IV tips and tricks

WOW! Good thing surgeons dont try this in the OR! or do they?

No tourniquet on little old fragile veins.

Be creative, we have veins everywhere, and I mean everywhere.

Lidocaine is our friend, use it.

Warm compresses, how simple..but it makes a lot of difference in a lot of ppl.

Vasopressors cramp my style.
Please don't try 6 times then call me...

You know surgeons who start IVs??????

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....

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

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.

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

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 ) 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

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 . 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

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......

I have NEVER been able to develop the skill of FEELING for good veins. Am I just stupid??? ugh.