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A STUDY TO ASSESS THE EFFECTIVENESS OF SELF-INSTRUCTIONAL
MODULE REGARDING ARTERIAL BLOOD GAS (ABG) TECHNIQUE
AMONG STAFF NURSES IN SELECTED HOSPITALS AT BANGALORE
M.Sc. Nursing Dissertation Protocol submitted to
Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore.
BY
MS. ASWATHY VARGHESE
MSc NURSING 1ST YEAR 2013 TO 2015
Under the Gudiance of
MRS.RAJESWARI
HOD, DEPARTMENT OF MEDICAL SURGICAL NURSING
Nightingale College of Nursing
Guruvana Devara Mutt,
Near Binniston Garden
Bangalore -23
RAJIV GANDHI UNIVERSITY OF HEALTHSCIENCE
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1
NAME OF THE
CANDIDATE AND
ADDRESS
MS. ASWATHY VARGHESE
1ST YEAR M.SC NURSING
NIGHTINGALE COLLEGE OF NURSING
BANGALORE-23
2
NAME OF THE
INSTITUTION
NIGHTINGALE COLLEGE OF NURING
GURUVANNA DEVARA MUTT,NEAR
BINNISTON GARDEN, MAGADI ROAD
BANGALORE-23
3
COURSE OF STUDY
AND SUBJECT
MASTER IN SCIENCE IN NURSING, MEDICAL
SURGICAL NURSING.
4
DATE OF ADMISSION
TO COURSE
01/07/2013
5
TITLE OF THE TOPIC
A STUDY TO ASSESS THE EFFECTIVENESS
OF
SELF-INSTRUCTIONAL
MODULE
REGARDING ARTERIAL BLOOD GAS (ABG)
TECHNIQUE AMONG STAFF NURSES IN
SELECTED HOSPITALS AT BANGALORE
6. BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
Arterial blood is presented to all organs for their metabolic
needs; its composition is uniform throughout the body. The composition of venous blood
is conditioned by the metabolic activity of the tissue which it drains and therefore varies
among different parts of the body. The largest difference between arterial and venous
blood is its oxygen content, but pH and carbon dioxide content also vary. All differences
between arterial and venous blood are magnified when the general or local circulation is
impaired. Arterial blood is obtained via arterial line sample or by puncture of the radial or
brachial artery in order to measure arterial blood gases and acid-base status of the patient.
Only those individuals who have been certified in arterial blood gas collection may
obtain arterial samples1.
Many life-saving diagnostic tests which are performed in clinical set up to
identify disease and are very essential tools in screening any deviations from normal
functions of the body. The methods used will of course vary from assessment of radial
pulse, blood pressure, and pulse oxymeter to the increasingly complex invasive
hemodynamic monitoring such as interpretation of ABG sample with super specialization
health care management in care of the patient. Though there are various diagnostic
procedures, ABG analysis can be thought of as a window through which ventilation,
respiration, metabolism and acid-base balance can be examined.
Arterial blood gas (ABG) analysis is an essential part of diagnosing and managing
a patient’s oxygenation status and acid–base balance. The usefulness of this diagnostic
tool is dependent on being able to correctly interpret the results. 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. A thorough
understanding of acid–base balance is mandatory for any physician, and intensivist, and
the anesthesiologist is no exception2.
ABG sampling provides valuable information on the acid-base balance at a specific
point in the course of a patient's illness. It is the only reliable determination of ventilation
success as evidenced by CO2 content. It constitutes a more precise measure of successful
gas exchange and oxygenation. ABG sampling is the only way of accurately determining
the alveolar-arterial oxygen gradient. Because the results of ABG sampling only reflect
the physiologic state of the patient at the time of the sampling, it is important that they be
carefully correlated with the evolving clinical scenario and with any changes in the
patient’s treatment3.
NEED FOR STUDY
An arterial blood gas (ABG) is a blood test that is performed using
blood from an artery. It involves puncturing an artery with a thin needle and syringe and
drawing a small volume of blood. The most common puncture site is the radial artery at
the wrist,[1] but sometimes the femoral artery in the groin or other sites are used. The
blood can also be drawn from an arterial catheter. Pulse oximetry plus transcutaneous
carbon dioxide measurement is an alternative method of obtaining similar information as
well. An ABG is a test that measures the arterial oxygen tension (PaO2), carbon dioxide
tension (PaCO2), and acidity (pH). In addition, arterial oxyhemoglobin saturation (SaO2)
can be determined. Such information is vital when caring for patients with critical illness
or respiratory disease. As a result, the ABG is one of the most common tests performed
on patients in intensive care units (ICUs).
The test is used to determine the pH of the blood, the partial pressure of carbon dioxide
and oxygen, and the bicarbonate level. Many blood gas analyzers will also report
concentrations
of
lactate,
hemoglobin,
several
electrolytes,
oxyhemoglobin,
carboxyhemoglobin and methemoglobin. ABG testing is mainly used in pulmonology
and critical care medicine to determine gas exchange which reflects gas exchange across
the alveolar-capillary membrane. ABG testing also has a variety of applications in other
areas of medicine. Combinations of disorders can be complex and difficult to interpret, so
calculators, nomograms, and rules of thumb are commonly used4.
Blood gas studies are concerned with repatriation of the exchange gases between
the lungs and blood and between blood and tissues. The term blood gas strictly refers to
the measurement of the tension or partial pressure of oxygen, CO2 and the estimation of
H+ ion concentration or PH is an integral part of blood gas measurement. Arterial bloodgas (ABG) analysis is one of the most basic tests of pulmonary function, performed
routinely in hospital inpatient floors and in intensive care units, pulmonary clinics,
emergency departments, surgical suites, and pulmonary function laboratories throughout
the world3. The measurement of arterial blood gases (ABG) has assumed an increasingly
important role in the process of clinical evaluation, and has been widely used during the
past three decades5.
ABG measurements have been increasingly used in different medical conditions
both in pulmonary and non-pulmonary disease conditions for accurate diagnosis14.
Alteration in oxygen, carbon dioxide, pH, and HCO3- level leads to conditions like
respiratory or metabolic acidosis or alkalosis. These conditions if not early diagnosed and
treated may lead to several complications and may unable to restore normal health.
Clients who manifest with hyper-metabolic states such as fever, sepsis, burns, client
receiving total parenteral nutrition or enteral tube feedings high in carbohydrate,
mechanically ventilated clients, clients with insulin- dependent diabetes mellitus, clients
with vomiting, diarrhea or enteric drainage are subjected for ABG analysis 6.
Nurses play an important role in early detection of high risk clients with acid base
imbalance in critical care units. The nurses collaborate in the administration drug therapy,
oxygen therapy and mechanical ventilation when indicated. In extreme circumstances in
which therapeutic compensation is required, the nurse should be knowledgeable about
potential risk of this therapy (drug, oxygen therapy) and able to carefully monitor
administration rates and therapeutic responses7.
Nursing as a profession is now responsible to account for its competence and
performance. This has seen the birth of the language of outcome. Outcome is mechanism
to evaluate quality, improve effectiveness and link practices to professional
accountability. ABG analysis requires skillful observations and careful analysis by
competent nurses, which can prevent fatal complication in ill patients. The nurse plays an
important role in monitoring the patient’s progresses. A nurse has to be competent and
skillful in handling situations that will result in effecting the ABG analysis of the patients.
A nurse has to make a decision which is beneficial to the client life. By carefully
analyzing the nurse is able to recognize early causes and manage problems before they
arise. When ABG analyses have been done properly, the patient experience more rapid
positive outcomes8.
6.2
REVIEW OF RELATED LITERATURE
Review of literature is a key step in the research process. The typical purpose
of analyzing a review of existing literature is to generate questions and to identify what is
known and what is unknown about the topic. The major goals of review of literature are
to develop a strong knowledge base to carry out research and non-research scholarly
activity.
Review of literature for the study has been organized under following headings.
6.2.1
Review related to the general information about ABG technique
6.2.2
Review related to the nurses knowledge about ABG technique
6.2.3
Review related to the effectiveness of self-instructional module
6.2.1 Review related to the general information about ABG analysis.
A study on the evaluation of an on-demand-bedside-blood-gas monitor on
pulmonary artery blood gas determinations on critically ill patients often having
cardiopulmonary disturbance and who required rapid and frequent assessment for optimal
care, cardiac output determinations and arterial blood gas analysis has been done. The
study suggested that the blood gas monitoring provided rapid and accurate determinations
of arterial blood gases allowing optimal therapeutic interventions in critically ill patients9.
A study about decision support alerts for clinical laboratory and blood gas data
stated that half of all critical alerts were detected caused by altered blood gas values from
amongst approximately 115,000 laboratory data10.
A study to observe utilization of ABG measurements portrayed that during the
study period of two weeks, 98 ABG sample were requested from adult patients (acute
care general wards). The researcher summarized that ABG measurements from acute care
wards in a tertiary-care teaching hospital were found to be used more frequently11.
Arterial blood gas (ABG) analysis is useful in evaluation of the clinical condition
of critically ill patients; however, arterial puncture or insertion of an arterial catheter may
cause many complications. This study evaluated whether pH, partial pressure of carbon
dioxide (PCO2) and bicarbonate (HCO3-) values of venous blood gas (VBG) could
accurately predict their ABG analogs for patients with acute respiratory failure treated by
mechanical ventilation in an intensive care unit (ICU). Forty six patients who were
admitted to the ICU due to acute respiratory failure and treated by mechanical ventilation
were included in this study. Blood for VBG analysis was sampled from the cubital or
dorsal palmar veins, while ABG was sampled simultaneously from the radial or brachial
arteries via an arterial catheter at the other upper extremity. Validation of the regression
equations and mean percentage-difference equations revealed only a small (clinically
insignificant) variation between the actual and predicted ABG values.12
6.2.2 Review related to the nurses knowledge about ABG technique
A study to examine attitudes and beliefs among nurses and third-year undergraduate
nursing students in hospital training regarding the use of local anesthesia when
performing arterial puncture and to assess their knowledge of the technique with a
questionnaire declared that local anesthesia was used routinely by 7 nurses (5%), of
whom 3 (27%) belonged to the respiratory medicine department; local anesthesia was not
used by any of the nursing students. The main reasons given by nurses for not using local
anesthesia were lack of knowledge (54%), need to perform 2 punctures when anesthesia
is used (11%), belief that the same amount of pain is caused with anesthesia (8%), and
success on the first attempt at arterial puncture (7%). The main reason given by student
nurses for not using local anesthesia was also lack of knowledge (53%), followed by the
fact that it was not used by the nurses (24%). Most of those surveyed (63%) indicated a
desire to receive anesthesia should they undergo arterial puncture. Local anesthesia is
used very little in arterial puncture. Knowledge about how to perform arterial blood
extraction for blood gas analysis is insufficient and needs to be improved among both
nurses and nursing students13.
Arterial blood gases sampling is one of the most common laboratory tests in
intensive care units and might be corrupted by pre-analytical factors that influence the
validity of results. Arterial blood gases are valuable only if obtained properly and
measured carefully. Corrupted factors in arterial blood gas sampling change significantly
the results and adversely affect patient-care decisions when the magnitude of the error is
clinically important .Therefore the nurses’ role is very important to control these factors.
A descriptive exploratory study to assess the different pre- analytical factors affecting
ABGs results’ validity among critically ill patients at Cairo University Hospitals showed
that all the studied subjects (100%) demonstrated unsatisfactory knowledge and practical
level in relation to ABG sampling and controlling the different factors that might affect
ABG results’ validity. Moreover, There were no significant statistical difference between
knowledge scores
regarding educational level (F=2.73; P=0.07), working area
(F=1.07;P=0.34), and gender (F=1.096;P=0.29) among the studied subjects. Results of
the current study indicated a real gap between nurses' knowledge and practices as
compared to the evidence based guidelines of American Association for Respiratory Care
in management of ABG sampling. The current study recommends an enrichment of
critical care nurses’ knowledge and practices related to this essential procedure in
addition to consideration of the different corrupting factors by hospital authorities to keep
with the related evidence based guide lines that will be great benefits for patient, hospital,
and all health professionals14.
A study on arterial blood gas (ABG) technique for health care professionals and
stated that arterial blood gas analysis is a critical skill required by the nurses in order to
provide safe and competent patient care. Nursing interventions focus on maintaining
patient alveolar exchange of CO2 or O2 by analyzing arterial blood gas concentration. The
results indicated that the teaching programme promoted better understanding by the
health care professionals about ABG analysis and aided in the application of knowledge
in the clinical setting15.
6.2.3 Review related to the effectiveness of self-instructional module
A study about effectiveness of a need based teaching protocol on nurse’s
responsibility in ABG analysis for the nursing personnel working in the critical care units
revealed that the teaching programme was effective and increasing the knowledge on
ABG analysis as the computed “t” test was significant at 0.05 level. The nursing personal
were motivated to learn and continuing nursing education is the key to up to date the
knowledge of the nursing personal which will help to provide comprehensive nursing
care16.
A research on demonstrating the effectiveness of an online, computer-based
learning module for arterial blood gas analysis envisaged that staff nurses' knowledge
increased significantly after viewing the computer-based learning module (t = 6.3; P <
.001). This improvement was irrespective of experience or department. Computer-based,
online learning has emerged as a means of providing continuing education to nurses.
Such a teaching strategy helps to overcome barriers pertinent to traditional classroom
settings17.
A study on comparison the effect of two clinical teaching models on performance
of nursing students in intensive care unit for assessment of nursing students’ clinical
performance in selected procedures (suctioning the airway, inserting naso-gastric tube,
rapid neurological examination, and taking arterial
blood sample) was done. In
comparison the pretest-posttest differences of two groups, the average score of
experimental groups in all procedures was further than control groups (p = 0.001). Also,
in the end of clinical education many of experimental students reached to mastery level,
but, few students in control groups reached to mastery level. Due to significant effect of
mastery learning method on clinical performance of nursing students, we suggest that
nursing trainers use this method as a basic clinical teaching method especially to educate
fundamental nursing skills18.
STATEMENT OF THE PROBLEM
“A study to assess the effectiveness of Self-instructional module regarding Arterial Blood
Gas (ABG) technique among staff nurses in selected hospitals at Bangalore.”
.
6.3. OBJECTIVES OF THE STUDY

To assess the existing level of knowledge regarding Arterial blood gas (ABG)
technique among staff nurses in selected hospitals

To evaluate the effectiveness of the structured teaching programme regarding
Arterial blood gas among staff nurses in selected hospitals

To find out association between knowledge level of the staff nurses with their
selected demographic variables.
6.4 HYPOTHESES OF THE STUDY
The study attempted to examine the following hypothesis,
H1: The mean post- test knowledge level will be significantly higher than the pre-test
knowledge level regarding Arterial Blood Gas (ABG) technique among staff nurses in
selected hospitals.
H2: There will be significant association between knowledge level of the staff nurses with
their selected demographic variables.
6.5 VARIABLES UNDER THE STUDY
Independent variable
Self-instructional module on ABG analysis.
Dependent variable
Knowledge about ABG analysis.
6.6 OPERATIONAL DEFINITIONS
Effectiveness:
refers to the extent to which the structured teaching program on ABG
(Arterial Blood Gas) techniques achieves desired effect in improving the
knowledge of staff nurses as evident from gain in knowledge scores.
Knowledge:
Refers to correct responses from the staff nurses about ABG Analysis
elicited through Structured Knowledge Questionnaire.
Self-instructional module:
Refers to planned instructional material regarding systematic ABG
technique which can be used oneself to improve knowledge.
Arterial Blood gas analysis:
Refers to a lifesaving diagnostic procedure to determine O2, CO2, HCO-3, PH
balance and related abnormalities.
Staff nurses:
Refers to an individual who is qualified as a registered nurse and is working
in a selected hospital.
6.7 ASSUMPTIONS
 Nurses may have some knowledge regarding ABG technique.
 Nurses may have interest to know more about ABG technique.
 This self-instructional module would enhance knowledge of nurses
about ABG technigue.
6.8 DELIMITATIONS
This study is delimited to:
 The staff nurses working in selected hospitals at Bangalore
 Who knows Kannada or English
 Who are willing to participate in the study
6.9 PROJECTED OUTCOME
This study will help the staff nurses to gain more knowledge about
ABG techniques and thus to improve their nursing capabilities
7.0 MATERIAL AND METHODS
7.1 SOURCES OF DATA
The data will be collected from the staff nurses in a selected
hospital at Bangalore.
7.2
METHODS OF COLLECTION OF DATA
Structured Questionnaire will be used to collect the data.
7.2.1 RESEARCH APPROACH
An evaluative research approach will be used to conduct the
study.
7.2.2 RESEARCH DESIGN
Quasi experimental one group pre-test post-test design will be
used to carry out the study.
7.2.3 SETTING OF THE STUDY
Study will be conducted in selected hospitals, Bangalore.
7.2.4 POPULATION
The population of the present study comprises of staff nurses
who are working in selected hospital, Bangalore.
7.2.5 SAMPLE SIZE
Sample size of the study will be 40 staff nurses working in
selected hospitals.
7.2.6 SAMPLING TECHNIQUE
Purposive sampling technique will be used to select the
samples for the present study.
7.2.7 SAMPLING CRITERIA
Inclusion criteria
 Staff nurses who are willing to participate in the study.
 Staff nurses who are available during the period of data
collection.
Exclusion criteria
 Staff Nurses who are on leave during the period of data
collection
7.2.8 TOOL FOR DATA COLLECTION
Structured knowledge questionnaire will be used to collect the data:
It consists of 2 parts i.e. part I and part II
Part I: items on demographic variables like, age, sex, educational
qualification, total years of experience, exposure to in-service education.
Part II: knowledge items on ABG technique.
7.2.9 DATA ANALYSIS METHOD
The data analysis through descriptive and inferential statistics.
Descriptive statistics
 Frequency, mean, mean percentage and standard deviation will be
used to describe demographic variables and interpreted knowledge
scores.
Inferential statistics
 Paired ‘t’ test will be used to compare pre and post-test knowledge
scores.
 Chi square (χ2) test will be used to find out the association between
knowledge scores with selected demographic variables.
7.3
DOES THE STUDY REQUIRE ANY INVESTIGATION OR
INTERVENTIONS TO BE CONDUCTED ON
NURSES OR OTHER HUMANS OR
STAFF
ANIMALS?
Yes, the intervention will have effect on staff nurses knowledge
level regarding ABG technique.
7.4
HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM
YOUR INSTITUTIONS?
Yes, the Ethical Clearance Certificate has been enclosed.
8. LIST OF REFERENCES:
1. National Committee for Clinical Laboratory Standards: Percutaneous Collection
of Arterial Blood for Laboratory Analysis, Second Edition, Document H11-A2.
2. Pramod Sood, Gunchan Paul, and Sandeep Puri.Interpretation of arterial blood gas,
Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of
Indian Society of Critical Care Medicine 2010 Apr-Jun; 14(2): 57-64
3. Mauricio Danckers, MD: Arterial Blood Gas Sampling, Pulmonary and Critical
Care Fellow, New York University Medical Center. ( available on:
http://emedicine.medscape.com/article/1902703-overview )
4. Kofstad J (1996). "Blood Gases and Hypothermia: Some Theoretical and Practical
Considerations". Scand J Clin Lab Invest. (Suppl) 224: 21–26. PMID 8865418.
5. Raffin T. indications for arterial blood gas analysis. Ann International Medicine
1986;105:390-8.
6. Severinghaus W.John, Astrup Paul et al. Blood gas analysis and critical care
medicine. American Journal of Respiratory and critical care medicine, 1998 April;
154(4).
7. Fine M J, Smith MA, et all. The incidence and effect of hypoxen hospitalized
medical patients. American Journal of Medicine 1994; 97:38-46
8. S Dodds, et al. Nurse – led arterial blood gas sampling for patients, Nursing
Times 2007 february; 103(8):44-45.
9. M L Franklin,T W Peruzzi,S G Moen,B A Shapiro. Evaluation of an on-demand ,
ex-vivo bedside blood gas monitor on pulmonary artery blood gas deter minations.
Anesthasia Analog 1996 sep; 83(3): 500-4.
10. M M Shabot, Bue .M Lo,Leyerle B J. Decision support alerts for clinical
laboratory and blood gas data . Int Journal Clinical Computer1990 ; 7(1):27-31
11. Moamary Al Mohamed, Daniel Diane, et al. Appropriateness of Arterial blood gas
measurements in acute general wards. Annals of Saudi Medicine 1999;19(2):153
12. Taylor L, Stephens D : Arterial Blood Gases, Clinical Application. The American
Journal Of Emergency Medicine, Volume 26, Issue 1, Pages 24-30 (January 2008)
13. Mr A.V. Valero Marco: Local Anesthesia in Arterial Puncture: Nurses' Knowledge
and Attitudes, Arch Bronconeumol. 2008;44:360-3. - Vol. 44 Num.07( available
on
http://www.archbronconeumol.org/en/local-anesthesia-in-arterial
puncture/articulo/13124793/)
14. Warda youssef, Ahmed Yahia, Nahla Shaaban Ali, Sameh Elhabashy: Factors
Affecting Validity of Arterial Blood Gases Results among Critically Ill Patients:
Nursing Perspectives, journal of education and practice Vol 4, No 15 (2013)
15. Maag M M . Arterial blood gas (ABG) interpretation: an online learning activity
for health care professionals. Computers and advanced technology in education
2005;24:506.
16. Schneiderman J, Corbridge S, Zerwic JJ. Demonstrating the effectiveness of an
online, computer-based learning module for arterial blood gas analysis. J Clin
Nurse Spec. USA 2009 May-Jun;23(3):151-5
17. Antonio Vicente Valero Marco, Carmen Martínez Castillo and Loreto Macia Soler
Local Anesthesia in Arterial Puncture: Nurses' Knowledge and Attitudes. Spain:
Archivos de Bronconeumologa (English Edition) 2008 44,(7), , 360-3
18. Azad Rahmani, Alireza Mohajjel Aghdam, Eskandar Fathi Azar. Iranian Journal of
Nursing and Midwifery Research Comparison the effect of two clinical teaching
models on performance of nursing students in intensive care unit. Iran: IJNMR
2008; 13(2): 81-86 2008 13, No 2 16.
9.
10.
11.
SIGNATURE OF THE CANDIDATE
REMARKS OF THE GUIDE
NAME AND DESIGNATION OF
11.1 GUIDE
11.2 SIGNATURE
11.3CO-GUIDE
11.4SIGNATURE
11.5 HEAD OF DEPARTMENT
11.6 SIGNATURE
12
12.1 REMARKS OF THE PRINCIPAL
12.2 SIGNATURE