IV tips and tricks

[kloock]

Hi all,

I am starting to compile a list of tips and tricks concerning starting venipuncture. The goal is to share experiences and tricks of the trade.

Tips e.g. on how to find that elusive "best vein", would be greatly appreciated. (and if you have a few that are not to be taken entirely serious those would be welcome as well).

Please answer me directly - no need to clutter up the board with this. I will post the text once it is finished.

Thanks in advance!

------------------

Katharina Loock, RN, BSN

Department of Education

Wadley Regional Medical Center

1000 Pine Street

Texarkana,TX 75501

[veronicajr]

For the record, I don't have peds experience, so I don't intend anything that I say to be taken in reference to peds.

I have to agree with the many who have stated that it's all about feel. IT IS!! I started working in the ER as a nurse tech during my last semester of nursing school (3.5 yrs ago) and while starting an IV once, one of the paramedics I work with proceeded to tell me that I was doing it all wrong since I was relying on sight. Although she hurt my feelings a little bit, I feel I owe much of my IV skills to what she taught me that day. Sure, it is possible to stick a vein that you can't feel. But, if you can train yourself to be able to stick veins that you can feel and perhaps not see whatsoever, you'll find that it's actually much easier to find a vein. Many people have great veins that can only be felt, not seen.

And to the poster who suggested that there will always be a vein near where you feel the brachial pulse, great tip...it's true, and often forgotten.

[nC09n34t0]

Just my 2 cents worth...

Make sure you and the patient are both comfortable. You can't do your best if you are in an awkward position or uncomfortable. A stool or chair works wonders.

Also, set up all your supplies somewhere other than the patients bed or stretcher. I don't know how many times I've seen co-workers pile all their supplies up on the patient only to see them land on the floor when the patient makes an unexpected move. Get a bedside table or Mayo Stand.

If you have the time...look, look and look some more. Especially if you think the stick will be difficult. I think many posters have mentioned listening to the patient. But, make sure the site the patient recommends will be appropriate for whatever treatment or test...CT, blood, fluid resus. Get the picture.

Know your limits. Don't stick just so you can say "I tried" to the "expert" when you have to call on them. Somethings are beyond our abilities.

If you ever become the "Expert," let everyone know to call you first if it looks like a very difficult stick. There's nothing I hate worse than coming behind someone or several someones who have ruined every possible site I could have attempted and now I'm supposed to perform a miracle.

If at all possible, avoid the AC. Not always an option. I've had patients go for contrasted CTs with access in the AC only to discover that they cannot put their arms above their head...for whatever reason. (think McCain)

It has already been mentioned but well worth repeating...your patient is not going to tolerate some IV infusions in the small veins of the hand or even other sites. Go for the largest vein you can find, preferably not in the hand or AC but do what you have to do for the sake of the patient.

Trauma patients need the largest IV you can get as quick as you can get it. Just because they look "OK" now has nothing to do with 15 minutes later when they start to crash. Be safe...not sorry.

Infants under say 60 days old will be easier sticks than say the chunky 10 mo old. Not as much baby fat.

Parents make poor and unpredictable assistants. Never trust them to be your holder.

Proper restraint and holding are essential in starting a pediatric IV. Find a team mate that can hold properly and always call on them if possible. Does not have to be a nurse. I've known several Phlebotomist who were excellent.

The flat veins of the anterior forearm, the ones you can see but cannot feel, are easily accessed by sticking almost parallel with the skin. Too much angle and you'll go right through the other side.

Some patients have a very large vein running on top of the bicep. Don't over look it. We have a tendency to look at AC and below. I've even had success at the shoulder. Depends on time and situation.

Let your doctor know quick when a central line is needed. Sure, I might get an "IV" but is it going to be appropriate and how long is it going to last...fingers...spider veins...???

If the patient wears a watch, there's probably going to be a rather large vein under the band. Don't forget to look there.

Secure the site properly. We use T-Ports at my facility. Some nurse let them dangle and they get caught on everything. I make a loop and tape in down. If fluids are connected I make a loop in the tubing and tape it down. If I think the patient might try to pull the IV out or is a "picker," I wrap it, especially if it was hard to start.

Practice makes for good IV skills. Stick...Stick...Stick and Stick some more.

Find out who is good. Watch them and ask questions. Everyone has little secrets. The nurses that are good usually love to share with others so they will not be called on so much.

Hope someone finds something they can use out this. I've learned a little from reading this thread and was reminded of a few things I had forgotten.

Thanks for posting it.

[shannonFNP, BSN, MSN, RN]

Someone mentioned earlier (and about 4 years ago! This is a great thread, I'm glad it's revived) that their friend had a hard time remembering where the vein was after she cleaned it. If you're using an Insyte catheter, look at the back of the chamber. You'll notice there is a hole in it. If you press this against the point of the vein you want to stick, it leaves a small red dot that stays there long enough for you to clean and start the IV.

[lotstolearn]

thanks for all these great tips nurses!! I started my first IV in clincal today!! whoo-hoo! I got it on try number two. How exhilarating.. i had to keep myself from doing the jig all the way down the hallway!!

[Jenny Renn]

Prior to starting an IV get all your equipment and open it all. Set up your flush, extension tubing and window dressing. Have it all conveniently placed within arms reach so that the risk of unneccessary bleeding is reduced. Fiddling around in front of your pt may make them lose confidence in you, so you might want to set up your trolly somewhere private. When in front of the patient if you're not sure of something, take a bottle of hand cleansing gel and wash your hands. This shows the patient you are busy and also gives you time to think. There are many pts who know what veins are better so don't hesisate to ask. Act confident, think positive and expect success.

[ChallyRN]

As you may guess from my screenname, I am a pediatric RN in the ER, I work at a level 1 trauma center.

Anyway here is something I use to help start IV

I hope I don't get in trouble for recommending this

http:// http://www.copquest.com/10-2270.htm

This helps illuminate the veins in preemies, and many old and young alike. It works well in all skin colors. It doesn't work well in obese patients, but is great usually for chubby lttle 1 year old rolly poly.

what color light do you recommend getting?

[Knoodsen]

It's a skill. One achieves expertise through practice. There are no "tricks".

P.S. Where did this "rolling vein" stuff come from? Is this what some nurses tell their patients after they have missed an IV?

[roses1130j]

so what Im getting from the last 3 or so posts is that adults commonly get an 18 or higher. If you can't get a stick, time to switch to a new site, not a new smaller gauge. In the case of elderly patients with fragile veins and skin, I have been taught to use a 20 to 22. You guys are saying its a waste to infuse fluids through a 22. This is good to know. My preceptor uses 20's for elderly patients and hates to have to use a 22, but has. Im really going to concentrate on trying to keep the gauge size as large as possible so the patient get the most effective infusion rate. Thanks

[ThrowEdNurse, BSN, RN]

I often have to use a 22 on our pts. Our pts in our community have a multitude of diseases that predisposition them to having rotten veins. It's not ideal, but better than having nothing. If elderly pts are an issue, try not using a tourniquet. This is especially true if they have those huge bulgey veins that blow as soon as they are touched.

[IVRUS, BSN, RN]

so what Im getting from the last 3 or so posts is that adults commonly get an 18 or higher. If you can't get a stick, time to switch to a new site, not a new smaller gauge. In the case of elderly patients with fragile veins and skin, I have been taught to use a 20 to 22. You guys are saying its a waste to infuse fluids through a 22. This is good to know. My preceptor uses 20's for elderly patients and hates to have to use a 22, but has. Im really going to concentrate on trying to keep the gauge size as large as possible so the patient get the most effective infusion rate. Thanks

Please remember Infusion Nurses Society standards... "Always choose the SMALLEST guage and length IV catheter for the prescribed therapy."

The key is NOT to go bigger. A 22 guage is most appropriate for that elderly patient, and for that 90 lb soaking wet 90y/o female, a 24 g may be appropriate. You want the smallest guage to allow for adequate blood flow around the IV catheter and decrease the damage to the smotth tunica intima. A 22 guage IV catheter can withstand infusion rates of up to 35ml/min or 2100cc/hr. If in doubt, look at the back of the package that your IV catheter came in. The flow rate is listed on it.

[veronicajr]

I understand it's best not to stick an unnecessarily huge IV in someone; however, I hate to use 22s for the simple fact that if for some reason that patient ends up needing blood or blood products, I'm going to have to stick them yet again. I know every hospital is different on this, but our ER's protocol is to not give blood/blood products in anything less than a 20g. And 90 yr old granny's weakness could be due to being severely anemic...so you really never know when you'll need a slightly bigger IV.

Just my opinion. :)

[IVRUS, BSN, RN]

I understand it's best not to stick an unnecessarily huge IV in someone; however, I hate to use 22s for the simple fact that if for some reason that patient ends up needing blood or blood products, I'm going to have to stick them yet again. I know every hospital is different on this, but our ER's protocol is to not give blood/blood products in anything less than a 20g. And 90 yr old granny's weakness could be due to being severely anemic...so you really never know when you'll need a slightly bigger IV.

Just my opinion. :)

If you are "pouring" that blood in a short time frame, then I would agree to have a larger lumen catheter, however, most of the elderly can not take blood infusions at a fast rate, and usually it's infused over 3-4 hours.

A 22 gauge IV catheter is quite appropriate in this situation. Perhaps your ER manager can check out references that review that fact in the AABB (American Association Of Blood Banks) manual and then subsequently your policies can change to reflect the appropriateness of care.