NEED FOR STUDY

*All the nurses are required to have specialized skills and knowledge to enable them to critically
think rapidly in life-threatening situations.

*One of the specific skill sets that is foundational for all nurses is to be able to competently
analyze arterial blood gas, which can be a difficult and daunting concept for all nurses to grasp.

In addition to shift responsibilities, nurses have other commitments, such as mandatory regulatory
agency requirements, committee work, and family obligations to fulfill.

These factors contribute to the challenges staff nurses encounter in accessing continuing education
programs.

The term ‘blood gas’ strictly refers to the measurement of the tension or partial pressure of oxygen
and carbon dioxide in blood but the determination of acid-base imbalance is an integral part of
blood gas measurement (Adams and Hohn, 1982)

* ABG sampling represents the gold standard method for acquiring patient’s acid-base status.

*Arterial blood gas analysis has become an essential skill for all healthcare practitioners.

*It provides important information with regard to adequacy of ventilation, oxygen delivery to the
tissues and acid–base balance. Although each patient’s clinical presentation will be judged
individually, situations that warrant analysis of a blood gas sample include respiratory compromise,
post-cardiorespiratory arrest, evaluation of interventions such as oxygen therapy, respiratory
support and as a baseline before surgery.2 Reasons to utilize ABG’s in the assessment process
include determining the need for and treatment of pulmonary disease, and determining acid-base
balance in a patient with heart failure, renal failure, uncontrolled diabetes, a sleep disorder, severe
infection, and drug overdose (Youngerman-Cole, 2006).

Blood can be drawn from an artery either via an indwelling arterial cannula or by direct arterial
puncture.

The commonest artery used is the radial artery.

It is therefore essential that the critical care nurse not only appreciates the correct techniques
involved in performing an ABG analysis, but also has an understanding of the changes in the blood
gas parameters in the commonly encountered clinical conditions.3

In Dec, 2007, a study was conducted to know how frequent ABG

analysis be performed during thoracoscopic surgery. The study concluded that intermittent ABG
analysis must be performed more frequently up to 10 minutes, to detect changes of 20% in arterial
partial pressure of oxygen.4

The frequent collection of blood specimens in the ICU may contribute to

iatrogenic blood loss. Because little is known to the nurses about the determination of hemoglobin
concentration.5 Arterial lines usually placed in unstable patients in ICU who need close monitoring.
ABG utilization in a surgical ICU over a 1-year period was evaluated to identify factors that might
help reduce over utilization This suggests that ABG’s are being drawn unnecessarily simply because
of the presence of an arterial line. To reduce the number of ABG’s drawn, a policy for specific
indications for placement of arterial lines and ABG analysis should be adopted. 6

** The researcher during her clinical experience in ICU found that majority of
patients ventilation is being monitored by ABG’s analysis in spite of continuous monitoring with
pulse oxymeter. Though the nurses take an active part in collection of ABG samples, their
knowledge in interpreting ABG reports is inadequate. Studies revealed that online tutorial
promotes an understanding of ABG analysis and application of knowledge in clinical settings.7,8

* Following the introduction of new guidelines in February 2006, assessments

for long-term oxygen therapy are now being undertaken by respiratory nurse specialists. The key
skill required for this is arterial blood gas sampling. This has traditionally been the role of the
doctor, however by using an education and training package along with a competency-based
assessment, nurses can now perform this extended role. The British Thoracic Society (2002)
guidelines recommend that staff providing non-invasive pressure ventilation should be able to
carry out ABG measurement, rather than relying on the on-call doctor. Sarah Dodds and Graham
Williamson, University of Plymouth describe a competency-based education and training
programme for nurses to carry out this procedure.9

Two registered nurses were trained to perform radial arterial punctures and
found that they have become more proficient in this technique than most of the house staff. In a
five month period, 1,541 punctures were performed by these nurses without morbidity.Thus the
researchers feels the need for nurses to improve their responsibility in ABG analysis.10

An audit of the patient’s experience of arterial blood gas testing conducted in

May 2004, patients often reported that arterial puncture as a painful and unpleasant experience,
which to date has not been explored. This audit concludes that the respiratory nurse specialist is in
an ideal position to implement changes to improve the patient’s experience of chronic disease
management.11

In view of the above findings, the investigator strongly felt that every
nurse working in the critical care units should have adequate skill in collection of ABG
samples, knowledge in analysis and interpretation of the ABG result. Thus, the teaching
protocol would greatly help the nurses to be more competent, hence the study is
undertaken.12 NEED FOR THE STUDY:

The arterial blood gases is one of the most important investigation for

assessment of clinical oxygenation and acid-base status in critically ill patients, it

provides us with information about ventilation, oxygenation, and acid-base status.

[Cardio Thoracic centre Pune (2004)]

 ***Valero Marco AV, Martinez Castill C. (2008), Turkey Stated that They

conducted study to staff nurses regarding local anesthesia in arterial puncture nurse’s

knowledge and attitudes, the aim of study is to examine attitudes and beliefs among

nurses and third-year undergraduate nursing student in hospital training regarding the

use of local anesthesia when performing arterial puncture and to assess their

knowledge and technique, of arterial puncture for arterial blood gas analysis the study

findings reported that knowledge of staff nurses and students regarding how to

perform arterial blood extraction for blood gas analysis is insufficient and need to be
improved among both nurses and nursing students. So these data should be taken in to

consideration when training nurses to perform arterial puncture

***Corbridge.et.al(2008) Germany they conducted the study to assess the

effectiveness of teaching module specific to arterial blood gas interpretation among

the staff nurses of health memorial hospital at germany, they found that stff nurses

knowledge is increased significantly after viewing the teaching module they

concluded that the teaching module is nessay for provind continuing education to

nurses.

*Coggon J.M (2008), Newyork states that Arterial Blood Gas analysis is

valuable diagnostic tool as it enables the objective evaluation of a patient’s

oxygenation, ventilation and acid-base balance. Such information demonstrates how

well a patients respiratory and metabolic system are working. Within the current

health care climate patients being nursed in all clinical areas are becoming sicker, It is

not unusual for a nurse to care for patients who need frequent arterial blood gas tests,

so it has become necessary for nurses to interpret the results of these tests. This will

enable medical staff to be rapidly alerted to any potential problems and care to be

tailored to the exact needs of the patient.

***Dodds (2007) Nursing time stated that assessment for long-term oxygen

therapy are now being undertaken by respiratory nurse specialists. The key skill

required is arterial blood gas sampling, This has traditionally been the role for the

doctor, however by using an education and training package along with a competency

based assessment, nurses can know to perform., this extended role. so sarah dodds and

Graham Williamson describe a competency based education and training programme

for nurses to carry out this procedure.

Graham Williamson describe a competency based education and training programme

for nurses to carry out this procedure.

***Allen K (2005) Nursing Times, stated that arterial blood gas analysis can

be complex. However, in many clinical areas the nurse is one of the first to see the

results. So they need to know whether immediate actions required, this articles stated

that guideline for ABG interpretation is useful to the nurses even when all the

complexities are not fully understood.

Simpson H. (2004) Nursing Times stated that arterial blood gas analysis has

become an essential skill for all healthcare practitioners. It provides important

information with regard to adequacy of ventilation, oxygen delivery to the tissues and

acid-base balance. If the nurse having proper skill regarding arterial blood gas

analysis can able to provide appropriate nursing intervention, and medical

consultation.

Cheng YJ. Kao EL (2003), Nursing times, stated that The study find out that

whether Arterial Blood Gas (ABG) analysis is helpful for deciding on the best

management plan in the study results concluded that ABG data can help the nurse to

make the right decision about treatment.

Coleman NJ (1999), Australia nursing Journal stated that information about

acid base balance is to be useful, we need to know how to interpret arterial blood

gases (ABG) inorder to intervene rapidly when the body is unable to restore a normal

acid-base balance in the face of an overwhelming derangement.

 Russell JM (1991), Australia stated that understanding acid-base disturbances is

essential in the care of the critically ill patient. Through systemic evaluation of patient

symptoms and arterial blood gas value, patient care can be improved. These formulas can

be effective tools for the nurse to use in the care of patients with acid-base imbalances.

1st ***Rabichoud-Ekstrnds (1990) Journal of cardiovascular nursing stated the

acid-base problems can be easily identified by the nurse when a systematic approach is

utilized during arterial blood gases interpretation. Understanding acid-base balance assist

the nurse in choosing the appropriate intervention, since the nurse in is the primary care

giver and is most readily available for the client, early interventions to correct acid-base

problems would expedite the client’s recovery. so the nurse understood the ABG report

and interpretation is very essential skill to provide appropriate intervention.

NEED FOR THE STUDY

Knowledge on ABG analysis is important for nurses in treating critically ill patients

because underlying acid base disturbances are inevitable in these patients. It plays a

significant role in documenting and monitoring respiratory failure and to detect the

presence and severity of Hypoxemia and Hypercapnea.

A study was conducted among student nurses to find the concept of acid base

balance. It presented a step by step approach to Arterial Blood Gas analysis along with the

components of ABG (pH, PaCo2, and HCO3), metabolic and respiratory abnormalities

(Acidosis and Alkalosis) in relation to causes, signs and symptoms, concept and degree of

compensation required, the five steps of ABG analysis and practice problems. The study

concluded that the student nurses can analyse the ABG values confidently in order to make

a wise choice regarding patient care.

 Despite marked efforts, experts suggest that patient safely has not substantially

improved. Efforts to improve safety has been hindered in part by the difficulty in

recognizing and reporting events that routinely occur in complex and the lack of expertise

in critical care and patient safety. Because these failures are more challenging to identify,

they will most certainly require more diverse and innovative reporting method NEED

FOR THE STUDY

Nurses are integral part to health care delivery and it is important that they have a

clear understanding of the nature of the procedures that they would have to perform for the

patients. The under-graduate students are the future nurses, responsible for providing the

nursing service, so it is necessary to have the knowledge of ABG assessment & analysis.

Adequate knowledge on the arterial blood gas (ABG) analysis & it’s interpretation in a

crucial situation is important to handle any critical situation to save the life.

Arterial blood gas (ABG) analysis is an essential part of diagnosing and managing a

patient's oxygenation status and acid-base balance. Disorders of acid-base balance can

create complications in many disease states, and occasionally the abnormality may be so

severe so as to become a life-threatening risk factor.4

More than 5 million patients are admitted annually to ICUs in the United States

with respiratory insufficiency/failure, postoperative management, ischemic heart disorder,

sepsis, and heart failure. Treatment of many serious conditions has become more frequent,

including gastrointestinal hemorrhage, hemodynamic abnormalities, multiple organ system

failure, respiratory insufficiency or failure, sepsis, and shock. Also evident is the dramatic

rise in patients 85 years and older, from 4.1% in 1991 to 6.9% in 2004. Between 2000 and
 2020, the population younger than 65 years is expected to grow by about 10%, while the

number of individuals 65 years and older is projected to rise by approximately 50%.

Frequently, patients in the ICU require ventilatory or cardiovascular support, invasive

monitoring, and intensive observation by nursing and physician staff members. The leading

causes of death in the ICU are multi-organ failure, cardiovascular failure, and sepsis.

Multi-organ failure has a mortality rate of 11% to 18%. Sepsis, the second leading cause of

death in non-coronary ICUs, carries a mortality rate of 25% to 30%.26

In the 55th annual report (2010-2011) of all India Institute of Medical Science
,New Delhi mentioned along with many other investigations arterial blood gas analysis test done
is 36000.Special investigations in ICU monitored 24 hours.27 Acid-base problems can be easily
identified by the nurse when a systematic approach is utilized during arterial blood gas
interpretation. Furthermore, understanding the underlying principles of acid-base balance assists
the nurse in choosing the appropriate intervention. By intervening early, many emergency
situations can be avoided. Since nurse is the primary care giver, and is most readily available for
the clients, early interventions to correct acid-base problems would expedite the client’s
recovery.11
A study on Arterial Blood Gas and pulse oxymetry in initial management of
patients with community acquired pneumonia revealed that in the initial management of
community acquired pneumonia, ABG analysis can be used widely .21
Based upon the above mentioned articles and studies and with the investigator’s
personal experience it is found that knowledge of nurses on Arterial blood gas (ABG) analysis
and its interpretation is not adequate. Arterial blood gas (ABG) analysis is one of the most
common tests ordered, as it provides clinicians with valuable information on a patient's
oxygenation and acid-base balance. Interpreting Arterial blood gas (ABG) analysis results can be
challenging, even for the most experienced nurses, because it requires knowledge of the
physiology and cause-and-effect relationship of the disturbances. Hence, nurses should be
educated regarding correct interpretation of Arterial blood gas (ABG) analysis to figure out the
correct value and have the appropriate intervention accordingly as life saving measures.