IV tips and tricks - page 5

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... Read More

  1. by   SWAT_RN
    You know surgeons who start IVs??????
    Quote from ERslave
    WOW! Good thing surgeons dont try this in the OR! or do they?
  2. by   newfloridaRN
    I"ve been an ER RN for almost two years now. I've gotten pretty good at IV starts.. yet I still freak out with peds. I work in an ER where we don't have a separate peds ER so we see LOTS of pedi patients....Lots! I get so nervous since I have a bad record with pedi IV's and I can feel myself get sweaty and start shaking. The parents, I think, are what make me most nervous... "you only get one try".. Those newborns...My god, I have a HARD time with them...Anyone under 3 is like a nightmare for an IV start in my brain..any one out there with advice? I know this sounds silly....
  3. by   veetach
    in my experience a good holder is very important. If you have a good holder who can stabilize the arm so the kiddo doesnt turn and roll the vein out of your way, it is much easier.

    Cut your tourniquet smaller for the little arms, and look look look. palpate a lot, until you feel something (you seldom ever see it) that is a good vein.

    I always look on the back of the hand first just in case I would luck out and find one there, if not I go straight to the AC. Of course it is more difficult to maintain, but the peds patients we put IV's in are usually those who have been vomiting, had diarrhea or high fever for so long that those veins in the hands are usually pretty flat. RN's in our ER do not do scalp veins but we do feet.


    keep trying! It takes a while before you are comfortable starting IV's on little kiddos. your steady hand is your best friend
  4. by   Danelle
    Hi All,

    I just want to add my horrindous IV experience in the ER last week. I am a nursing student, but this was as a patient.

    I was taken to the ER Monday for a bimalleolar fracture and dislocation of my ankle (Foot was at a 90 degree angle to my knee). Needless to say I was in SEVERE PAIN. Rn tries to start an IV in my left hand but misses, so he tries again and misses again. By this time, after all of the digging around in my hand on top of the pain in my leg, I am crying and screaming. When he starts his third attempt he starts yelling at me to relax. I scream that I am trying but its not exactly easy. Once he misses the third time, I ask could someone else please try. All he says is "Yep ", drops everything and walks out of the room. About ten minutes later a new RN comes in. Note that at this point it is about 2 hours after my injury and I have had nothing for pain so far. She tries in my right hand. When she can't get it in, she and RN #1 start yelling at me to relax again. Rn #1 says "WE are TRYING to get you Pain Medicine." Rn #2 says "The reason we can't get the IV in is Because you are too tense, and it is not going to go in if you don't relax." WHAT!?!?! Why can't the Dr order an injection of something to help ease to pain so I can relax!? Why couldn't the nurses try lidocaine!?! They finally got it in a vein on the pinky side of my wrist, which I now have phlebitis in. It is a week later and both of my hands are still black and blue.

    Am I being unreasonable to think that I received poor care? Is this common in the ER? When I was admitted the floor nurses, who were WONDERFUL by the way, thought that this was excessive.
    Any feedback is welcome.
  5. by   FZ1Tom
    Danelle,

    Your story brings back dark memories. I went through a very similar leg and ankle injury back in Feb. '91. Dunking off a picnic table, crash landed on the left ankle and turned it outwards - snap, crack, pop (heard 100 yds away). Broke the tib, fib in 2 places and the ankle as well as badly dislocating it to where my foot was behind and to the side of the calf, amazingly not an open fracture. It was over four hours of shaking on a gurney before the doc reset it (a horrible explosion of pain) and not once did I get any form of pain meds. I tried to be stoic, but it was very hard. I'm really sorry you had to go through that same time tunnel of hell. It's not anything I would wish on my worst enemies if I had any to begin with Please let me know how the rest of your recovery/treatment (I presume you had an ORIF) went, what they did, how its turning out. Oh yeah, at least they didn't pester me with that pain scale back then :chuckle

    I have to ask - why an IV for pain meds in the first place? Perhaps there was a good reason I (at the time a healthy 22 yr old male) deserved to suffer 4 hrs of dislocation, then forcible reduction, Xrays with my foot flopping around, then the doc yanking up my entire leg by the big toe as they wrapped it up, and only then the nurse FINALLY came forward with a huge syringe of painkiller (I said bring it on, baby! ). In fact, my experience with my leg motivated me to reset a grossly dislocated thumb (sticking straight up from my hand and twitching - not for the squeamish :imbar ) by myself because I just KNEW that they'd wait forever at the clinic (this was on the job) and the pain would just get worse. Fortunately, I was able to reduce it without too much trauma (took my time and didn't force it, just a little pull on the thumb and gentle pressure on the base and kerplunk, it fell back into place). The clinic doctor was NOT amused, though. Said something about possible ligament damage (got a thumb splint for about a month, it healed in about a year, full range of motion, just a really loose thumb with a thick knuckle now).

    Tom
  6. by   FZ1Tom
    Back to the original IV thread......

    Someone said it may have been discussed ad nauseum, but I think its pretty interesting! I learned on the enw.org link why the emergency room RN put my IV in where he did (preparatory to CT scan, it went in the right elbow). I wanted him to put it elsewhere because I just KNEW that needle in my elbow would bug me to death, but he said in no uncertain terms that it had to go RIGHT THERE. Just didn't explain the why of it. Fortunately, he must be a hell of an IV magician. No Lidocaine or other med, just slid it right in and it didn't even hurt a bit. I've had 5 IV's done in my lifetime (top of left hand, top of right hand, top of right wrist, middle of right forearm and right elbow) and of those 5, one REALLY hurt (middle of right forearm), 2 of them were modestly painful, and one they used lidocaine on (top of left hand). Its not that I'm a wuss, just that like anyone else some locations are more sensitive than others. And other locations just itch less

    I got some copies of labs and notes, and it appears the RN used a 20 gauge. It was entirely painless, apparently stuck deep (couldnt even palpitate it with a finger), and never bothered me to bend the elbow. It DID set off the infuser alarm if I bent my elbow more than about 45 degrees. Could go 44 degrees and never a beep. 46 degrees and BEEP, BEEP, line stopped, please reset. Couple nurses were a bit unnerved to find I had found out how to reset and start the infuser (duh, it tells you how on the display). But I had to do it about 30 times, so it saved them a trip or two :chuckle . It looks like I got off pretty lucky, the potassium therapy is apparently supposed to be irritating on the veins, but I never noticed.

    So, I gotta ask......where's the best and worst locations (in general) for IV's? For those on the receiving end (I'm not a nurse, never stuck anyone so I wouldn't know about the giving end ) how did your experiences go?

    Any and all banter is appreciated, as usual.

    Tom
  7. by   veetach
    Danelle, I am sorry you had this experience. There are lots of reasons that nurses with good IV skills miss IV's but it is NEVER acceptable to blaim the patient!! I wonder if they were trying to get a larger bore IV if this is required by the OR.... did they ever go to the AC? It is usually a good bet that you can find something there.

    Tom, suggestion for the future... dont mess with the IV pumps, especially if you have a potassium drip hanging. I had a patient once whose family played around with the pumps, they thought they were saving the nurses some steps... ended up overdosing poor old dad on Dobutamine......
    Last edit by veetach on Aug 30, '04
  8. by   SmilingBluEyes
    I have NEVER been able to develop the skill of FEELING for good veins. Am I just stupid??? ugh.
  9. by   apaisRN
    Quote from veetach
    Tom, suggestion for the future... dont mess with the IV pumps, especially if you have a potassium drip hanging. I had a patient once whose family played around with the pumps, they thought they were saving the nurses some steps... ended up overdosing poor old dad on Dobutamine......
    I had a patient with Dilantin running - the pump started beeping and the retired nurse who was visiting just turned off the pump "because the patient needed to sleep." The sitter, luckily, told me. I'd have lost the line probably if I hadn't known to flush it quickly. I was livid. This visitor wasn't just out of line, she was rude as hell.

    Not as bad as dobut, though. What happens when you OD someone on that?

    As for the horrible fx described and the impatient ER nurses - I think after the first unsuccessful IV attempt I'd have demanded some IM pain meds. I hate IMs as much as the next person, but my god, no pain meds for two hours! I'd take a stab in the butt any day. Then you'd probably have relaxed and wouldn't have cared while they poked around for a vein.
  10. by   veetach
    Quote from apaisRN
    I had a patient with Dilantin running - the pump started beeping and the retired nurse who was visiting just turned off the pump "because the patient needed to sleep." The sitter, luckily, told me. I'd have lost the line probably if I hadn't known to flush it quickly. I was livid. This visitor wasn't just out of line, she was rude as hell.

    Not as bad as dobut, though. What happens when you OD someone on that?

    As for the horrible fx described and the impatient ER nurses - I think after the first unsuccessful IV attempt I'd have demanded some IM pain meds. I hate IMs as much as the next person, but my god, no pain meds for two hours! I'd take a stab in the butt any day. Then you'd probably have relaxed and wouldn't have cared while they poked around for a vein.
    this happened when I was a new RN and worked med-surg. I totally freaked out, and put the pt in trendelenberg, opened up the saline line and in a panic called the doc. The pt immediately vomited profusely and went hypotensive. The doc told me to calm down and explained that the half life of dobutamine was very short, I monitored him closely (he was already on a tele unit) and soon his BP returned to normal and things settled down. I think I wrote volumes of paperwork on it though. LOL
  11. by   RN92
    It was over four hours of shaking on a gurney before the doc reset it (a horrible explosion of pain) and not once did I get any form of pain meds. I tried to be stoic, but it was very hard.
    I work at a trauma center with many many orthopedic surgeons. They are notorious for not using pain meds - that way they dont have do deal with any complications. After dealing with them for 2 yrs - I learned how to handle them. If I believe a pt is truly in pain and deserves to have relief, then i will say (right in front of the patient), " Do you want to order him anything for pain before you get started?" 9 times out of 10 they'll say, "Oh yeah. Sure. Lets give him so and so....as if he had planned on it all along.
    I say "deserves pain relief" because we have several pts who intentionally manipulate old wnds and injuires to get pain medicine. Im all for pain relief - but come on....
  12. by   Danelle
    [QUOTE=FZ1Tom]Danelle,

    Please let me know how the rest of your recovery/treatment (I presume you had an ORIF) went, what they did, how its turning out. Oh yeah, at least they didn't pester me with that pain scale back then :chuckle


    Hi Tom!

    Yes, I did have ORIF. He put a plate and screws in my fib, I cracked my tib, but doc said it did not need a screw because when he set the fibula, that break fell back into place. My ankle was severly dislocated as well. The scary part is that the doc wanted to do the reduction in the ER before going to surgery. He asked me if he could go ahead and reduce it or did I want to wait until we got to surgery. I said I want to be unconscious before anyone else touches my leg. He looked disappointed and told the other doc, "I usually reduce these in the ER, but since she wants to wait, I guess we will." WHAT!?!?! :angryfire Does he not think I've been through enough pain already.

    I have a question for you, How long after your injury did you experience any true pain releif? I have pretty much been in pain since my spinal anesthesia wore off. He sent me home with demerol/phenergan for pain, but I am still hurting. I just want to know when it starts getting better.
  13. by   FZ1Tom
    Danelle,

    How quick you heal up and the pain subsides naturally varies from person to person, but this was my experience..... When in hospital (Sun night to Sat morning, ORIF on Monday morning) after the surgery I got a IM injection of something every 4 hours, right in the hip. Started with a D, wasn't Darvocet, Demerol or Dilaudid. No idea what it was, but it was VERY effective - 10 minutes after the shot and I wouldn't feel a thing. They had to alternate sides for whatever reason (bruising?).

    I was discharged with an Rx for some kind of codeine med, if memory serves it was 2 tabs twice a day, 2 week supply. I took as directed for the first week, then backed off to one tablet twice a day for a few days, then one tablet once a day, till it ran out. No problems with the pain after I left the hospital, it was more of a dull ache than anything else. Methinks if you're experiencing pain on a par with a badly sprained, or even modestly sprained ankle after more than a couple weeks you might at least want to ask the doc about it. Your regular doc, NOT the sadistic ortho surgeon (I've decided after contemplation they're all sadists at heart :angryfire ).

    Keep the leg elevated, and when you get the cast off, TRY TO BE AS ACTIVE AS POSSIBLE......I dropped from 225# to 190# when the cast came off (12 weeks on crutches is great exercise), the doc said no running till he took one of the screws out. Alas, I didn't find an alternative activity (I played basketball) and being the huge eater I was (6000 cal/day!) I quickly gained about 75#. And the rest of my weight story has been pretty much downhill from there.

    You can definitely expect your injured ankle to be bigger than the other one for years, possibly forever. Dislocations do that. I had to buy two sizes of shoe, one 10 and one 11 for a year or so. If the surgeon did a halfway decent job, you keep the weight down, stay active (if you can't do running, try swimming or bicycling), and don't reinjure the area for about a year, you should get 95% ROM back or better. Forget 100% unless you're Supergirl. And oh yeah, if you turn that ankle again it WILL let you know about it, loud and clear, way more than the other one would. I speak from long experience; had many, many severe (grade II/III) sprains in both ankles,could tell almost as soon as it happened how long it would take to recover ("ah darn, that'll be 5 (or 10) days before I can play again". From my junior year ('86) through 1991 I'd wager I sprained one ankle or the other just about every month - have trashed ankles the way NFL football players do knees. Except I never got my ankles 'scoped or traded in

    Good luck!

    Tom

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IV tips and tricks