Can anyone give me pointers? - page 2
My lab skill is taking an ABG from the Radial artery. I have no problems with the brachial artery, and i have a hard time hitting the radial. I can feel it by palpation, but out of the 2 i have... Read More
Oct 17, '01i am oh so happy i dont have to deal with these sticks
(now watch ill go in to work and find a new procedure memo in my mailbox...lol)
Oct 17, '01In my facility, arterial sticks are strictly the nurses responsibility if there is no arterial line in the patient. As such, arterial sticks are a cause of some stress in our orientees. They require that you are direct and decisive in your technique. I have three ways that I teach people to perform an arterial stick. I will address them shortly, but first some important points.
Always perform an Allen test, (feel for the ulnar artery and then occlude the radial, making sure there is still an ulnar pulse. If not, do not perform the puncture on that arm.) feel all of the available sites. In our unit we stick the radials and the pedals frequently. Never, do we consider a brachial stick. This is because the brachial artery is the only supply of blood to the hand. Occlude or clot it and you are in trouble. It is policy on our unit to only stick a patient there only in times of crisis. We would rather see our nurses attempt a groin stick than a brachial, although, hopefully by this point a physician will be present to do a groin stick.
Get your supplies together. Usually I have a 20g one inch needle and a 10cc syringe, a 2x2, and a pre-torn piece of tape. ( I have found that I have a hard time using smaller and shorter needles. Also, we use the 10cc syringe, because we are generally drawing more than one lab when getting an ABG. YMMV) In setting up for the procedure, I will align the bevel on the needle so it is in line with the numbers on the syringe. This allows me to assess where the bevel is once I have entered the skin. Prep the site with betadine, and allow it to dry, as betadine only kills bacteria on drying. Never go back and wipe the betadine off prior to sticking, as you are reintroducing pathogens into the sterile field. To facilitate the movement of the palpating hand, paint the fingers with betadine.
The three ways I have used to Palpate the pulse are.
One, use your index finger to palpate the pulse, moving it in a side to side manner to feel where the artery is and isn't. I usually start palpating one inch proximal to the radial head. I will then stop palpating and leave my index finger on the point where I felt the best pulse. Most books sat to enter the skin at a 45 degree angle, but I prefer a more acute angle and usually enter at 30 degrees or less, especially on little old ladies. I usually hold the syringe as if I was holding a pencil. Then I will stick the point where I feel the pulse, taking care to remove my finger prior to sticking. This has saved me, many times as most people can handle the digging around that occurs subsequent to the stick, but cannot handle the skin puncture, without flinching. ( This is the technique I use as we have the highest hep C rates in the country, currently out of 10 patients, 3 have hep C.) Now that I have entered the skin, I should see a flash if I indeed stuck at the point of maximal pulsation. I not, I will draw back my needle to a point where my bevel is just under the skin and redirect the needle toward a new area, after reassessing the pulse. At this point, I usually leave my finger on the pulse, as most people won't jerk once you are in the skin. Then it is happy hunting until you find the artery. If you don't find the artery in less than a minute, pull out your needle, as you probably have a clot in it and won't see a flash. Get a new needle, and try again, moving more proximal to the elbow. This is the method I currently use the most, and usually can hit an artery on the first stick, and on the first pass of the needle.
Two, do all the procedural stuff detailed above, but to palpate the pulse, place your index finger distally and your middle finger proximally on the radial artery. Then you draw an imaginary line between your two fingers and stick at some point on that line between your fingers.
Three, do all the procedural stuff detailed above, but to palpate the pulse, place your index and middle finger together and the artery between them. Move your finger side to side until booth fingers feel equal pulsation. Note that sometimes no pulsation will be felt, especially in times of hypovolemia, or shocky states.
On successful penetration of the artery, anchor the syringe hand by pushing down with your wrist on the patient?s hand. Take your free hand and withdraw the plunger to collect the sample on non self-filling syringes. Also on non self-filling syringes, remember to break the seal prior to sticking the patient, this will allow for a better visualization of the flash on successful entry of the artery.
When enough volume has been collected, withdraw the needle, while simultaneously pulling back on the plunger. This will keep the dripping down, from the pressurized syringe. Apply a pressure dressing with your 2x2 and also hold pressure for a sufficient time period to assure blood clotting. This time will vary depending on the coags of the patient, but three to five minutes ought to be sufficient.
The same techniques work very well on pedal arterial sticks. You should be aware that pedal arteries are very shallow generally and not for the squeamish, as you will hit bone a great deal of the time.
Take your time palpating, a preceptor once told me to be one with the artery. There is a great deal of truth in that statement. Arterial sticks, are not a visual skill, hence some peoples difficulty in performing them.
I hope this helped. Thanks go to my wife for posing in the photos. Note her freshly painted nails. Obviously you would use gloves and possibly a mask when performing this procedure. For clarity, they have been omitted in the photos. The area of the artery has been highlighted with marker. Also despite advances in needless systems, you would do better to use a needled syringe, rather than the one pictured.Last edit by nilepoc on Oct 19, '01