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Wednesday, July 24, 2013

Tips for drawing ABGs

I like the way he is facing the patient, although I can find many things
I would do different.  For instance, I would use the left middle finger to
hold the skin taut (the two finger technique).  It holds the artery stable
and almost guarantees you'll hit it.  I would also prop the wrist
up by using a towel.  However, do whatever works for  you.  The
student (or teacher) in the lab coat looks bored here. 
Your question: I'm a first  year student and I'm 0 for 3 during clinicals drawing ABGS so far.  Can you give some tips to help.  Putting the patients in pain with no results is pretty discouraging for me. Maybe you can teach me a few tips you've heard of (or use) if you can. 

My answerThere are a couple things you can try.  I could probably show you faster than I can tell you.  Yet the following advice was given to me when I was a student in your same situation, having missed my first several ABGs.  I give this same advice to all students I have to supervise doing ABGs, and it seems to work well for them too.  
  1. Have all your stuff ready before you enter the room.  Make sure the cap easily comes off the syringe, label the syringe, have the bandage ready, etc.  Also have a towel that you can ball up under the wrist if needed.  Wear gloves too, but make sure the the rubber is taught over your left pointer finger (right if you're right handed). Also pull the syringe back to 1cc (most syringes are self filling).  Do this prior to entering the room so you're not fumbling in front of the patient.
  2. Here is a good picture of the two finger technique I love.  I would poke right
    under the tip of that finger, over where I feel the pulse, as opposed to above
     the finger.  The angle of the syringe here is perfect.  Likewise, he (or she)has
     the wrist properly propped up using a towel. Of course this is my personal
    preference, you may have (or develop) your own preferences.  
  3. Identify pt.  Introduce yourself and say you're going to draw some blood.  Do not give out any further information unless the patient asks.  Do not say, "I'm a student," or "I have never poked a patient before," or "it's going to be a big poke," or "It's going to hurt more than a normal blood draw."  Be honest if asked a question, though.  I know this goes against contrary wisdom, but it works.  The less you say the less scared the patient will be.  Trust me.  It also makes you look more confident than you actually are.  Oh, and don't say "I'm nervous."  Chances are, no one will know you are nervous unless you say so.
  4. Feel both radial arteries to decide which one has a better pulse, or which one is easier to access.  Always take time to do this, because many times one artery is easier to feel than the other.
  5. Cock the patient's wrist up on either a pillow or on a rolled up towel.  The radial artery should be easy to access then.  You can either do this on the side of the bed if the patient is lying down, or on a table if the patient's sitting up (a table is preferable)
  6. Position yourself facing the patient.  You can sit in a chair, alongside the bed, or even stand.  Just get comfortable.  If you're comfortable with it, you can even spark a conversation at this point to help the patient relax.  Ask the patient a question or something like that.  Or not. 
  7. Uncap the syringe and hold it like a pencil 
  8. I'm right handed, so I palpate the pulse with my left pointer finger.  I use the my left middle finger to draw back any loose skin so the skin around the artery is taught.  Sometimes I use whatever fingers aren't holding the syringe to draw back skin on that side too, if the skin is really wrinkly.  This secures the artery so it will not move when you're poking.  This is important.  This is called the 2-finger technique.  
  9. Your left middle finger should stay put (the one holding the skin taut), but you can move your left pointer finger to find the artery using the tip of the finger.  Try to find a spot as close to the hand as possible because the artery is more stable here (although some say they like to go higher). 
  10. Poke at a 30-60 degree angle toward the patient. Make sure you poke right under your pointer finger where you feel the pulse. You'll want to poke as close to your finger as you can.  (some people teach to poke to the left or right of their pointer finger, but I find this to be less effective for me.  It's better to poke right in front of your pointer finger, which should be right over the artery if you're feeling a pulse)  This is a key tip here, and greatly improved my success rate, thus improving my confidence. 
  11. Insert the syringe slowly (very slowly). Stop as soon as you get blood flow. If you don't get blood and can still feel a pulse, (make sure you went deep enough first, especially if the patient has thick wrists) pull the syringe out slightly (and very slowly in case you went through it to begin with) and re-insert toward the direction the pulse feels strongest. 
  12. Once you have blood flow do not move anything.  Allow the syringe to fill completely before moving any fingers or the syringe.  
  13. Cap the syringe immediately, and do whatever else you've been trained to do to prepare the sample.
  14. Make sure you check what oxygen the patient is on, as you'll need to report it.  
If you do steps 7-11 correctly you will succeed at 90% of your ABG draws.  Note, however, that you must always listen to your preceptor, and do as he says (even if he disagrees with me).   

I checked out the videos on youtube and none are as good as the way I teach it. Actually, they all make it look harder than it really is (IMO of course).  They all skipped my step #1 too and fumbled with the kit in the patient's room.  Oh, and make sure you wear goggles like the lady in this video (just kidding).  



Loretta said...

I had 3 different people (1 RT and 2 ICU Docs) try to draw my ABG... and they all failed a total of 5 times! on both wrist! They even used an ultrasound machine which I never seen used before.

I guess my ABG been poked too many times and are too difficult to get now!

Rick Frea said...

It was probably a dopler, which is used to find pulses. I have used one occasionally.

Anonymous said...

Vascular Ultrasound (Sonosite, Site-rite, etc) is commonly used for inserting central lines, arterial lines, etc. Occasionally, if the ABG is difficult to draw and the clinician has been trained to insert lines, they will use ultrasound to guide the ABG needle.