility of the field
● KY jelly (water-soluble lubricant) - to
ensure the catheter can go easily
through the urinary tract
● Sterile water - to inflate the balloon
● Drapes - to maintain sterility around the
area of interest
Steps on IFC insertion:

Male Urinary Tract
● First verify patient identity and explain the procedure to the patient and/or the parents.
● A sterile field should be set up next to the patient since the catheter should be inserted in
the most sterile condition possible.
● Betadine should be applied in ample amounts on the head of the penis to sterilize the
field. Apply it in a circular motion starting from the center moving outward.
○ In uncircumcised patients, gently retract the foreskin until the urethral meatus is
exposed before application. Careful attention should be paid to not retract the
foreskin so much as to cause bleeding or other injury.
○ However, if there is physiologic phimosis and the foreskin cannot be retracted to
visualize the urethral meatus, the betadine should just be applied generously
over the area of catheter insertion.
● Next, the foley catheter should be lubricated with KY jelly.
○ Some clinicians recommend that the balloon be inflated before inserting the
catheter to ensure that the balloon inflates and does not leak, since leakage
could cause the catheter to accidentally fall out.
○ Other clinicians do not routinely practice this, as stretching of the balloon could
enlarge the diameter of the catheter, making it difficult to insert.
● With the left hand holding the penis straight, the foley catheter is inserted into the
urethral meatus.
○ In uncircumcised patients with tight foreskin, aiming at the 6 o’clock position
allows for catheter insertion into the urethral meatus, oftentimes without actually
visualizing the meatus itself.
○ If any resistance occurs, stop the insertion and reevaluate the situation before
attempting another pass of the catheter.
● Once the catheter has been inserted, urine should flow out freely.
○ It is not uncommon for the lubricant to plug up the opening and prevent urine
from flowing.
○ Sometimes, flushing the catheter with a little water can help begin the process to
ensure the catheter is in.
○ If there is inadequate urine flow from the catheter, then it should be flushed with
water to confirm that it is indeed in the bladder.
● Once it has been confirmed to be in the bladder, the balloon should be inflated (if it has
not been already). For most pediatric Foley procedures, 3-5 cc of fluid is adequate.
● Once this has been done, the catheter can be gently pulled back to remove all excess
catheter from the bladder and to allow the Foley to rest securely at the bladder neck.
○ If blood is seen in the Foley, the catheter should be left in position and ask for
assistance.
Female Urinary Tract

● Identify the female urethra by looking for the clitors (slit-like orifice at 6 o’clock position)
● Sterile field must first be created around the perineum. The female patient must be
placed in a frog leg position to help open the introitus, allowing for better visualization of
both the vaginal and urethral openings.
○ Betadine will be applied to the introitus, around the vaginal and urethral areas.
○ It is important to inspect the introitus. This will allow for the catheter to be placed
expediently as well as minimize trauma.
● Once ready, the catheter should be inserted into the urethral opening, the catheter
should be similarly placed - aiming towards the head. If there is any resistance, this
means the catheter is in an inappropriate place.
○ In this case, inspection should be done again to see where the urethral meatus
could be. Again, if the catheter is placed into the vaginal opening, it can be left
there while a second catheter is used to probe for a urethral opening above the
landmark created by the vaginal insertion.
■ If not, irrigation should be placed through the Foley catheter to confirm
proper placement.

● Elevating the hips using a small towel or blanket to bring the perineum into better view
● Identifying landmarks such as the clitoris and vaginal introitus, in order to locate the
urethral meatus.

● Bleeding
Stands for arterial blood gas and is a test that measures the blood levels of oxygen and
carbon dioxide, as well as the level of acid-base in the body. Normally, healthy lungs move
function, the ABG results can be abnormal.
Importance of ABG
ABG test is routinely used in the diagnosis and monitoring of patients suffering from critical
conditions. This test provides precise measurements of the levels of oxygen and carbon dioxide
in the body. It helps the doctor determine the patient’s lung and kidney function.

● Check the acid-base balances in patients with kidney disease, diabetes, and those
recovering from drug overdoses
● For the assessment of the patient’s response to ● The patient had an abnormal modified Allen test
treatment strategies such as mechanical ventilation ● The patient had clotting problems
● To determine the patient’s oxygen carrying capacity ● The patient has a local infection or damage at the
● To determine the need for supplemental oxygen injection site
● For the diagnosis of respiratory, metabolic, and mixed ● The patient is on anticoagulation therapy
acid-base disorders ● The patient is taking thrombolytic agents
● To monitor the patient’s acid-base status ● The patient has a disease affecting the blood vessels
● For the procurement of a blood sample in emergency ● The patient has arteriovenous fistulas or vascular
situations when access to the vein is not possible grafts
Arterial Blood Gas Values
Parameter Normal Values Description
pH 7.35-7.45 Measurement of acidity or basicity of blood in the body
PaO2 75 - 100 mmHg Amount of O2 in arterial blood, reflects how efficiently O2 is being
(Partial pressure of O2) transported from the lungs to the blood.
PaCO2 35 - 45 mmHg Measures how efficiently CO2 is being transported to the lungs to
(Partial pressure of CO2) be removed from the body.
HCO3 22 - 26 mEq/L Measurement of the amount of bicarbonate in blood.
SPO2 94 - 100% Measures the degree to which Hgb in the RBC are saturated with
O2.
JI Garong, Maria Ana Therese D.R.
IFC and ABG
November 29, 2022
Urethral catheterization is insertion of a flexible catheter through the urethra into the
urinary bladder.
Indications: Bladder catheterization can be done for diagnosis and/or treatment.

The main reason to insert a bladder catheter in children is to
● Collect a sterile urine sample for testing in very young children who cannot
void on command
Less common reasons include:
● Relief of acute or chronic urinary retention (obstructive uropathy)
● Intermittent catheterization of a neurogenic bladder
● Instillation of contrast agent for cystourethrography
● Bladder irrigation
● Instillation of a drug
● Monitoring of urine output in certain hospitalized patients (indwelling
catheter; not discussed here)
Contraindications:
Absolute contraindications
● Suspected urethral disruption from recent urethral trauma
● In trauma patients, lower urinary tract disruption (suggested by perineal
hematoma, bleeding from the meatus, or pelvic bone injury) should be ruled
out by retrograde urethrography (and sometimes cystoscopy) before doing
bladder catheterization
Relative contraindications
● Known major abnormalities of the lower urinary tract
● History of urethral strictures
● Prior urethral or bladder neck reconstruction
● History of difficult catheter placement
Complications:
● Superficial urethral or bladder injury with bleeding (common)
● Urinary tract infection (UTI; common)
● Creation of false passages
● Scarring and strictures
● Bladder perforation (rare)
● Paraphimosis, if the foreskin is not reduced after the procedure
Equipment:
Sometimes prepackaged kits are available; if not, equipment required typically includes
● Sterile drapes and gloves
● An absorbent underpad
● Antiseptic solution (eg, povidone iodine, chlorhexidine) with applicator
sticks, cotton balls, or gauze pads
● Sterile water-soluble lubricant (with or without 2% lidocaine)
● Sterile cup for collecting urine specimen
● Urethral catheter size varies with age: neonate (full term) to 6 months—5 to
6 French (Fr); infant or toddler—6 to 8 Fr; prepuberal child—10 to 12 Fr;
adolescent—12 to 14 Fr
● Washcloth for removing antiseptic solution after the procedure
Positioning:
● Position the patient supine with hips comfortably abducted, knees bent in
frog position (hips and knees partially flexed, heels on the bed, hips
comfortably abducted).
● A clinical assistant should hold the legs or knees.
Procedure in a Male Child:

● Allow one or both parents or caretakers to remain present to comfort the
child. Having them hold the child's hand, provide a stuffed animal for the
child to play with, or engage in other distraction techniques can help.
Occasionally sedation is needed.
● Place all equipment within easy reach on an uncontaminated sterile field on
a bedside tray.
● Open the prepackaged kit, taking care not to contaminate the contents.
● Place the absorbent underpad with the plastic side down beneath the
buttocks.
● Remove diaper if present and clean the area with a wet washcloth using
soap and water. Dry the area with a dry towel. Then wash your hands with
soap and water.
● Put on gloves using sterile technique.
● Apply the sterile lubricant to the end of the catheter and place on the sterile
field.
● Saturate the application sticks, cotton balls, or gauze pads with povidone
iodine.
● Place the sterile fenestrated drape over the pelvis so that the penis remains
exposed.
● Grasp the shaft of the penis using your nondominant hand, hold the penis
perpendicular to the abdominal wall, and apply gentle traction. Retract the
foreskin if the patient is uncircumcised. Do not force the foreskin to retract.
Remember to hold the sides of the penis and not directly underneath; the
urethra runs through here and you may compress the area, making it
difficult to advance the catheter. This hand is now nonsterile and must not
be removed from the penis or touch or any of the equipment during the rest
of the procedure. If needed, new sterile gloves can be used.
● Cleanse the glans penis with each application stick, gauze pad, or cotton
ball saturated in povidone iodine. Use a circular motion, beginning at the
meatus, and work your way outward. Discard or set aside the newly
contaminated application sticks, gauze pads, or cotton balls. If using
povidone iodine, clean 3 times then allow the area to dry.
● Hold the catheter in your dominant free hand.
● Advance the catheter slowly through the urethra just until urine is obtained.
If the patient is old enough to cooperate, ask him to relax and take slow
deep breaths as you continue to apply steady pressure. There may be
some resistance due to bladder sphincter contraction during insertion of the
catheter. Maintain steady gentle pressure so the catheter will advance when
the sphincter relaxes. Do not poke repeatedly or force the catheter. Urine
should flow freely.
● Collect urine in the specimen container. If the volume is insufficient, gently
massage the lower abdomen over the bladder (suprapubic area).
● Remove the catheter by pulling out gently.
● Remove all remaining povidone iodine with a wet washcloth.
● Reposition the foreskin in the uncircumcised male over the glans to avoid
paraphimosis
Procedure in a Female Child:

● Allow one or both parents or caretakers to remain present to comfort the
child. Having them hold the child's hand, provide a stuffed animal for the
child to play with, or engage in other distraction techniques can help.
Occasionally sedation is needed.
● Place all equipment within easy reach on an uncontaminated sterile field on
a bedside tray.
● Open the prepackaged kit, taking care not to contaminate the contents.
● Place the absorbent underpad with the plastic side down beneath the
buttocks.
● Remove diaper if present and clean the area with a wet washcloth using
soap and water. Dry the area with a dry towel. Then wash your hands with
soap and water.
● Put on gloves using sterile technique.
● Apply the sterile lubricant to the end of the catheter and place on the sterile
field.
● Saturate the application sticks, cotton balls, or gauze with antiseptic solution
(eg, povidone iodine).
● Place the sterile fenestrated drape over the pelvis so that the vulva is
exposed.
● With your nondominant hand, separate the labia to expose the meatus.
● Cleanse the area around the meatus with each application stick, gauze pad,
or cotton ball saturated in povidone iodine. Clean the area with an
anterior-to-posterior motion. Discard or set aside the newly contaminated
application stick, gauze pad, or cotton balls. If using povidone iodine, clean
3 times then allow the area to dry.
● Hold the catheter in your dominant free hand. Separate the labia with your
nondominant hand. If the meatus is difficult to see, gently pull the vaginal
introitus mucosa downward.
● Advance the catheter gently through the urethra just until urine is obtained.
Do not poke repeatedly or force the catheter. Urine should flow freely.
● If the catheter has entered the vagina, leave that catheter in place as a
landmark and obtain another catheter.
● Collect urine in the specimen container. If the volume is insufficient, gently
massage the lower abdomen over the bladder (suprapubic area).
● Remove the catheter by pulling out gently.
● Remove all remaining povidone iodine with a wet washcloth.
Arterial Blood Gas

● Measures the blood levels of oxygen and carbon dioxide, and levels of acid-base
in the body
● Usually requested when a patient presents with breathing difficulties, mental
status changes, nausea and vomiting
Normal Values
● pH: 7.35-7.45
● PaO2: 75-100 mmHg
● PaCO2: 35-45 mmHg
● HCO3: 22-26 mEq/L
● SpO2: 94-100%
Indications
● Assessment of patient’s response to treatment strategies such as mechanical
ventilation
● Determination of patient’s oxygen carrying capacity
● Determination if the patient needs supplemental oxygen
● Aid in the diagnosis of respiratory, metabolic, and mixed acid-base disorders
● Monitor the patient’s acid-base status
● Procurement of a blood sample in emergency situations when access to vein is
not possible
● Quantification of hemoglobin levels
Contraindications
● Abnormal modified Allen test
● Blood clotting disorders
● Local infection or damage at the injection site
● Taking anticoagulation therapy
● Taking thrombolytic agent
● Disease affecting the blood vessels
● Arteriovenous fistulas or vascular grafts
Modified Allen Test
● Non-invasive method of assessing the patency of a patient’s arteries
● Used to check for collateral circulation of the radial and ulnar arteries in the wrist
● Procedure:
○ Instruct the patient to make a fist to enhance the circulation in the arteries
○ Locate the radial and ulnar arteries
○ Grab the patient’s hand
○ Locate the pulse
○ Apply pressure to both arteries
○ Instruct the patient open their hands to assess for blanching which
signifies arterial occlusion
○ Slowly release the pressure on the ulnar artery
■ If it flushes within 5-15 seconds, the ulnar artery is patent (+
Modified Allen test) - may proceed with ABG
■ No flushing (- Modified Allen test) - do not puncture
ABG Sites
● Radial artery
○ Preferred site due to collateral circulation and superficial location
● Brachial artery
● Femoral artery
Interpretation
● Determine the pH
○ <7.35: acidosis
○ >7.45: alkalosis
○ 7.35-7.45: normal
● Determine if the problem is metabolic or respiratory
○ Respiratory (deranged CO2, acid)
■ If high: acidosis
■ If low: alkalosis
○ Metabolic (deranged HCO3, basic)
■ If high: alkalosis
■ If low: acidosis
● Determine if it is compensated or uncompensated
○ Uncompensated: counterpart did not compensate to balance the body’s
pH
○ Fully compensated: pH was completely corrected
Partially compensated: pH was not corrected
JI Gonzales, Jan Chloe C.
ABG and IFC
November 29, 2022
ARTERIAL BLOOD GAS AND CATHETER INSERTION
results can be abnormal
Importance of ABG
function.

Normal ABG values

o 7.35-7.45
the blood
o 75-100mmHg
o 35-45mmHg
o 22-26mEq/L
o 94-100%
*Normal values may very slightly vary in different publications
Indications for ABG


Modified Allen Test

● The Allen test for assessment of blood flow was originally developed by Edgar V.
Allen in 1929 as a non-invasive method of assessing the patency of a patient’s
arteries
● Since then, it has been adopted as the modified Allen Test, and is used to check
for collateral circulation of the radial and ulnar arteries in the wrist
● The difference between the Modified Allen test and the original Allen Test is that
hand at a time.
● The Modified Allen test measures the competency and quality of the artery and

● Have the patient make a fist: ask the patient to clench the fist in order to
● Locate the radial and ulnar artery: face the patient and locate the radial and
● Grab the patient’s hand: using your right hand, slowly grab your patient’s left
on your preference.
● Locate the pulse: place your middle finger on top of the radial pulse and your
● Apply pressure to both arteries: when the pulses can be felt, apply occlusive
● Have the patient open their hand: this is done to check if palms and fingers
● Slowly release the pressure on the ulnar artery: you can release the pressure
*However, if flushing is not observed within 5-15 seconds, this result suggests that the
artery.
Sticking an ABG
● An ABG test requires collecting a small sample of blood from an artery the
technician
● Before sticking the patient, you must determine the best site for collecting the
○ Wrist (radial artery)
○ Upper arm (brachial artery)
○ Groin (femoral artery)
● In addition, a blood sample can also be obtained in a pre-existing arterial line
● An ABG blood sample cannot be obtained from a vein
● Sterilize the injection site using and antiseptic or antimicrobial solution. Radial
● Position the patient either lying down or sitting with the arm well supported. You
● After the radial artery is located, the practitioner will insert a sterile needle into
● Once the blood sample is obtained, a sterile gauze and bandage will be placed
needed in order to draw the sample, however repeated puncture of a sing site
increases the prevalence of hematoma which is welling of clotted blood within the
tissue and also scarring. In severe cases, it can also cut the artery and cause a
significant amount of bleeding. You might need to use an alternative site in order
to draw sample if too many unsuccessful attempts is done in the same spot.

● Drawing the blood sample from the incorrect patient
○ Obviously, this can significantly alter the course of treatment of a critical
● Obtaining a blood sample from a vein instead of an artery
○ In some cases, inexperienced healthcare provider might stick the vein
● Blood clotting
○ It is highly recommended to analyze the blood sample 10 minutes after
specimen useless
● Obtaining a blood sample on incorrect settings or support
○ This can significantly affect the course of the treatment of the patient and
● Air contamination of the blood sample
○ Air contamination can alter the results of an ABG sample by causing the
● Contamination caused by too much heparin
○ Too much liquid heparin dilutes the blood sample and cause changes in
values
● Inappropriate mixing of the blood sample
○ Depending on hospital or laboratory protocol, healthcare providers
blood components
● Prolonged delays in blood sample analysis
○ The blood sample must be sent to the laboratory for analysis no longer
ABG Interpretation
○ Acidosis: <7.35
○ Alkalosis: >7.45
○ Carbon dioxide (PaCO2) is being regulated by the lungs, it is acidic
○ Bicarbonate (HCO3) is being regulated by the kidneys, it is alkalotic
○ PaCo2 is abnormal and bicarbonate is normal: respiratory issue
○ PaCO2 normal, bicarbonate abnormal: metabolic issue
○ Respiratory problem, body will compensate with bicarbonate
○ Metabolic problem, body will compensate with carbon dioxide
○ Respiratory acidosis: compensation is increase bicarbonate in our system
○ Respiratory alkalosis: compensation is decrease amount of bicarbonate
○ Bicarbonate is still within normal limits, no compensation going on
○ Metabolic acidosis: compensation is decrease the amount of carbon dioxide
○ Metabolic alkalosis: compensate by increasing carbon dioxide
○ Partially compensated if the pH is not yet back to normal, complete if pH is
normal.
○ Look at the PaO2 value
PaO2 SaO2
oxygenation
Mild 60-79 mmHg 90-94%
hypoxemia
hypoxemia
hypoxemia
CATHETER INSERTION
toddler 8-10 French
should be selected


balloon

procedure
● drape the patient to maintain a sterile field
● apply betadine to the head of the penis. Apply in a circular motion, starting from
● Lubricate Foley Catheter
●
● Insert the catheter by holding the penis straight with the left hand and the
● Inflate the balloon. Usually around 3-5cc of sterile water is adequate
● Gently pull back in order to remove excess catheter in the bladder
● If blood is observed, keep the catheter in place and ask an expert for assistance


clitoris
●
better view
meatus
placement
Conclusion
● Bleeding

15 Ifc, Abg

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

15 Ifc, Abg

Uploaded by

Copyright:

Available Formats

IFC, ABG

PRIME 2 JUNIOR INTERNS

Arzaga, John Joel C. Gaite, Summer Marionne *

Ascano, John Christian Gamilde, Lourdes Gayle R.

Garcia, Jan Rossana S.

Garcia, Marc Wilhelm M.

Garong, Maria Ana Therese D.

Gille, Genree Ann B.

Fortes, Hannah Selina V.

Francisco, Jenica Vianca Loren

Francisco, Krizza Mae A.

INDWELLING FOLEY CATHETER

AGE AND APPROPRIATE CATHETER SIZE

Age Weight (kg) Foley (Fr)

0-6 months 3.5-7 6

12 years varies 12-14

PROCEDURE FOR INSERTION OF URINARY CATHETER

ARTERIAL BLOOD GAS

Procedure General: Step Action

2 Select an appropriate site for the arterial

3 Check the FIO2 prior to initiation of the puncture.

5 Determine that collateral circulation is adequate by using the

6 Scrub the site with iodine solution on cotton swab.

9 Advance the needle slowly until arterial blood is obtained or

10 When the artery has been punctured, attach pre-heparinized

12 Check sample for presence of small bubbles. If a small bubble gets

13 Label the syringe.

INDWELLING FOLEY CATHETER

AGE AND APPROPRIATE CATHETER SIZE

★ Infant male: 6 to 8 french

ANATOMY OF THE MALE URINARY TRACT

CATHETER INSERTION IN UNCIRCUMCISED MALE

MALE INFANT CATHETER INSERTION

ANATOMY OF THE FEMALE URINARY TRACT

★ Urethra is located at the 6 o’clock position of the clitoris.

FEMALE CHILD CATHETER INSERTION

ARTERIAL BLOOD GAS

★ Arterial blood gas monitoring is the standard for assessing a patient’s

PARAMETERS AND NORMAL VALUES AND INDICATIONS

★ Abnormal modified Allen test

MODIFIED ALLEN TEST

Normal ABG values

Indications for ABG

Contraindications for ABG

Steps in performing Modified Allen test

An ABG blood sample cannot be obtained from a vein

Anatomy of the male urinary tract

Catheter insertion in uncircumcised male

Male infant catheter insertion

1. drape the patient to maintain a sterile field

Anatomy of the female urinary tract

Female child catheter insertion

INDWELLING FOLEY CATHETER

AGE RANGE CATHETER SIZE

Infant Male 6-8 French

Infant Female 8-10 French

Toddler 8-10 French

Older Children 12-14 French

URINARY CATHETER SUPPLIES

MALE INFANT CATHETER INSERTION

FEMALE CHILD CATHETER INSERTION

PaO2 75-100 mmHg Refers to the amount of

PaCO2 35-45 mmHg Measures how efficiently