AORN Journal - 2015 - Larkin - Interpreting Arterial Blood Gases Successfully

CONTINUING EDUCATION
Interpreting Arterial Blood Gases

Successfully 2.6 www.aorn.org/CE
BRENDA G. LARKIN, MS, RN, ACNS-BC, CNS-CP, CNOR;

ROBERT J. ZIMMANCK, MD
Continuing Education Contact Hours Approvals

indicates that continuing education (CE) contact hours are This program meets criteria for CNOR and CRNFA recerti-
available for this activity. Earn the CE contact hours by fication, as well as other CE requirements.
reading this article, reviewing the purpose/goal and objectives,
and completing the online Examination and Learner Evalua- AORN is provider-approved by the California Board of
tion at http://www.aorn.org/CE. A score of 70% correct on the Registered Nursing, Provider Number CEP 13019. Check
examination is required for credit. Participants receive feed- with your state board of nursing for acceptance of this activity
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Conflict-of-Interest Disclosures
Event: #15542 Brenda G. Larkin, MS, RN, ACNS-BC, CNS-CP, CNOR,
Session: #1001 and Robert J. Zimmanck, MD, have no declared affiliations
Fee: Members $20.80, Nonmembers $41.60 that could be perceived as posing potential conflicts of interest
in the publication of this article.
The contact hours for this article expire October 31, 2018.
Pricing is subject to change. The behavioral objectives for this program were created by
Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor,
Purpose/Goal with consultation from Susan Bakewell, MS, RN-BC, direc-
tor, Perioperative Education. Ms Starbuck Pashley and
To provide the learner with knowledge specific to interpreting
Ms Bakewell have no declared affiliations that could be
arterial blood gases (ABGs).
perceived as posing potential conflicts of interest in the pub-
lication of this article.
Objectives
1. Explain what ABGs are.
2. Discuss what ABGs measure. Sponsorship or Commercial Support
3. Discuss how acidosis and alkalosis may be identified using No sponsorship or commercial support was received for this
ABG results. article.
4. Explain how the nurse can determine whether respiratory
or metabolic factors are causing an imbalance.
Disclaimer
Accreditation AORN recognizes these activities as CE for RNs. This
AORN is accredited as a provider of continuing nursing recognition does not imply that AORN or the American
education by the American Nurses Credentialing Center’s Nurses Credentialing Center approves or endorses products
Commission on Accreditation. mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.08.002
ª AORN, Inc, 2015
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Interpreting Arterial Blood
Gases Successfully 2.6 www.aorn.org/CE
BRENDA G. LARKIN, MS, RN, ACNS-BC, CNS-CP, CNOR;

ROBERT J. ZIMMANCK, MD
ABSTRACT
Arterial blood gas (ABG) analysis is a crucial skill for perioperative nurses, in particular the RN circu-
lator. This article provides the physiological basis for assessing ABGs perioperatively and presents a
systematic approach to blood gas analysis using the Romanski method. Blood gas sample data allow
the reader to practice ABG interpretation. In addition, four case studies are presented that give the
reader the opportunity to analyze ABGs within the context of surgical patient scenarios. The ability to
accurately assess ABGs allows the perioperative nurse to assist surgical team members in restoring a
patient’s acid-base balance. AORN J 102 (October 2015) 344-354. ª AORN, Inc, 2015. http://dx.doi
.org/10.1016/j.aorn.2015.08.002
Key words: arterial blood gases, perioperative, Romanski method, blood gas interpretation.
L eviticus 17:11 states that “the life of a creature is in

the blood.”1(p118) The ability of health care
providers to appropriately interpret the clinical
relevance of elements carried in the blood is essential to
maintaining homeostasis and patients’ lives. Nowhere is this
pressure of carbon dioxide (PaCO2), concentration of bicar-
bonate (HCO3), and base excess and base deficit (Table 1).2
It is critical that perioperative nurses know how to interpret
ABGs and what interventions may contribute to the full
restoration of homeostasis. The results of an ABG test can
more important than in the OR, where patients entrust the provide a plethora of information about a surgical patient’s
perioperative team with their lives, relying on their physiological state. In addition to pH, blood gases provide
knowledge and expertise. The RN circulator is charged with data about the adequacy of a patient’s oxygenation and
the oversight of the OR and with assisting the team in ventilation and indicate the primary source of a disturbance
successfully intervening when difficulties are encountered. (ie, respiratory or metabolic) in homeostasis. Additionally,
When there is the potential for large blood loss or major ABG results can indicate how effectively the patient’s body
fluid shifts during surgery, the interpretation of arterial is compensating for the acid-base disturbance and whether
blood gases (ABGs) and correct intervention by the RN the patient’s total blood volume is adequate for transporting
circulator and the anesthesia professional can mean the all the nutrients that the body’s tissues require.
difference between life and death for the patient.
Several shortcuts have been suggested to determine the
To accurately interpret ABG samples, perioperative nurses meaning of acid-base disorders in an effort to make the process
must understand all the components that are measured and less daunting, such as assigning colors to values or using only a
how they contribute to maintaining the individual’s normal few values to make a determination.3-5 This article presents
physiological function. Arterial blood gas test results show the the Romanski method6 of blood gas analysis because it is
patient’s acid-base balance, which is measured by the hydrogen straightforward and is easily mastered (Figure 1). Four
ion (Hþ) concentration present in the blood (pH), its oxygen examples are presented to illustrate how to apply the
saturation (SaO2), partial pressure of oxygen (PaO2), partial Romanski method. The discussion of each example helps
http://dx.doi.org/10.1016/j.aorn.2015.08.002
ª AORN, Inc, 2015
344 j AORN Journal www.aornjournal.org
October 2015, Vol. 102, No. 4 Interpreting Blood Gases
1,2
Table 1. Components of Arterial Blood Gas Test Results
Measurement Meaning Normal Range Critical Values

pH Concentration of hydrogen ions (Hþ) in blood 7.35 to 7.45 <7.25 or >7.60
SaO2 Percent saturation of oxygen (O2) in hemoglobin 80% to 100% <80%
PaO2 Partial pressure of O2 in arterial blood 80 mm Hg to 100 mm Hg <50 mm Hg
PaCO2 Partial pressure of carbon dioxide (CO2) in 35 mm Hg to 45 mm Hg Acidosis
arterial blood <20 mm Hg or
>60 mmHg
>45 mm Hg
Alkalosis
<35 mm Hg alkalosis
HCO3 Concentration of bicarbonate in blood 22 mEq/L to 26 mEq/L Alkalosis
<10 mEq/L or
>40 mEq/L
>26 mEq/L
Acidosis
<22 mEq/L
Base excess/base Excess or deficit of bicarbonate in blood 2 mEq/L to þ2 mEq/L <2 mEq/L or
deficit >2 mEq/L
1. Common Laboratory (Lab) ValuesdABGs. Globalrph. http://www.globalrph.com/abg_analysis.htm. Accessed June 30, 2015.
2. Blood Gas Critical Values. Dartmouth-Hitchcock Medical Center. http://labhandbook.hitchcock.org/criticalTestLimits.html#BloodGas.
Accessed June 30, 2015.
the nurse determine suitable interventions and treatments to blood pH because changes in the concentration of any ion will
help restore any acid-base imbalance in patients. Finally, result in a change in the overall blood pH.
four case studies and the correct answers are presented to
allow nurses to practice what they have learned. The normal range for pH in human blood is 7.35 to 7.45.
Neutral blood pH is considered to be 7.4. A pH
approaching 7.35 is considered acidic. Conversely, as the
THE NEED FOR ABG MEASUREMENTS
pH approaches 7.4, it is considered alkalotic.8 When
Blood gas interpretation can be useful in a wide variety of
carbon dioxide (CO2) concentration is increased in the
surgical procedures. The results of an ABG test can be
blood, via the respiratory system, water present in the
particularly helpful in any surgery in which large fluid shifts or
blood plasma (H2O) dissociates into Hþ and hydroxide
blood loss are expected (eg, bowel resection, Whipple proce-
ions (OH). Hydrogen and OH also react with sodium
dure, liver resection), thus providing information regarding the
ions (Naþ) circulating in the blood, which creates sodium
patient’s fluid status and metabolic state. A patient requiring
bicarbonate (NaHCO3). This leads to the following
fluid resuscitation can have a large base deficit and metabolic
chemical reaction:
acidosis.7 In any thoracic procedure, especially those in which
one-lung ventilation is used, blood gas analysis can provide CO2 þH2 O4H2 CO3 4Hþ þHCO3 4Naþ 4NaHCO3
information on adequate gas exchange. In addition to these
procedures, the anesthesia professional and surgeon rely on The amounts of the ions present can then shift back and
ABGs during cardiac, neurological, or long oncological forth depending on either the metabolic or respiratory state
procedures to direct care. of the individual. According to the Henderson-Hasselbach
equation, pH is calculated based on the relationship be-
INTERPRETING ABG MEASUREMENTS tween the concentrations of CO2 and HCO39(A/B Reg)
Successful interpretation of ABG results begins with an un- and is used to accurately determine pH in a solution such as
derstanding of pH and the effect of acidosis and alkalosis on blood. This equation is expressed as follows:
tissue oxygenation. The body’s regulation of Hþ is influenced
HCO3
by both the respiratory and metabolic systems. Nurses should pH ¼ 6:1 þ log10
0:03 pCO2
know the relationships between all the ions that contribute to

LarkindZimmanck October 2015, Vol. 102, No. 4
respiratory acidosis or respiratory alkalosis. Carbon dioxide is

expressed in ABG results as PaCO2 and represents the total
amount of dissolved CO2 in arterial blood. Clinically, for
example, a patient with a disease such as chronic obstructive
pulmonary disease (COPD) or emphysema will have addi-
tional CO2 in the blood because of respiratory compromise.
Other conditions that can result in acidosis are shown in
Table 2.8 As CO2 increases, it forces the Hþ concentration to
increase, and the patient’s blood becomes more acidic and pH
values decrease from 7.4 toward 7.35 or lower.
A patient who is hyperventilating or who has a medical con-

dition that affects respiratory rates experiences a decrease in
CO2, and his or her ABGs will show a pH of 7.4 or higher,
which is known as alkalosis.8 As CO2 decreases, it forces Hþ
ions to decrease, resulting in alkalosis. Respiratory alkalosis is a
rare physiological phenomenon. It is associated with
conditions in which CO2 is “blown off” or exhaled at a
rapid rate (Table 3). It can also be seen in patients with
signs and symptoms of vasoconstriction and perhaps
hypocalcemia, as well as when there is artificial
overventilation. Flash pulmonary edema would result in
CO2 retention and acidosis, as would asthma and hypoxia.
Metabolic System Effects

Figure 1. The Romanski method of arterial blood gas When changes in the acid-base balance result from primary
evaluation. changes in extracellular HCO3, they are referred to as
metabolic acid-base disorders.9 If the bicarbonate
These two equations show why it is important to know the
concentration increases, the blood’s Hþ concentration
relationships of all the ions that contribute to blood pH.
decreases. This causes the pH value to increase from 7.4
Changes in the concentration of any ion will result in a
toward 7.45 or higher, which is called metabolic alkalosis.
change in overall pH. The following overview discusses acid-
Metabolic alkalosis is caused by a primary decrease of
base physiology and the effects of the respiratory and meta-
HCO3 from conditions such as kidney disease, electrolyte
bolic systems on blood pH.
imbalances, prolonged vomiting, hypovolemia, diuretic use,
and hypokalemia.10
Respiratory System Effects
The lungs regulate the amount of CO2 in the blood, so Metabolic acidosis occurs when the bicarbonate concentration
changes in CO2 concentration can be referred to as either decreases, resulting in the Hþ concentration increasing, which
1
Table 2. Conditions Associated With Respiratory Acidosis by Physiological Mechanism
Central Nervous System Ventilation Control Peripheral Nervous System Ventilation Control Ventilation-Perfusion Mismatch
Anesthetic medication toxicity Myasthenia gravis Pneumothorax
Benzodiazepine overdose Poliomyelitis Pleural effusion
Opioid overdose Polymyopathy Atelectasis
Stroke Neuromuscular blockade Pneumonia
Spinal cord injury Pulmonary edema
1. Nelligan PJ, Deutschman CS. Perioperative acid-base balance. In: Miller RD. ed. Miller’s Anesthesia. 8th ed. Philadelphia, PA: Elsevier
Saunders; 2015:1811-1829.

hemoglobin (Hgb) rapidly. This is the normal physiological

Table 3. Conditions Associated With Respiratory picture in the capillary system in which O2 is released to the
1
Alkalosis by Physiological Mechanism
tissues and CO2 binds to Hgb and is carried to the lungs
Central Nervous System Pulmonary Function for exchange.
Head injury Asthma
Stroke Pulmonary edema Physiological Shift of the Oxyhemoglobin
Hypoxia Embolism Curve as it Relates to pH
Hyperventilation The oxyhemoglobin dissociation curve, also known as the
1. Neligan PJ, Deutschman CS. Perioperative acid-base balance. oxygen-hemoglobin dissociation curve, is shown in Figure 2.
In: Miller, Ronald D, ed. Miller’s Anesthesia. 8th ed. The oxyhemoglobin dissociation curve depicts the
Philadelphia, PA: Elsevier Saunders; 2015:1811-1829.
relationship between PaO2 in the blood to the percent
saturation of Hgb with O2. The middle solid line shows
in turn lowers the pH from 7.4 to 7.35 or lower. Metabolic this relationship when the pH is normal. A patient’s pH
acidosis is seen in patients with an accumulation of ketones level has a major influence on the degree of saturation of
and lactic acid, as in shock-induced hypoxemia (which results Hgb in red blood cells because it affects the ability of red
in anaerobic metabolism), renal failure, excessive physical ex- blood cells to transport O2 to all the tissues of the body
ercise without adequate caloric intake, drug or toxin ingestion, and remove CO2 from the tissues. The 30-60-90 rule
and gastrointestinal or renal HCO3 loss.10 shows the typical relationship of PaO2 and SaO2. A PaO2
lower than 60% is considered a critical level because this
Tissue Oxygenation Status may indicate hypoxia.11,12 For example, in a patient with
Arterial blood samples are used for diagnostic testing. At acute alkalosis, in which pH levels are higher, the
pressures less than 60 mm Hg, O2 dissociates from oxyhemoglobin curve shifts toward the left and produces
Figure 2. The oxyhemoglobin dissociation curve (also known as the oxygen-hemoglobin dissociation curve). O2 ¼
oxygen, PaCO2 ¼ partial pressure of carbon dioxide, PaO2 ¼ partial pressure of oxygen, SaO2 ¼ oxygen saturation.

an increase in the affinity of Hgb for O2. This results in a interventions that may be needed to assist the patient in
higher saturation of Hgb with O2 than at neutral pH at returning to a normal pH.
the same PaO2. The converse is true for acute acidosis, in
which pH levels are decreased. When this occurs, there is a PaO2 and PaCO2
decrease in the affinity of Hgb for O2, and this results in The PaO2 and PaCO2 values represent the status of a patient’s
less O2 saturation of Hgb than occurs at neutral pH for respiratory function. If the PaO2 values fall below 80 mm Hg,
the same PaO2. To see this more clearly, locate the * on this may indicate that the patient does not have sufficient
the curve in Figure 1 at PaO2 30 mm Hg and you will see oxygen to adequately fuel cellular aerobic respiration. Cells
that a patient with acidosis will only have 42% saturation, that are not adequately oxygenated are unable to fuel the tri-
while at the same PaO2, a patient with normal pH will cyclic acid cycle production of adenosine triphosphate (ATP),
have an SaO2 of 60%. the primary source of cellular energy. In this situation, the cells
resort to using anaerobic respiration. Anaerobic respiration is
less efficient than aerobic and contributes protein acid waste in
Respiratory and Metabolic Compensation the form of lactic acid. As lactic acid builds up in the patient’s
Two main organs regulate acid-base balance: the lungs and the circulation, it increases the severity of acidosis.8
kidneys. The respiratory system regulates the amount of car-
bonic acid in the blood by controlling PaCO2, and a patient’s Patients with hypoxemia have inadequate PaO2 levels. Hyp-
respiratory rate will change to attempt to correct PaCO2 levels oxemia may exist in diseases that inhibit O2 from reaching the
that are out of the normal range. Respiratory regulation and bloodstream in the lungs, such as COPD and emphysema.
compensation can occur within minutes. If patients are unable Other conditions, such as anemia or acute blood loss from
to compensate via their own respiratory system, mechanical trauma, decrease the oxygen-carrying capacity of blood by
interventions such as a ventilator, continuous positive airway decreasing the amount of available Hgb.8
pressure (CPAP), or bilevel positive airway pressure (BiPAP)
may be needed. Respiratory rate influences PaCO2 levels in arterial blood.
When there are increases in a patient’s ventilatory rate, such as
The patient’s kidneys control the NaHCO3 buffering sys- occur in anxiety states or as a result of sudden anemia from any
tem and are able to excrete both Hþ and HCO3 into the cause, PaCO2 levels will decrease. Levels of PaCO2 below
urine. Metabolic compensation occurs primarily in the 35 mm Hg produce primary respiratory alkalosis. Increases in
kidneys and can take from three to five days to occur. When respiratory rates that result in alkalosis are rare events
acidosis persists, the kidneys are also able to produce new compared with respiratory acidosis. Respiratory acidosis exists
HCO3, which further contributes to the restoration of when PaCO2 rises above 45 mm Hg. Levels of PaCO2 rise in
normal pH.9 When there is a large of amount of Hþ medical conditions that also cause decreases in PaO2.
present in the renal tubules, more Hþ is excreted in the
urine than HCO3, which results in the urine becoming SaO2
more acidic and the blood becoming more alkalotic. Hemoglobin saturation with oxygen is expressed as a per-
Because it takes time to filter blood in the kidneys, this centage. As discussed earlier, the saturation of Hgb is directly
process is much slower than the regulation of CO2 by related to PaO2. The normal range for SaO2 is 80% to 100%.
the lungs.9 The SaO2 value represents the amount of oxygen available to
the patient’s tissues from the arterial blood. Values less than
Actions of pH 80% may not be sufficient to meet the oxygen needs of tissues,
A patient’s pH level indicates the status of acid-base balance. especially tissues that have normally high oxygen consumption
Values less than 7.35 indicate that the patient is experiencing requirements (eg, brain, heart, kidneys). Low SaO2 levels
acidosis, while values above 7.45 indicate alkalosis. However, along with low PaO2 values indicate that the patient is in a
information about pH values are insufficient to diagnose the hypoxemic state, which requires supplemental oxygen
cause of an imbalance or to determine whether the body is administration. Hypoxemia is classified as mild, moderate,
attempting to compensate in response to the imbalance. Other or severe:
ABG measurements that are crucial for determining the pa- mild hypoxemia is defined as a PaO2 of 60 mm Hg to
tient’s full physiological status include PaO2, PaCO2, SaO2, 70 mm Hg,
bicarbonate, and the base excess or base deficit. These mea- moderate hypoxemia is defined as a PaO2 of 40 mm Hg to
surements guide the perioperative team toward instituting 59 mm Hg, and

severe hypoxemia is defined as a PaO2 of less than 40 mm

Hg.7 Table 4. Severity of Circulating Blood Volume Loss
1
in Relation to Base Deficit Values
The resulting SaO2 values can be determined from the
oxyhemoglobin curve after taking into account any shifts in Blood Volume Mean Arterial
Loss Base Deficit Range Pressure
the curve from acid-base disturbances and other factors that
may shift the curve. Mild 2 mEq/L to 5 92 2.3 mm Hg
mEq/L
Moderate 6 mEq/L to 14 84 2.4 mm Hg
Bicarbonate mEq/L
Bicarbonate values range from 22 mEq/L to 26 mEq/L and Severe 15 mEq/L 68 4.2 mm Hg
represent the metabolic component of the ABG result. Bi-
1. Davis JW, Shackford SR, Mackersie RC, Hoyt DB. Base deficit as
carbonate levels exceeding 26 mEq/L indicate metabolic a guide to volume resuscitation. J Trauma. 1988;28(10):1464-
alkalosis, while levels below 22 mEq/L indicate metabolic 1467.
acidosis. Medical conditions that are associated with metabolic
acidosis include starvation, diabetic ketoacidosis, and severe
diarrhea. Renal failure is the most common cause of metabolic acid-base disorder as primarily respiratory, the metabolic
acidosis. Metabolic alkalosis caused by high levels of HCO3 component indicates whether compensation is occurring and
(as opposed to low levels of Hþ) are associated with vomiting to what degree. In the same way, if the disorder is primarily
or the removal of gastric secretions via nasogastric suction.8 from a metabolic cause, the respiratory component must also
be evaluated for the existence of compensation and its extent.
Base Excess/Base Deficit Compensation may be complete if pH levels are nearly neutral
The value of the base excess or base deficit of bicarbonate is (ie, 7.40). Partial compensation is indicated if the pH values
useful in evaluating metabolic compensatory efforts and can are moving toward normal. The best way to understand this
also estimate the blood volume deficits associated with trau- process is to practice ABG analysis with several examples.
matic blood loss and direct the titration of fluid and blood
products needed for resuscitating trauma patients in hypo-
volemic shock.7 This measurement has direct implications for
ROMANSKI METHOD OF ABG ANALYSIS
Analyzing ABGs is the first step in managing the patient’s
life-saving interventions by perioperative team members
because many trauma patients require surgical procedures. acid-base status. Results of blood gas analysis must be used
along with an assessment of the patient’s history, comorbid-
Bicarbonate values provide information on the metabolic ities, and other diagnostic blood tests to determine which
component of acid-base disorders, while base deficit values interventions, if any, will be needed. The RN circulator must
provide information on the level of excess or deficit of bicar- work in concert with the anesthesia professional to develop the
bonate available in the patient’s system. Some laboratories best plan of action after results are obtained.
report only base excess; therefore, a negative base excess is
actually a base deficit. Values outside the normal range Some clinicians master the skill of evaluating ABG results
quickly by just looking at them, while others need to work it
of 2 mEq/L to þ2 mEq/L suggest a metabolic cause for the
out step by step.14 The Romanski method of blood gas
acid-base imbalance. Base excess is defined as the amount of
analysis5 uses each value of the blood gas result to determine
Hþ that would be required to return the pH of blood to 7.35
if the PaCO2 were adjusted to normal.13 Severe volume which acid-base disorder is present and what is the primary
depletion is related to the amount of base deficit present as cause of the disorder. Further analysis using this method
reveals whether the results show respiratory or metabolic
shown in the ABG result. Base deficit in relation to mean
compensation. The Romanski method breaks the process of
arterial pressure ranges is shown in Table 4.7
ABG evaluation into four steps.6
Compensation for Acidosis and Alkalosis While most blood gas results provide all the measurements
After the nurse identifies the cause of the pH imbalance discussed previously, it is possible to analyze an ABG without
(whether the respiratory component [PaCO2] or the metabolic SaO2 and base deficit/base excess values. The hypothetical
component [HCO3]), the remaining value is used to deter- ABG scenarios to follow discuss how the RN can analyze test
mine whether the patient’s body is making an effort to correct results. These four examples lead the reader through ABG
the condition. If the anesthesia professional identifies an analysis using a step-by-step process, and sidebars 1 through 4

provide the RN with additional case studies of the ABG results are critically low. However, a complete patient history and
that demonstrate how to determine the patient’s conditions physical examination also are needed before any treatment is
and potential interventions. carried out. If the patient has COPD, attempting to increase
oxygenation could disable the patient’s respiratory drive
Scenario 1 centers in the brain.
On room air, the patient has a pH of 7.24, PaCO2 of 38 mm
Hg, PaO2 of 80 mm Hg, and HCO3 of 15.5 mEq/L. Scenario 3
While undergoing surgery via general anesthesia, the pa-
In step 1, the RN should look at the pH. In this case, the
tient’s pH is noted to be 7.45, PaCO2 is 32 mm Hg, PaO2 is
pH value is below the low end of normal (ie, 7.35), which
138 mm Hg, HCO3 is 23 mEq/L, base deficit is 1 mEq/L,
indicates acidosis.
and SaO2 is 92%.
In step 2, the RN should evaluate the results for respiratory
or metabolic components. In this scenario, the PaCO2 is In step 1, the nurse determines that the pH indicates alka-
normal and the HCO3 indicates acidosis. losis. The patient’s PaCO2 is in the alkalotic range, while the
In step 3, the RN should look for the value consistent with HCO3 is at the low end of the normal range.
the pH results. The value that is consistent with the pH in In step 2, the nurse evaluates for respiratory or metabolic
this scenario is the HCO3, indicating a metabolic cause. components and determines that the patient is in respiratory
In step 4, the RN should evaluate for evidence of alkalosis.
compensation. To do this, he or she would search for the The consistent value (step 3) is the PaCO2, which is below
value that is not consistent with the pH. In this scenario, normal range and is consistent with the alkalotic pH value.
that is the PaCO2, which is within normal range, indicating Because the HCO3 is in the normal range, there is no
that there is no compensation occurring. compensation (step 4), and the base deficit and SaO2 are
both in normal range.
After this analysis, the nurse determines that this patient is in
metabolic acidosis with no compensation. These data are Based on these results, the nurse determines that this patient
insufficient to determine an appropriate intervention. The is in respiratory alkalosis with no compensation. To correct
nurse needs to perform a physical assessment and review the this, the anesthesia professional may attempt to overcome
patient’s history to guide the next steps in treatment. the alkalosis by hyperventilating the patient (as indicated by
the high PaO2) or may gather more data to determine
Scenario 2 whether the hyperventilation of the patient may be causing
The patient has a pH of 7.39, PaCO2 of 51 mm Hg, PaO2 of the respiratory alkalosis. More data are needed to guide
59 mm Hg, and HCO3 of 30 mEq/L. further intervention.
Starting with step 1, the nurse notes that the pH is in in the
Scenario 4
normal range, using 7.4 as an absolute value to determine
The ABG results indicate that the patient’s pH is 7.27, PaCO2
the presence of acidosis or alkalosis; 7.39 is lower than 7.4,
is 55 mm Hg, PaO2 is 93 mm Hg, HCO3 is 41 mEq/L, base
so the patient is experiencing acidosis.
excess/base deficit is 10 mEq/L, and SaO2 is 82%.
In step 2, the nurse notes that the patient’s PaCO2 is higher
than normal, indicating acidosis, and the HCO3 is in the Based on these results, the nurse determines that the pa-
alkalotic range. tient’s pH is acidotic (step 1).
Finding a consistent value (step 3), the nurse sees that the The elevated PaCO2 indicates acidosis, and the elevated
value that matches the acidotic state is PaCO2, indicating HCO3 indicates alkalosis (step 2).
that the cause of the acidosis is respiratory. The value that is consistent (step 3) with the pH is the
To determine if compensation is occurring (step 4), the PaCO2; this indicates that acidosis is from a respiratory
nurse sees that the patient’s HCO3 is greatly elevated, cause.
indicating a metabolic effort to compensate. The HCO3 value is not consistent with the pH and is in
the alkalotic range, so there is a metabolic attempt to
Based on the assessment, the nurse determines that this
compensate (step 4).
patient is in respiratory acidosis with complete metabolic
compensation because the pH has returned to the normal However, compensation is only partial because the pH has not
range (ie, just 0.1 below absolute normal of 7.40). This returned to normal. The nurse determines that this patient is
patient may need supplemental oxygen because PaO2 levels in respiratory acidosis with partial metabolic compensation;

therefore, the nurse knows that the patient has a pre-existing

Using the Romanski method,1 the RN interprets the
respiratory condition because it takes more than three days
ABG analysis.
for metabolic compensation efforts to be effective. Although
the patient’s PaO2 is in the normal range (because of sup- Step 1 (evaluate pH): pH is in the normal range; using
plemental O2), the patient’s saturation is below normal. This 7.40 as the cutoff point, the pH value indicates alkalosis.
indicates that the cause of the respiratory acidosis is ventilation Step 2 (evaluate respiratory and metabolic compo-
mismatch, such as occurs in obstructive lung disease. nents): The PaCO2 is low, indicating alkalosis; the
HCO3 is normal.
Step 3 (determine consistent value): The value that is
Case Studies consistent with the pH is the PaCO2; this indicates that
Using the Romanski method of analysis, the following ex- acidosis is from a respiratory cause.
amples walk the nurse through the process of identifying a Step 4 (determine compensation): The HCO3 value is
patient’s condition. not consistent with the pH and is normal, so there is no
metabolic attempt to compensate. The base deficit/base
excess and SaO2 are both normal.
Case Study One
Mr F is an 83-year-old man with the following comor- Results: This patient is in respiratory alkalosis with no
bidities: aortic valve disease with systemic hypertension, compensation.
dyslipidemia, and mild to moderate mitral regurgitation.
He has good functional capacity and is able to walk without Interpretation: The PaO2 setting and/or the rate of
dyspnea, angina, or dizziness, but gets tired in the evening ventilation must be corrected by the nurse and physician
and is taking more naps. According to his wife, he is more managing the patient to correct the acid-base imbalance
tired and has episodes of confusion with slight memory without affecting SaO2 by managing the settings on the
impairment. He is well nourished and his baseline vital ventilator to achieve desired outcomes. Additionally, the
signs are within normal limits. His physicians have opti- nurse should consider that the patient’s hyperventilation
mized his medical status to prepare him for an aortic valve could be the result of anxiety from being intubated post-
replacement with myocardial revascularization. After the operatively, causing ventilator hyperventilation, or it could
procedure, the surgical team transfers him to the intensive be the result of pain from the surgical incision.
care unit with an endotracheal tube in place to maintain his 1. Romanski SO. Interpreting ABGs in four easy steps. Nursing.
airway, and they place him on a ventilator. The surgeon 1986;16(9):58-64.
orders an arterial blood gas (ABG) to be drawn, which
shows the following results.
Case Study Two
Ms A is a 78-year-old woman suspected by her gynecol-
Blood Gas ogist of having a rectovaginal fistula. The gynecologist
Measure Values Acidotic? Alkalotic? Normal? refers her to a colorectal surgeon for fistula repair. In
pH 7.44 Yes addition to the suspected fistula, she has the following
Partial Pressure 36 mm Hg Yes significant comorbidities: well-controlled diabetes, hy-
of Carbon
Dioxide pertension, hyperlipidemia, emphysema, protein-calorie
(PaCO2) malnutrition, history of malignant neoplasm of the thy-
Partial Pressure 349 mm Hg No, on roid for which she takes daily levothyroxine, and history
of Oxygen ventilator
(PaO2) of neoplasm of the uterus and cervix. The colorectal
Concentration 24 mEq/L Yes surgeon performs an exploratory laparotomy with lysis of
of Bicarbonate adhesions and small-bowel resection. Before surgery, the
(HCO3)
patient exhibits extreme anxiety with rapid respiratory rate
Base Deficit/ 0 mEq/L Yes
Base Excess (ie, hyperventilation). The anesthesia professional orders
Oxygen 99% Yes midazolam 2 mg IV for anxiety reduction and orders an
Saturation arterial blood gas (ABG) analysis to be drawn, which
(SaO2)
shows the following results.

Blood Gas Measure Values Acidotic? Alkalotic? Normal? Case Study Three
pH 7.37 Yes Mr W is a 78-year-old man with a history of recent pul-
Partial Pressure 58 mm Hg Yes monary embolism and cardiovascular stent placement for
of Carbon
Dioxide coronary artery disease. Other significant comorbidities
(PaCO2) include bronchoalveolar carcinoma, surgically treated by
Partial Pressure 65 mm Hg No partial lung removal of the left upper lobe, and seizure
of Oxygen
(PaO2) disorder. He presents at an emergency department with
Concentration of 29 mEq/L Yes sudden vision changes in his left eye. Computed tomog-
Bicarbonate raphy reveals an occipital mass, and the emergency physi-
(HCO3)
cian refers him to a neurosurgeon. The day before Mr W
Base Deficit/ 0 mEq/L
Base Excess undergoes surgery for right occipital craniotomy to remove
Oxygen 87% No the brain lesion, he has an episode of respiratory distress
Saturation and complains of chest pain. The nurse acts on an existing
(SaO2)
order to have a respiratory therapist draw an arterial blood
gas (ABG), which shows the following results.
Using the Romanski method,1 the RN interprets the

ABG analysis.
Blood Gas
Step 1 (evaluate pH): This patient’s pH is in the normal Measure Values Acidotic? Alkalotic? Normal?
range; using 7.40 as the cutoff, the patient is acidotic. pH 7.46 Yes
Step 2 (evaluate respiratory and metabolic compo- Partial Pressure 34 mm Hg Yes
nents): PaCO2 indicates acidosis; HCO3 is in the of Carbon
Dioxide
alkalotic range. (PaCO2)
Step 3 (determine consistent value): PaCO2 is consis- Partial Pressure 86 mm Hg Yes
tent with the pH; therefore, there is respiratory acidosis. of Oxygen
(PaO2)
Step 4 (determine compensation): HCO3 is in the Concentration 24 mEq/L Yes
alkalotic range and the pH is in the normal range, of Bicarbonate
resulting in full compensation. The base deficit/base (HCO3)
excess is normal and SaO2 is low. Base Deficit/ 1 mEq/L Yes

Base Excess
Results: This patient is in respiratory acidosis with full Oxygen 97% Yes
Saturation
metabolic compensation. (SaO2)
Interpretation: Because the patient’s SaO2 is low and her

PaO2 value is nearing the critical point, she may need Using the Romanski method,1 the RN interprets the
supplemental O2 to correct the SaO2 toward normal, but
ABG analysis.
not enough O2 that it deters her from taking spontaneous
respirations postoperatively. The determination to give Step 1 (evaluate pH): The pH value indicates alkalosis.
supplemental O2 should be made in light of her preoper- Step 2 (evaluate respiratory and metabolic compo-
ative need for O2 because of her emphysema and baseline nents): PaCO2 indicates alkalosis; HCO3 is in the
hypoxic respiratory drive. Additionally, the 2 mg of mid- normal range.
azolam given for anxiety reduction preoperatively could Step 3 (determine consistent value): PaCO2 is consis-
have resulted in a decreased respiratory drive. The nurse will tent with the alkalotic pH.
need to monitor this patient’s respiratory status carefully Step 4 (determine compensation): The value that is not
both preoperatively and postoperatively. consistent with the pH is HCO3, and it is within the
normal range, so there is no compensation occurring. The
1. Romanski SO. Interpreting ABGs in four easy steps. Nursing.
base deficit/base excess and SaO2 are normal.
1986;16(9):58-64.

Results: This patient is in respiratory alkalosis with no Step 2 (evaluate respiratory and metabolic compo-
compensation. nents): PaCO2 is in the normal range; HCO3 is alkalotic.
Step 3 (determine consistent value): The HCO3 value
Interpretation: This scenario can be caused by hyperven- is consistent with the pH, so the cause of imbalance is
tilation associated with pain and/or anxiety. The respiratory metabolic.
distress the patient is experiencing also may be related to the Step 4 (determine compensation): PaCO2 is in the
complaint of chest pain and not an oxygenation/ventilation normal range, so there is no compensation occurring.
mismatch from the previous lung surgery or a pulmonary Base excess is elevated and SaO2 is normal.
embolism. If the patient is hyperventilating, the nurse
should take measures to calm and reassure the patient to Results: This patient is in metabolic alkalosis with no
help him slow his breathing. Additionally, assessing for pain compensation.
and obtaining analgesic medication orders is also an option.
Intervention: There is presence of a base excess, which in-
1. Romanski SO. Interpreting ABGs in four easy steps. Nursing. dicates that the patient may need fluid resuscitation and/or
1986;16(9):58-64.
blood products to correct the acute anemia associated with
Case Study Four the vaginal blood losses. The RN circulator should be ready
Ms P is a 67-year-old woman with recent episodes of to assist the anesthesia professional by helping to establish a
postmenopausal vaginal bleeding and the following secondary IV access or an arterial line. Circulating volume
comorbidities: cerebral palsy with chronic pain and spas- may need to be replaced with either IV lactated Ringer’s
ticity, neurogenic bladder, hypothyroidism, hyperlipidemia, solution or blood products. Other interventions to consider
hypercholesterolemia, peripheral artery disease, systolic include reviewing the patient’s history for recent episodes of
heart failure, chronic hypokalemia, hypomagnesemia, vomiting, nasogastric tube placement with suction, and
controlled type 2 diabetes, mitral valve disorder, and acute diuretic use leading to volume and electrolyte depletion.
anemia. Her physician has cleared her to undergo a total Other diagnostic tests may include checking the patient’s
abdominal hysterectomy with bilateral salpingo- hematocrit, basic chemistry panel, and blood glucose.
oophorectomy and possible pelvic and periaortic lympha- 1. Romanski SO. Interpreting ABGs in four easy steps. Nursing.
denectomy. The anesthesia professional draws an arterial 1986;16(9):58-64.
blood gas (ABG) during the first 30 minutes of the pro-
cedure, which shows the following results.
Analysis of ABGs and Interventions for
Blood Gas Measure Values Acidotic? Alkalotic? Normal? Perioperative RNs
pH 7.49 Yes Major procedures are not the only instances during which
Partial Pressure 39 mm Hg Yes blood gas analyses are important. In any patient with pul-
of Carbon monary disease (eg, COPD, severe asthma, interstitial lung
Dioxide
(PaCO2)
disease), a blood gas analysis also may be critical. For
Partial Pressure 249 mm Hg Elevated example, patients with severe COPD may have an elevated
of Oxygen baseline PaCO2. Decreasing the patient’s PaCO2 to normal
(PaO2)
perioperatively may suppress respiratory drive. This affects
Concentration 30 mEq/L Yes
of Bicarbonate
the anesthesia professional’s ability to extubate the patient
(HCO3) at the end of the procedure because the patient would lack
Base Deficit/ 6 mEq/L Elevated the “normal” hypercapneic drive to breathe, which is higher
Base Excess
than for healthy adults. This may necessitate the need for
Oxygen Saturation 99% Yes
(SaO2)
ventilator support in the postanesthesia care unit or the
intensive care unit. In the postanesthesia care unit or the
intensive care unit, blood gas measurement can provide
Using the Romanski method,1 the RN interprets the important insight into the etiology of a patient’s altered
ABG analysis. mental status or varied respiratory pattern. The case studies
give the reader an opportunity to practice ABG analysis
Step 1 (evaluate pH): The pH value clearly indicates
using the Romanski method and increase confidence in
alkalosis.
clinical ABG analysis.

CONCLUSION 6. Romanski SO. Interpreting ABGs in four easy steps. Nursing.

Although the need for accurate interpretation of ABGs may be 1986;16(9):58-64.
7. Davis JW, Shackford SR, Mackersie RC, Hoyt DB. Base deficit as a
rare in some OR settings, it is essential for the perioperative
guide to volume resuscitation. J Trauma. 1988;28(10):1464-1467.
RN circulator to be able to quickly assess and interpret ABG 8. Neligan PJ, Deutschman CS. Perioperative acid-base balance. In:
results when blood gas reports arrive in the OR. These skills Miller RD, ed. Miller’s Anesthesia. 8th ed. Philadelphia, PA:
help the perioperative RN assist the entire surgical team, Elsevier Saunders; 2015:1811-1829.
especially the anesthesia professional, in helping the patient 9. Acid-base regulation. In: Hall JE, ed. Pocket Companion to Guyton
maintain acid-base balance. The perioperative nurse should and Hall Textbook of Medical Physiology. 12th ed. Philadelphia,
anticipate the need for ABGs in patients with pre-existing PA: Elsevier Saunders; 2012:230-237.
respiratory compromise, such as COPD, or metabolic 10. Metabolic acidosis. Medscape. http://emedicine.medscape.com/
article/243160-overview. Accessed June 30, 2015.
compromise, such as hypermetabolic states (eg, malignant
11. The pulmonary system. In: McCance KL, Huether SE, eds. Path-
hyperthermia), as well as in patients undergoing trauma, ophysiology: The Biologic Basis for Diseases in Adults and
oncological, cardiothoracic, and neurological or other lengthy Children. 7th ed. Philadelphia, PA: Elsevier Mosby; 2014:
procedures. Understanding the interpretation of ABGs helps 1229-1232.
ensure that the perioperative RN is prepared to respond to 12. Horne C, Derrico D. Mastering ABGs. The art of arterial blood gas
measurement. Am J Nurs. 1999;99(8):26-32.

critical acid-base imbalances and provide appropriate
interventions. 13. Pathophysiology of shock. In: Vincent JL, Abraham E, Moore FA,
Kohanek PM, Fink MP, eds. Textbook of Critical Care. Philadelphia,
Acknowledgment: The authors acknowledge Holly Schmidtke, PA: Elsevier Saunders; 2011:677-683.
MBA, BSN, RN, CNML, chief nurse executive, Aurora Health 14. Pruitt WC, Jacobs M. Interpreting arterial blood gases: easy as
ABC. Nursing. 2004;34(8):50-53.
Care, Milwaukee, WI, and Steven Mayo, MD, chief of medical
staff and anesthesia for the Burlington-Walworth Patients Service
Market of Aurora Health Care, Milwaukee, WI, for support for
this article. Brenda G. Larkin, MS, RN, ACNS-BC, CNS-CP,
CNOR, is a perioperative and gastrointestinal clinical
nurse specialist for Aurora Health Care, Burlington-
References Walworth Patient Service Market, Milwaukee, WI. Ms
1. Leviticus 17:11. In: Thompson FC, ed. Thompson’s Chain- Larkin has no declared affiliation that could be perceived
Referenced Bible. New International Version. Grand Rapids, MI: as posing a potential conflict of interest in the publication
Zondervan Bible Publishers; 1982:118. of this article.
2. Common Laboratory (Lab) ValuesdABGs. Globalrph. http://
www.globalrph.com/abg_analysis.htm. Accessed June 30, 2015.
3. Shoulders-Odom B. Using an algorithm to interpret arterial blood Robert J. Zimmanck, MD, is a staff anesthesiologist
gases. Dimens Crit Care Nurs. 2000;19(1):36-41. at Aurora Health Care, Milwaukee, WI. Dr Zimmanck has
4. Wallace LS. Using color to simplify ABG interpretation. Medsurg no declared affiliation that could be perceived as posing
Nurs. 2000;9(4):205-207. a potential conflict of interest in the publication of this
5. Wong FW. A new approach to ABG interpretation. Am J Nurs. article.
1999;99(8):34-36.

EXAMINATION
Continuing Education:
PURPOSE/GOAL
To provide the learner with knowledge specific to interpreting arterial blood gases (ABGs).
OBJECTIVES
1. Explain what ABGs are.
2. Discuss what ABGs measure.
3. Discuss how acidosis and alkalosis may be identified using ABG results.
4. Explain how the nurse can determine whether respiratory or metabolic factors are causing an imbalance.
The Examination and Learner Evaluation are printed here for your convenience. To receive
continuing education credit, you must complete the online Examination and Learner Evaluation
at http://www.aorn.org/CE.
QUESTIONS 4. In addition to pH, blood gases provide data about

1. Clinical interpretation of elements carried in the blood is 1. the adequacy of a patient’s oxygenation.
essential to health care providers’ ability to maintain pa- 2. disturbances in homeostasis.
tients’ lives and homeostasis when providing care. 3. levels of carbon monoxide in the blood.
a. true b. false 4. whether the disturbances are respiratory or metabolic.
a. 1 and 3 b. 2 and 4
2. Two events that trigger the need for ABG results are c. 1, 2, and 4 d. 1, 2, 3, and 4
1. shifts in calcium levels.
2. shifts in fluid levels. 5. Arterial blood gas results can indicate how effectively the
3. major blood loss. patient’s body is compensating for the acid-base distur-
a. 1 and 2 b. 1 and 3 bance and whether the patient’s total blood volume
c. 2 and 3 d. 1, 2, and 3 is adequate for transporting the substances measured by
the test.
3. Arterial blood gas test results include measurements of a. true b. false
1. the concentration of hydrogen ions present in the
blood (pH). 6. The results of an ABG test can be particularly helpful in
2. oxygen saturation (SaO2). 1. procedures in which large fluid shifts or blood loss
3. partial pressure of oxygen (PaO2). are expected.
4. partial pressure of carbon dioxide (PaCO2). 2. procedures that require fluid resuscitation.
5. the concentration of bicarbonate (HCO3). 3. procedures of the oropharynx.
6. base excess and base deficit. 4. procedures in which one-lung ventilation is used.
a. 1, 3, and 5 b. 2, 4, and 6 a. 1 and 3 b. 2 and 4
c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6 c. 1, 2, and 4 d. 1, 2, 3, and 4

7. As CO2 increases, it forces the hydrogen ion concentration 9. Which element represents metabolic changes in acid-base
to increase and the patient’s blood becomes more alkalotic. status?
a. true b. false a. Intracellular HCO3.
b. Partial pressure of PaCO2.
8. What might be seen in the ABG results of a patient with c. Base excess.
alkalosis? d. Extracellular HCO3L.
1. A decrease in CO2.
2. An increase in CO2.
3. A pH of 7.5 or higher. 10. Which element represents respiratory changes in acid-
4. A pH of 7.4 or lower. base status?
a. 1 and 3 b. 2 and 4 a. pH. b. PaO2.
c. 1, 2, and 4 d. 1, 2, 3, and 4 c. Base excess. d. PaCO2.

LEARNER EVALUATION
Continuing Education:
T his evaluation is used to determine the extent to

which this continuing education program met your
learning needs. The evaluation is printed here for
your convenience. To receive continuing education credit, you
must complete the online Examination and Learner Evaluation
8.
8A.
Will you change your practice as a result of reading this
article? (If yes, answer question #8A. If no, answer
question #8B.)
How will you change your practice? (Select all that

at http://www.aorn.org/CE. Rate the items as described below. apply)
1. I will provide education to my team regarding why
OBJECTIVES change is needed.
To what extent were the following objectives of this 2. I will work with management to change/implement
continuing education program achieved? a policy and procedure.
1. Explain what arterial blood gases (ABGs) are.
3. I will plan an informational meeting with physicians
Low 1. 2. 3. 4. 5. High to seek their input and acceptance of the need for
2. Discuss what ABGs measure. change.
Low 1. 2. 3. 4. 5. High 4. I will implement change and evaluate the effect of
the change at regular intervals until the change is
3. Discuss how acidosis and alkalosis may be identified incorporated as best practice.
using ABG results. 5. Other: __________________________________
Low 1. 2. 3. 4. 5. High
4. Explain how the nurse can determine whether respiratory 8B. If you will not change your practice as a result of
or metabolic factors are causing an imbalance.
reading this article, why? (Select all that apply)
Low 1. 2. 3. 4. 5. High 1. The content of the article is not relevant to my
practice.
CONTENT
2. I do not have enough time to teach others about the
5. To what extent did this article increase your knowledge of
purpose of the needed change.
the subject matter?
3. I do not have management support to make a
Low 1. 2. 3. 4. 5. High
change.
6. To what extent were your individual objectives met? 4. Other: __________________________________
Low 1. 2. 3. 4. 5. High
7. Will you be able to use the information from this article 9. Our accrediting body requires that we verify the time
in your work setting? you needed to complete the 2.6 continuing education
1. Yes 2. No contact hour (156-minute) program: _____________

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CONTINUING EDUCATION

Interpreting Arterial Blood Gases

BRENDA G. LARKIN, MS, RN, ACNS-BC, CNS-CP, CNOR;

Continuing Education Contact Hours Approvals

BRENDA G. LARKIN, MS, RN, ACNS-BC, CNS-CP, CNOR;

L eviticus 17:11 states that “the life of a creature is in

Measurement Meaning Normal Range Critical Values

www.aornjournal.org AORN Journal j 345

respiratory acidosis or respiratory alkalosis. Carbon dioxide is

A patient who is hyperventilating or who has a medical con-

Metabolic System Effects

346 j AORN Journal www.aornjournal.org

hemoglobin (Hgb) rapidly. This is the normal physiological

www.aornjournal.org AORN Journal j 347

348 j AORN Journal www.aornjournal.org

severe hypoxemia is deﬁned as a PaO2 of less than 40 mm

www.aornjournal.org AORN Journal j 349

350 j AORN Journal www.aornjournal.org

therefore, the nurse knows that the patient has a pre-existing

www.aornjournal.org AORN Journal j 351

Using the Romanski method,1 the RN interprets the

excess is normal and SaO2 is low. Base Deﬁcit/ 1 mEq/L Yes

Interpretation: Because the patient’s SaO2 is low and her

352 j AORN Journal www.aornjournal.org

www.aornjournal.org AORN Journal j 353

CONCLUSION 6. Romanski SO. Interpreting ABGs in four easy steps. Nursing.

354 j AORN Journal www.aornjournal.org

QUESTIONS 4. In addition to pH, blood gases provide data about

www.aornjournal.org AORN Journal j 355

356 j AORN Journal www.aornjournal.org

T his evaluation is used to determine the extent to

How will you change your practice? (Select all that

www.aornjournal.org AORN Journal j 357

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