Physiological skills

PhysiologicalSkills
KEIHAN Foundation
Clinical SkillsTraining Program
N. Rahim, MD.

Content
 Measuring blood pressure
 Venepuncture procedure
 Periphery intravenous cannulation
 Intra muscular and subcutaneous injection
 Arterial puncture and blood gas analysis

BLOOD PRESSURE LEVELS
BLOOD PRESSURE MEASUREMENT

Step 1 - Choose the right equipment: stethoscope, blood pressure cuff, blood pressure measurement instrument
Step 2 - Prepare the patient
Step 3 - Place the BP cuff on the patient's arm: Palpate/locate the brachial artery and position the BP cuff so
that the ARTERY marker points to the brachial artery.
Step 4 - Position the stethoscope: the antecubical fossa (crease of the arm)
Step 5 - Inflate the BP cuff: 30 to 40 mmHg above the person's normal BP reading.
Step 6 - Slowly Deflate the BP cuff: pressure should fall at 2 - 3 mmHg per second
Step 7 - Listen for the Systolic Reading: the first occurrence of rhythmic sounds
Step 8 - Listen for the Diastolic Reading: continue to listen as the BP cuff pressure drops and the sounds fade.
Step 9 - Double Check for Accuracy: the AHA recommends taking a reading with both arms and averaging the readings.

Venepuncture
procedure
Safety first!
Try to do the venepuncture as save as possible for yourself.
Hepatitis B and C, HIV and other diseases are easily spread
by accidents and have serious consequences for yourself. If
you have a puncture accident, follow your local protocol
from the hospital and go to see a doctor.
 Necessary equipment: medical gloves, antiseptic/iodine/alcohol, 2 gauzes,
syringe 10 mL, needle, tourniquet.

 Explain the procedure to the patient and ask for his/her permission.
 Know/ ask if he/she:
• Has got a preference for right or left arm.Try to choose the non-dominant arm.
• Uses anticoagulants.
 Never take blood near a skin infection.
 Never take blood from the arm without axillary lymph nodes (increased risk in infections and lymph edema)
 Never take blood from a hemodialysis arm.
 Never take blood from the hemiplegic side/paralyzed arm.
 Never take blood from a thrombosis arm.
 Never take blood from the arm where a cannula is inserted. If you have no choice:
• Put the cannula on hold and wait 3 minutes.
• Take the blood.
• Put the cannula on again.
• Write down on the syringe/blood document that it was from a cannula arm.
PROCEDURE – STEP BY STEP

Procedure-
step by step
 Put on your hand gloves, sit in a
comfortable position (If possible)
next to the patient.
 Prepare the needle and the syringe,
directly out of the packaging.
 Apply the tourniquet. Hold one
finger under the tourniquet so that
the skin of the patient will not get
hurt.

Procedure-
step by step
 Palpate the vein you want to use.
Tricks:
 Let the patient make a fist with the
hand, opening and closing several
times.
 Let the arm hang downwards.
 Tap a few times firmly on the
puncture spot.
 Wrap the spot in with warm towels.
 Rinse the area you want to puncture
with antiseptic/iodine/alcohol and a
gauze

Procedure-
step by step
 Take the needle in your dominant
hand.
 Hold the needle with the opening
upward.
 Retract the masher in forehand 1-2
mL back, so you have a space filled
with air.

Procedure-
step by step
 Position the vein
 Insert the needle with your dominant
hand, with an angle of 15-30 degrees

Procedure-
step by step
 Release the tourniquet during withdrawing blood, so there will not be any
stasis of the blood.
 Make sure you have a vein and not an artery!
 Veins: dark, red, continuous blood.
 Arteries: red, pulsating blood.
 Withdraw the needle and cover it / dispose it.
 Never touch the needle with your own hands!
 Never put the needle back in the package with your own hands!
 Put a cap on the syringe.
 Press a clean new gauze on the puncture site press this for a while.
 Complications are: pain, hematoma under the skin, bleeding.

Periphery
intravenous
cannulation
Safety first!
 Necessary equipment: Medical gloves, antiseptic/iodine/alcohol, 3 gauzes,
IV, syringe 10 mL, tourniquet, towel, fixation tape, 3-way crane, IV line.

Procedure-
step by step
 Choose the size of the IV cannula:

Procedure-
step by step
 There are several places you can place an IV cannula in the veins of the
patient, depending on the situation.Try to stay as far away from the joints
as possible due to their movements.
 Emergency: in the elbow, but only for short periods. Bending the elbow will
stop the IV line from flowing.
 Long duration: underarm because of the stable placement.This is also the
least painful place to place an IV cannula. Radial side of the wrist is also
possible (but this is an unstable place).
 Operation: on the hand.
 If none of the above works, try on the foot.

Procedure-
step by step
 Prepare the cannula and the IV line. Keep the
end of the IV line sterile.
 Check if there are any air bubbles left in the
line.
 Put on your hand gloves, sit in a comfortable
position (If possible) next to the patient.
 Prepare the needle and the syringe, directly
out of the packaging.
 Apply the tourniquet. Hold one finger under
the tourniquet so that the skin of the patient
will not get hurt.

Procedure-
step by step
 Stretch the vein with the thumb of your non-dominant hand, to prevent
the vein to roll away (happens mostly in elderly patients).
 Hold the needle with the opening upward.
 Take the IV cannula between the index finger and the thumb of your
dominant hand.
 Insert the needle with your dominant hand, with an angle of 15-30
degrees, with the needle puncturing over your left thumb.
 Let the patient stretch the puncture spot completely.
 In the control room of the IV, blood will appear, if the needle is in the vein.
 Pull the needle back into the IV catheter some millimetres so that the
needle is not puncturing and scratching the vein.

Procedure-
step by step
 Release the tourniquet during withdrawing blood,
so there will not be any stasis of the blood.
 Press the IV carefully further into the vein, while
holding the needle still with the other hand.
 Put a little gauze under the needle/IV opening.
 With your non-dominant hand, close the vein by
pressing it when pulling back the needle out of the
IV.

Procedure-
step by step
 Withdraw the needle and cover it / dispose it.
 Never put the needle back in the package with your own
hands!
 Open the IV-line a little bit so there will be no air bubbles when
connecting.
 Connect the IV cannula to the 3-way tap and the IV-line. Make sure
you let some blood going out the IV cannula as well, so no air
bubbles will be caught.

Procedure-
step by step
 Apply the butterfly fixation with the fixation
tape.
 Also fixate the IV-line to the skin of the patient
with 2 pieces of fixation tape.
 Before you add any medicine/fluids trough the IV
cannula, always withdraw a little bit blood, and
flush it with normal saline.

Procedure-
step by step
 Complications:
 IV cannula insertion into the artery:
 Feeling pain, when the fluid flows into the artery.
 Paleness of the limb, distal from the IV-catheter.
 Necrosis.
Remove the cannula directly and press the puncture site for 10 minutes firmly and
get a doctor as fast as possible.
 Catheter movements: a subcutaneous swelling will appear. Place a new IV
cannula on a different spot. Depending on the fluid in the IV-line, this can
even cause necrosis of the skin (hypotonic and alkalic fluids)
 Hematoma: by perforating the vein. Press the puncture spot for 3 minutes or
longer if the patient uses anticoagulants.
 (Thrombo)phlebitis: late complication. Mostly a-septic. Signs: dolor, rubor,
calor, hardening of the vein.When pus appears, it is a bacterial phlebitis with
a big risk of sepsis. Remove the IV cannula in case of these symptoms.

Subcutaneous
and
intramuscular
injection
Safety first!
 Necessary equipment: antiseptic/iodine/alcohol, 2 gauzes, needle,
vaccination fluid, tape. Medical gloves are only necessary when there is
contact to body fluids or if the injector has got open wounds on his/her
hands.

 Try to make the room as quiet and organized as possible. Sit or stand in
a comfortable position next to the patient.
 Let the patient sit on a chair.
 Let children sit on the lap of their parents.
 Instruct the parents to immobilize the arms of their children firmly by
embracing them.
 Make sure there is room for patients in case of collapse of anaphylactic
reaction.
 Make sure a phone is close by.

Procedure-
step by step
 Prepare the vaccinations.Always check the expiration day and the colour
of the vaccine. Make sure to read the reader of the vaccination.Check in
the reader if vaccines can be mixed together. Otherwise, vaccinate in two
different arms/sites.
 Attach the needle to the vaccine but leave it sterile in the package.
 Before you give the injection, you will have to:
 Make sure that you have the correct vaccine.
 Explain the procedure to the patient.
 Ask the patient/the parent for his/her permission for the vaccination
 Know/ ask if he/she:
 Has got a preference for right or left arm.Try to choose the non-dominant arm.
 Has ever had an allergic reaction to vaccines and/or medications before. If so,
reconsider the vaccination.

Procedure-
step by step
 Never place the injection near a skin infection.
 Do not vaccinate in a hemiplegic side/paralyzed arm.
 Placement of intramuscular injection:
 0-1 years old: halfway in the vastus lateralis
 > 1 years old: in the m. deltoideus, m. gluteus maximus

Procedure-
step by step
 Clean the skin with an antiseptic/iodine/alcohol and a gauze.
 Instruct the patient to let the arm hang loose and relaxed.
 Take the skin and the muscle between the index finger and thumb
of your non-dominant hand and pull this out a little bit.
 Take the needle in your dominant hand with a 90 degrees angle
and insert this firmly into the skin.
 Push the needle 2-3 cm into the muscle (in order to cross the
subcutaneous layer).

Procedure-
step by step
 Before you insert the vaccine, check if you haven’t punctured a
vein/artery by pulling back a bit air with the needle. If no blood is
filling the syringe, you can continue. Otherwise, repeat the
procedure on a different site.
 Insert the vaccine fluid into the muscle.
 After you completed the injection, withdraw the needle.
 Press a clean gauze on the injection site, rub the site for better
distribution of vaccine.
 Register the vaccines that you’ve injected.

Procedure-
step by step
 Placement of subcutaneous injection:
 Outer arms
 Abdomen
 Hips
 Outer thighs

Procedure-
step by step
 Clean the skin with an antiseptic/iodine/alcohol and a gauze.
 Instruct the patient to relax.
 Take the skin and the muscle between the index finger and thumb of your
non-dominant hand and pull this out a little bit.
 Take the needle in your dominant hand with a 45 degrees angle and insert
this firmly into the skin.
 Push the needle around 0.5 cm into the skin, in order to reach the
subcutaneous layer.

Procedure-
step by step
 Insert the vaccine fluid into the subcutaneous layer.
 After you completed the injection, withdraw the needle.
 Press a clean gauze on the injection site, do not rub the site due to
causing more pain!
 Register the vaccines that you’ve injected.

 Complications:
 Serious complication  anaphylactic shock! In this case, call
assistance immediately and start treatment.
 Irritation/ inflammation of the skin on injection site.
 Granuloma
 Necrosis

Arterial Blood
GasAnalysis
Purposes
 To assess gas exchange and acid base status
 To provide immediate information about electrolytes
 It is also useful to have access to any previous gasses.This is particularly
important if your patient is known to have chronic respiratory disease
with existing chronic ABG changes.

pH 7.35 – 7.45
pO2 10 – 14 kPa 80 – 100 mmHg
pCO2 4.5 – 6 kPa 35 – 45 mmHg
HCO3
- 22 – 26 mmol/l
Base excess (BE) -2 – 2 mmol/l
O2 saturation 95 – 100 %
Normal values for arterial blood gas (ABG)
*1kPa = 7.5mmHg. p stands for the ‘partial pressure of…’

Components
Partial pressure (PP)
 Partial pressure is a way of assessing the number of molecules of a
particular gas in a mixture of gasses. It is the amount of pressure a
particular gas contributes to the total pressure.
For example, we normally breathe air, which at sea level has a pressure of 100kPa,
oxygen contributes 21% of 100kPa, which corresponds to a partial pressure of 21
kPa.
 When used in blood gasses, Henry’s law is used to ascertain the partial
pressure of gasses in the blood. This law states that when a gas is
dissolved in a liquid, the partial pressure (i.e. concentration of gas) within the
liquid is the same as in the gas in contact with the liquid.Therefore, you
can measure the partial pressure of gasses in the blood:
 PaO2 is the partial pressure of oxygen in arterial blood
 PaCO2 is the partial pressure of carbon dioxide in arterial blood

Components
pH and CO2
 pH is a logarithmic scale of the concentration of hydrogen ions (H+) in a
solution. It is inversely proportional to the concentration of H+.
 Normally the body’s pH is closely controlled at between 7.35 – 7.45.This is
achieved through buffering and excretion of acids.
 Buffers include plasma proteins and bicarbonate (extracellular) and proteins,
phosphate and haemoglobin (intracellularly).
 Bicarbonate buffer system:
CO2 + H2O H2CO2 H+ + HCO3
-
 H+ is excreted via the kidney, CO2 is excreted via the lungs.

Components
 Ventilation is controlled by the concentration of CO2 in the blood.
 Changes in ventilation are the primary way in which the
concentration of H+ is regulated.
 If the buffers and excretion mechanisms are overwhelmed and
acid is continually produced, the pH falls.This creates a metabolic
acidosis.
 If the ability to excrete CO2 is compromised this creates a
respiratory acidosis.
 Note that a normal pH doesn’t rule out respiratory or metabolic
pathology.This is why you must always look at all the values other
than pH, as there may be a compensated or mixed disorder.

Components
Bicarbonate (HCO3
-)
 HCO3
- is produced by the kidneys and acts as a buffer to maintain a normal
pH.The normal range for HCO3
- is 22 – 26 mmol/l.
 If there are additional acids in the blood, the level of HCO3
- will fall as ions
are used to buffer these acids.
 If there is a chronic acidosis, additional HCO3
- is produced by the kidneys to
keep the pH in range.
 It is for this reason that a raised HCO3
- may be seen in chronic type 2
respiratory failure where the pH remains normal despite a raised CO2.

Components
Base excess (BE)
 This is the amount of strong base which would need to be added or
subtracted from a substance in order to return the pH to normal (7.40).
 A value outside of the normal range (-2 to +2 mmol/l) suggests a metabolic
cause for the acidosis or alkalosis. In terms of basic interpretation:
 A base excess more than +2 mmol/l indicates a metabolic alkalosis
 A base excess less than -2 mmol/l indicates a metabolic acidosis

Components
Electrolytes
 Quick way to check potassium and sodium values.This is particularly
important in the immediate management of cardiac arrhythmias as it
gives an immediate result.
Lactate
 Lactate is produced as a by-product of anaerobic respiration.A raised
lactate can be caused by any process which causes tissue to use anaerobic
respiration. It is a good indicator of poor tissue perfusion.
Haemoglobin (Hb)
 Haemoglobin acts as a guide, but is notoriously inaccurate in an ABG.
Glucose
 In the management of the patient who has decreased consciousness or
seizures, patients with known or suspected diabetes, patients with severe
sepsis or other metabolic stress.

Other
Components
Carbon monoxide (CO)
 NormallyCO is <10%. In people who live in the city and/or smoke, levels
can rise up to 10%.
 Level >10% indicates poisoning, commonly from poorly ventilated boilers
or old heating systems.
 At levels of 10 -20%, symptoms such as nausea, headache, vomiting, and
dizziness will be predominant.
 At higher levels patients may experience arrhythmias, cardiac ischemia,
respiratory failure and seizures.
Methaemoglobin (metHb)
 MetHb is an oxidized form of haemoglobin.
 Levels of >2% are abnormal.
 Methaemoglobinaemia is a rare condition but again it is important not to
miss. It may be caused by errors of metabolism or by exposure to toxins
such as nitrates.

Compensation
Respiratory Compensation
 If a metabolic acidosis develops, the change is sensed by chemoreceptors
centrally in the medulla oblongata and peripherally in the carotid bodies.
 The body responds by increasing depth and rate of respiration, therefore
increasing the excretion of CO2 to try to keep the pH constant.
 The classic example of this is ‘Kussmaul breathing’ the deep sighing
pattern of respiration seen in severe acidosis including diabetic
ketoacidosis.
 Here you will see a low pH and a low pCO2 which would be described as a
metabolic acidosis with partial respiratory compensation (partial as a
normal pH has not been reached).

Compensation
Metabolic Compensation
 In response to a respiratory acidosis, for example in CO2 retention
secondary to COPD, the kidneys will start to retain more HCO3
- in
order to correct the pH.
 Here you would see a low normal pH with a high CO2 and high
HCO3
-.This process takes place over days.
 The kidneys also help control pH by eliminating H+.The way the
two systems interact is through the formation of carbonic acid
(H2CO3)
 Movement through the H2CO3 system is fluid and constant.What
this means is that H2O can combine with CO2 and form H2CO3. If
necessary, H2CO3 can then break up to form H+ and HCO3
-.

Respiratory
failure
Respiratory failure can be split intoType one orType 2.These are
differentiated by the pCO2:
 Type 1 Respiratory failure (T1RF):
 Defined as a pO2 less than 8 kPa and a pCO2 which is low or normal.
 T1RF is caused by pathological processes which reduce the ability of the lungs
to exchange O2, without changing the ability to excrete CO2.
 Examples ofT1RF are pulmonary embolus, pneumonia, asthma and
pulmonary oedema.
 Type 2 respiratory failure (T2RF)
 Defined as a pO2 of less than 8 kPa and a raised pCO2.
 T2RF is caused by a problem with the lungs or by a problem with the
mechanics or control of respiration:
Pulmonary problems Mechanical problems Central problems
COPD Chest wall trauma Opiate overdose
Pulmonary oedema Muscular dystrophies Acute CNS disease
Pneumonia Motor neuron disease
Myasthenia Gravis

Procedure –
step by step
 Make sure the patient is seated comfortably. He should rest his arm on a
pillow/towel in front of him, palm facing up.This position is necessary to
perform the procedure and is the most comfortable for the patient.
 Assess the patency of ulnar artery and adequacy of distal arteries to wrist
by Allen test:
 Instruct the patient to clench his or her fist; if the patient is unable to do this,
close the person's hand tightly.
 Using your fingers, apply occlusive pressure to both the ulnar and radial
arteries, to obstruct blood flow to the hand.
 While applying occlusive pressure to both arteries, have the patient relax his
or her hand, and check whether the palm and fingers have blanched. If this is
not the case, you have not completely occluded the arteries with your
fingers.
 Release the occlusive pressure on the ulnar artery only to determine whether
the modified Allen test is positive or negative.
 Positive modified Allen test –> If the hand flushes within 5-15 seconds it
indicates that the ulnar artery has good blood flow; this normal flushing of
the hand is a positive test.
 Negative modified Allen test –> If the hand does not flush within 5-15 seconds,
it indicates that ulnar circulation is inadequate or non-existent; in this
situation, the radial artery supplying arterial blood to that hand should not be
punctured.

Procedure –
step by step
 Wear gloves.
 Clean the area over the radial artery with alcohol wipes.
 Hyper extend the patient's hand to stretch the radial artery.
 Line up the artery with two fingers with the bevelled edge facing upper
portion of the vessel.
 Enter the artery with a 45 degrees angle and slowly withdraw the syringe,
stopping as soon as it begins to fill spontaneously.
 Withdraw the needle while applying pressure to the vessel with gauze.
 Expel any air from the syringe and then cap the needle. Caution!
 Send the specimen immediately to the lab for analysis.
 Either you or the patient should keep applying pressure to the vessel for a
few minutes.Then apply a band-aid and the procedure is complete.

Analysis – step
by step
Analyse the pH
 Normal blood pH is from 7.35 to 7.45.
 pH < 7.35  acidosis
 pH > 7.45  alkalosis
 If it falls into the normal range, look at what side of 7.4 it falls on.
< 7.4 is normal/acidic
> 7.4 is normal/alkalotic

Analysis – step
by step
Analyse the CO2
 Normal pCO2 levels are 35-45 mmHg or 4.5 – 6 kPa.
 < 35 mmHg or 4.5 kPa  alkalosis
 > 45 mmHg or 6 kPa is acidosis

Analysis – step
by step
Analyse the HCO3
-
 Normal HCO3
- level is 22-26 mmol/L.
 < 22 mmol/L  acidosis
 > 26 mmol/L  alkalosis

Analysis – step
by step
Match the CO2 or the HCO3
- with the pH
TEST NORMALVALUE ↓VALUE ↑VALUE
PH 7 .35-7 .45 Acidosis Alkalosis
PCO2 35-45 mmHg / 4.5 – 6 kPa Alkalosis Acidosis
HCO3
- 22-26 mmol/l Acidosis Alkalosis
ABG PH PCO2 HCO3
-
METABOLIC ACIDOSIS normal
RESPIRATORY ACIDOSIS normal
METABOLIC ALKALOSIS normal
RESPIRATORY ALKALOSIS normal
Is there any compensation?
Does either the pCO2 or HCO3
- go in the opposite direction of the pH?
If so, there is compensation by that system.

Analysis – step
by step
Analyse the pO2 and the O2 saturation
 If they are below normal there is evidence of hypoxemia.
TEST NORMALVALUE ↓VALUE ↑VALUE
PO2 80-100 mmHg / 10 – 14 kPa Hypoxemia O2 therapy
SAO2 95 -100 % Hypoxemia --

How to present an ABG
 State that this is an arterial blood gas sample (rather than venous).
 State the patients name and outline history/pertinent examination findings.
 State the time the sample was taken and how much oxygen the patient was on, at the time.
 Present your findings: e.g. this showed type one respiratory failure with a pO2 of 7 kPa
 Present any abnormal findings or important negatives from the rest of the values.
 A one-line summary of your findings.

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