IV tips and tricks

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

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....

[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


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!?!?! 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.

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 ).

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

[quote=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?).


Thanks So Much! I think the problem is that I have never had an injury this bad before, and I just want it to be better RIGHT NOW, and of course, that's not going to happen. thanks again, the information has been very helpful

Not only 'rope' veins, but for patients using steroids. Those blow in a heartbeat.

I've found that approaching the task with confidence, talking with the patient while setting up (tape, dressing, etc.) and smiling all the while helps to put the patient at ease. While placing the tourniquet, I say " You know, there's a very important trick to this....You've gotta slowly open & close your hand 3 times. Now, it's gotta be just 3." By this time, they've usually done it 5 or 6, so it becomes a little joke. I also utilize light touch and the warmth of my hand resting lightly over the site to promote dilation. (My hands are always warm. Cold heart? ) Always tell them every step and never say it's a "little stick".

This has been an information thread for me. Thanks, everyone, who has contributed tips.

Don't usually have time for this in the ER (or the wax bath either ), but an oncology unit uses the hot wax bath intended for arthritis treatments to raise veins on the chemo pts who have "no veins" left at all. Dip the hand into the wax (it feels really good), wrap plastic, then a towel, and in 5-10 minutes MAMBO veins come up. Really impressive.

(Using the bath was my student teaching project in the late 70's, now you can buy them at Walmart for softening your skin).

1. Be confident! Do not go in to the pt and say I'm going to "try" to start your IV. Would you like the nurse who's going to try or the one who's going to get it?

2. Bacteriostatic saline is the greatest thing since sliced bread. Use 10 units in an insulin syringe and inject intradermally alongside the vein. The benzyl alcohol works as a local anesthetic but it doesn't burn like lido and it works instantly. It only works for about 45 secs though so don't inject until you have everything ready. (I started a 16 g on someone using this technique and they THANKED me for starting the IV. When was the last time that happened to you?)

3. On elderly people with huge veins, tie the tourniquet very loosely. The reason those veins are so big is because they have a lot of back pressure. With the sudden release of the tourniquet, the pressure is released and the vein blows. You can use a BP cuff but make sure it's not one of the leaky ones.

4. When you palpate the vein always use the same fingers. This trains them to feel the vein. If you keep switching fingers, they never learn. Also when you palpate the vein, "bounce" your finger. Veins bounce, other things don't (like tendons).

5. Finally, in the ER, all adult pts get an 18 in the AC period end of discussion (as long as I can get it). In order to do a CT PE protocol, this is where it has to be. I can give blood, run a code, fluid bolus, send them for an emergency angioplasty etc. I have been messed up too many times but someone who comes in with a stubbed great toe or some other stupid complaint, put in a 20, and the doc says "Let's do a PE protocol." Now I have to stick them again. The only exceptions are traumas, big bleeds or tearing back pain (possible dissecting AAA), they get something bigger.

6. If you are on the floor, then you can use a smaller bore catheter, but this the ER and you just never know.

I was on the IV Team for 3 years and we each started about 3000 IVs a year. There is no substitute for practice. IV therapy is 10% talent and 90% practice. Good luck!

PS I was also the only IV nurse on nights, so I had no backup. It's amazing how good you get when you don't have a choice.