IV Therapy

psu_213, BSN, RN · Jul 12, 2013

SO my question is should I just preemptively start an IV on all adults? So long as they're not there for something like suture removal of course...

There are only a few categories of CC for which I preemptively start a line: "true" chest pain (i.e. not the 20 year old with a sore chest after helping a friend move yesterday), when it appears a long bone is broken/there is a dislocation (such as a leg that is shortened and rotated), severe vomiting, HR way out of normal parameters (like HR of 32 or one of 170). Other than that I am going to wait for the doc to see them. Each time someone is "lined" is one less time you are going to get a line on them later in life. When I see what a nightmare it can be to get an IV on the most frequent of frequent fliers, I realize that I should not put an IV in everyone "just in case." Not to mention the fact that some pts. have gotten really ticked off when an IV was put in and it was never used.

turnforthenurse, MSN, NP · Jul 14, 2013

It will come with time. Typically patients who come in with chest pain, SOB, abdominal pain (esp with nausea and vomiting), flank pain and musculoskeletal trauma (think pain meds in possible conscious sedation if the bones need to be set) will always get line and labs. Acute headache/migraines, too. Those patients will typically get IV medications and will end up going for a head CT. ESI levels 1, 2 and (most of the time) 3's typically always get line and labs. Our psych patients are always supposed to be ESI level 2 per policy but we usually only do labs and no line, unless something comes back on their labs that will require a line. ESI level 4s very rarely require a line and ESI level 5, never, at least from my experience so far.

Use your nursing judgement. I had a patient who came in who had right-sided chest pain that started 2 days ago but with "sudden" onset. There was only pain with movement, palpation and when the patient took a deep breath, which to me sounded more like muscular pain instead of possible pulmonary embolus. VSS, patient was in no acute distress, no shortness of breath or anything. Patient was triaged as an ESI level 3. Despite all that, I had a feeling in my stomach and though, "maybe I'll go ahead and place a line and labs on this patient just in case." I drew a rainbow and sent it to the lab. Provider sees the patient, and decides to order labs including a d dimer, which came back positive. Patient went for CT, had a PE, and ended up being admitted.

Then there are times where I have placed a line but didn't end up needing it after all, or didn't place a line and ended up needing one. It depends on the patient's presentation and of course on who is working with you that night. Some providers will want EVERYTHING done, others will not.

Ciale · Jul 16, 2013

Each time someone is "lined" is one less time you are going to get a line on them later in life. When I see what a nightmare it can be to get an IV on the most frequent of frequent fliers, I realize that I should not put an IV in everyone "just in case." .

Wow I never even thought about that. NOW I know why it's so hard to start a line in frequent fliers! I just never put two and two together. Heh. Invaluable stuff here...(sorry new grad excitement...it's the little things) :)

psu_213, BSN, RN · Jul 16, 2013

Wow I never even thought about that. NOW I know why it's so hard to start a line in frequent fliers! I just never put two and two together. Heh. Invaluable stuff here...(sorry new grad excitement...it's the little things) :)

At first, I thought some people were just naturally "tough sticks" (and some are), however, with experience, I have learned that most tough sticks have been stuck many, many times and the quality of their veins has decreased with each stick.

SweetMelissaRN · Jul 17, 2013

Wow I never even thought about that. NOW I know why it's so hard to start a line in frequent fliers! I just never put two and two together. Heh. Invaluable stuff here...(sorry new grad excitement...it's the little things) :)

Don't feel bad, I never thought about it that way either!

emtb2rn, BSN, RN, EMT-B · Jul 17, 2013

With the hard sticks, esp frequent flyers, I tend to look away from the obvious. Toothbrush veins & upper arm can yield good veins.

weirdscience · Jul 17, 2013

"Toothbrush" veins? Somebody clue the noob (me) in on what that term means. School me, please! :-)

emtb2rn, BSN, RN, EMT-B · Jul 18, 2013

While brushing your teeth, look at your forearm in the mirror.

LilgirlRN, ADN, RN · Jul 18, 2013

Most ER's have standing orders for just about anything except medications. ie... 40 year old female with abdominal pain, nausea would get at least a saline lock, UA, UCG, CBC, chemistry, amylase and CT abd.

As far as headaches go, is this the worst one they've ever had? Do they have a fever? Is it different from their usual migraine? Then I would put a line in. If they have fever over 101 I'd get blood cultures while I was at it and anticipate the need for a tap.

Guests · Jul 19, 2013

You can rarely go wrong by lining 'em up as soon as you're finished with your assessment.

There are very few ED patients who won't at least get a CBC/BMP and perhaps an NS bolus.

I've spoken to a bunch of docs about it: "Will you ever be upset if I make the choice to start a line and draw a rainbow?" While the question generally prompts a discussion, the final answer is always, "Nope."

Guests · Jul 19, 2013

If they have fever over 101 I'd get blood cultures while I was at it

I'd probably pull a gray top, as well... depending on the docs I was working with, anyway.