How to cannulate without pain?

  1. I'm working for almost 1 year in HD now and still I suffer rejection from patients, one of which is that insert needles painfully. I'm not good with deep accesses either so I really want to get this right. *sigh*

    We don't use lidocaine in our unit. We just prep the access and stick the needle. They rarely complain with other nurses but they usually complain to me. I observed that old insertion sites are less painful but that is not good...

    My senior once told me to insert slowly but that doesn't work for everybody either...

    How do you insert your needles? Is there a certain angle that I'm missing here? Or I'm just the nurse with those heavy hands? God forbid that, I'm now considering a career change...

    Tips? Anyone?
    Last edit by hazyblue on May 17, '12
    •  
  2. 17 Comments

  3. by   iluvhrts
    I think each pt is different. I think your attitude and demeanor is important. If you act all timid and unsure then the pts are not going to trust you. Breaking the skin is what hurts. I don't go slow, I find that it hurts worse. Also, rotating the sites. I go in , get a flash then level out....
  4. by   mtmt99
    I find that if the skin is very taut the needle goes in easier. Try the "3 finger" method--stabilize the access on either side with thumb and forefinger of your non-needle hand. Use the middle finger (or whatever one feels right) of your cannulation hand to pull back and press down slightly to tighten the skin before guiding the needle in. This prevents the skin from stretching as the needle attempts to go in, and the slight pressure seems to help with numbing the area a little. Also, make sure when you are not accidentally rubbing the cap against the needle tip as you remove the cap. This can cause a little hook or snag on the needle tip--ouch! See if your facility will send to to an inservice on cannulation. Our area has ones sponsored by MARC (Mid-Atlantic Renal Coalition). Also, sometimes access centers will provide inservices for whole clinics to reinforce their skills. Good luck.
  5. by   hazyblue
    Thanks for responding people. I honestly feel stupid for asking this question. I haven't really gotten around on pressing down access sites because of fear of the tiniest amount of blood oozing. I'll try to practice that one.
  6. by   tyvin
    Confidence is key...along with knowing how the patient usually reacts to shots. I never let them see the supplies or draw it up in front of them. I cover everything with a sterile towel. Distraction works well. I always go in swift and fast; half the time they don't even know I've given the injection.

    The angle is always determined on where you are giving the injection. Sometimes I will taunt the skin, sometimes I wlll bunch it or even just use my non-dominant hand as a guide. Depends on the circumstances; as with thin frail patients I bunch up the skin so as to not hit any bone as opposed to an obese person where I will stretch the skin depending on the shot.

    Technique it crucial and something that you teach yourself. Practice is the only way to get good at injections IMO.
  7. by   iluvhrts
    I went to a class today and we had a mini cannulation "workshop". I remembered something I practiced on.. I used the tubing of a needle and cannulated it over and over.. To get the hand of the "pop". It is roughly the size of a fistula or graft, rolls... I totally agree with the "taut" skin. Also, on a fistula a good tourniquet to pop it out. And when you get in and level out, I use my forefinger to make sure I'm threading it the right direction. It helped that one of my fav patients joked from day one that he "enjoyed pain" so I could try on him anytime.... And I can NEVER get his venous... Dang thing acts like a freaking snake 10% of the time... my old preceptor can never get his arterial... so we tag team him
  8. by   hazyblue
    Oh the "popping sound" Yesterday, I had this patient on which I never get a popping sound and so I thought "Does this mean I am not quite 'in'?" despite having a blood flow. I'm like "Could I get any better?" and so I pushed the needle some more and got the popping sound It turns out that I hit the bottom. I reposition the needle but it was too late. There was so much pain according to my patient and I have no idea to comfort him. Thank God there is something called a nurse in-charge.

    It was saddening but at least now I know that the popping sound doesn't have to be "loud" . I wish I knew about that practice of cannulating the tubings before so that I don't..err...try things on an actual patient. ^_-
  9. by   statnie83
    Me too. Find the best spot,prep it, and go right in. DO NOT BE TIMID! it's going to hurt them. the needles are huge. if they don't feel anything...well kudos to them for having tough skin. If you don't use lidocaine, talk to their Nephrologists about maybe prescribing the pt EMLA cream. it's basically a lidocaine numbing cream. i hear its amazing
  10. by   statnie83
    25 degree angle for AV fistulas and 45 Degree angles for AV grafts. then level out.
  11. by   Filipino RN
    Yes, *CONFIDENCE* is usually the key to successful cannulations. As an inexperienced dialysis personnel, I practiced by sticking the tubes over and over to get a feel for that "pop". I'm very glad I stumbled upon this useful forum for the tips and tricks of the trade. My manager also sent me to a chronic unit where I was precepted by a very knowledgeable and skillful dialysis technician. Even though it's difficult to find willing patient volunteers who would let a newbie stick them, you'll have the selected few who would. I've found that "mapping out" the AV fistula/graft works wonders, meaning you're already knowing the route your needles will go in as you're palpating and auscultating for bruits and thrills. In the end, *EXPERIENCE* is hands-down still the best teacher.
  12. by   Guttercat
    Quote from mtmt99
    I find that if the skin is very taut the needle goes in easier. Try the "3 finger" method--stabilize the access on either side with thumb and forefinger of your non-needle hand. Use the middle finger (or whatever one feels right) of your cannulation hand to pull back and press down slightly to tighten the skin before guiding the needle in. This prevents the skin from stretching as the needle attempts to go in, and the slight pressure seems to help with numbing the area a little. Also, make sure when you are not accidentally rubbing the cap against the needle tip as you remove the cap. This can cause a little hook or snag on the needle tip--ouch! See if your facility will send to to an inservice on cannulation. Our area has ones sponsored by MARC (Mid-Atlantic Renal Coalition). Also, sometimes access centers will provide inservices for whole clinics to reinforce their skills. Good luck.
    Excellent advisement. Three-finger, if done well, works great.

    I also retract the skin in opposite directions (simultaneously). Retract skin proximally and distally at the same time, and also make sure the fistula or graft is stabilized laterally.

    Another thing I do, especially for anxious patients, is to engage the patient in distracting conversation while cannulating.

    Also, and perhaps my best "trick" is to make sure to exhale just before and as I breach the skin. The technique of exhaling is the same technique they teach in target practice for marksmanship when squeezing the trigger. It steadies the hand.
  13. by   adamlvndtx115
    Hi, my name is Adam and I am currently enrolled in a Dialysis Tech class. I love it. I wanted to ask anyone here if they know which needle to remove after completing dialysis treatment. I could of sworn that my teacher said to remove the arteriol line first, then after 10 min, you can remove the venous needle. She said that if you had to give emergency meds or fluids you would have a venous access. Well today, another teacher said that you are to remove the venous line first, then the arteriol line. Which is true?
  14. by   Chisca
    Venous needle is removed first, then the arterial needle. The blood in the access is a mixture of arterial and venous blood because it is an artery (high pressure) connected to a vein (low pressure). Think of the flow as a river and you want to work your way upriver removing needles. Everytime you pull a needle and apply pressure this increases pressure in the access upstream of where your finger is at. If you pull the arterial needle first when you go to pull the venous needle you will be causing an increase in pressure upstream and the arterial site will begin to bleed. Start downstream and work your way up.

close