New ER nurse...needs help :)

[lvnlrn]

My preceptor (she actually is fairly new as well) and I were starting an iv on this sweet high school girl. I had no problem getting flash, but her skin was so tough that I couldn't get the cannula to thread. She didn't tan (which I know makes skin leathery), but she was definitely cool to the touch. I tried twice and couldn't get it. My preceptor tried once (pulled the cannula out, with it bent at a 30-40 degree angle). I grabbed the flight medic to finish the IV and he said she was a tough stick but really didn't have any advice. I would love feedback, tips, whatever on how to handle this next time...tia!

[DeBerham]

Practice, the more you do the better that you'll get. Often times that tough stick had that one vein that has been pierced so many times that it has a nice layer of scar tissue built up around it which can make starting a line difficult to impossible in that area. Look around for another site. Hands, feet, upper arms, breasts are all places to look at when you need access. If your department has it I would HIGHLY suggest getting trained up on using an ultrasound machine to start the IVs on the tougher patients. Generally now, instead of fishing around for 10 minutes if I don't see something I'll grab the machine and can usually (95% of the time) place a 20 guage on the first shot where it looked like I MIGHT only be able to get a 24 in.

[TestifyToLove]

Another option, as we say "go for the gusto." If you need access and the arms and hands don't look good, just head for the ac.

I occasionally have a few patients that have skin that tough. Are you advancing the needle and catheter 1-2mm after hitting flashback before trying to thread the catheter? Are threading with the turniquet on or off? While most literature I've seen says to thread with the tourniquet applied, we always release it for hard to thread patients, as it makes it easier to thread once we've hit the vein. You can also float the catheter in if you've got good flashback but not threading well. However, in the ED you would probably just opt for bigger veins in the ac than trying to do an intricate manuver to float a catheter into the vein. Inside of the forearm will have less tough skin, although ime you can't always tell from looking at skin if it's going to be tough.

We're an infusion center. We don't have u/s. We do have a vein light which does wonders for visualizing veins when we're struggling to see good options though.