I am a moron--I need I.V. help

jeannet83 · Apr 3, 2003

Hi, BiffMalibu!

In our ED, we prefer to use the antecubitals with 18g to allow for high volume resuscitation if needed. I especially like the AC area for those patients who are on the heavier side or check the hand veins or the wrist area.

Usually I use an 18g or 20g (I don't work with children). Sometimes a 22g if the veins are really tiny. Very rarely a 24g if it is an extremely tiny vein and the patient is an extremely tough stick.

If the patient seems tough, always ask the patient where their best veins are!! They will usually know if they have been tough in the past.

On men whom I don't see a vein right away, I always check the back of the arm as those veins pop up nicely in men.

For those difficult sticks, I do a few things. If the vein is small or not particularly palpable, I will get a washcloth as warm as possible (without being hot) and wrap it around the preferred vein, then wrap a chux or dry towel around the wet washcloth to keep the warmth in. It only needs to stay on about 5 minutes and in the meantime you can be doing other things, like checking the other arm for possible veins, etc. (Plus taking this 5 minutes and being able to hit a vein is alot easier than not doing it and taking 30 minutes of 5 sticks to find a vein!) The heat really helps to dilate the vein to make it easier to dilate, palpate, see and stick. You would not believe how much this helps. I will then use either a BP cuff OR 2 tourniquets. For some reason, the 2 tourniquets helps the veins to pop up better-I only use the BP cuff OR 2 tourniquet method in difficult sticks- otherwise one tourniquet will suffice. Place one tourniquet about 5 inches above the preferred vein and the other one another 3 inches above the first tourniquet.

For any stick:

I stick at a 15 degree angle and to the right side of the vein with my right hand while anchoring the vein with my left hand. I prefer to gently anchor the vein from above the stick site but don't press too hard or as someone said, the blood won't flow and the vein will flatten out. (Some people prefer to anchor the vein from below the site). Once you see a GOOD flashback, advance the whole catheter a little bit more. If your flashback is slow, don't get nervous and feel rushed- wait a few seconds to see if it will flow in, then if not, advance the catheter towards the direction of the vein and see what happens. Once in the vein with a good flashback, hold the apparatus with your insertion hand and use your OTHER hand to advance the actual catheter with your thumb and forefinger. I was never able to use that same-hand finger advancing method myself either.

Always make sure the arm you are using is in a downward direction to improve blood flow.

In those older folks, sometimes it is actually easier not to go for the huge rope veins because they tend to roll. Go for smaller diameter vein.

Just remember that starting IV's is like learning to ride a bike. Once you get it down, it is like second nature, and you'll hardly ever think about it!!

Good luck, you'll do fine! Jeanne

:) :) :)

BiffMalibu · Apr 4, 2003

hi jeanne

well i go back to work on sunday after a few days off. I'll let you know how it goes. I really appreciate your in depth advice, I printed it out and will refer to it often. That goes for everybody. I thank you all very much

Biff

ensense · Dec 22, 2003

As one of the ones that always gets called to start those hard to stick old ones, I can tell you every one has bad days, no matter how good they are. The best trick I use for starting IVs is to use a tourniquet as little as possible. I know that sounds crazy but as soon as every one sees you use gravity to engorge the vein then you stick and it doesn't blow you'll be a believer. Sometimes even that trick doesn't work on those dehydrated malnourished little old people where as you just try to get in the vein and advance past the blown area as fast as you can. I have done this alot and, yes, you have to hold pressure over the actual puncture site for a short time but you have your IV. Aside from practice, practice, practice I hope these help.

Happy Sticking.

athomas91 · Dec 22, 2003

for some reason - old women big veins blow easily - sometimes not using a tourniquet helps....

oneLoneNurse · Dec 22, 2003

I worked as a travel nurse for some years. I went down to San Angelo, TX for six weeks one time. They trained me real well. Next spot was Medical City, Dallas, TX. After I started an IV for my preceptor during the first couple of hours, I knew that I had passed my preceptorship.

Keep trying. Its a skill you pick up in the field. If you are into corrections inmates sometimes have great veins to learn on. But, be careful I had one want to take my head off one time.

Scis · Dec 22, 2003

BiffMalibu:

It's definitely an art. Some people are so great at it, others, well, so-so. Practice is the key, unfortunately, most people don't like you to practice on THEM, so make sure you never let on that you're not sure of getting it on the first try! Once you have a dry-spell like the one you're apparently having, it's hard to get over the hump. Just keep trying, read that website that was posted, it was very helpful, but the only way to get proficient is to keep attempting even the most difficult sticks. ScisRNCEN

LilgirlRN, ADN, RN · Dec 22, 2003

There have been several threads on this.. I am one who gets called allover the hospital before they call a CRNA to start IV's. My secret weapon is lidocaine, I put just a tad under the skin with a diabetic needle and stick through the bleb. I figure if the vein can't feel the needle coming it doen't know to run! lol. I use BP cuffs for torniquets sometimes and sometimes I don't use a torniquet at all, just depends on the situation. I like veins in the upper arm, most of the time they haven't been used. I've been known to use shoulders too. I don't like feet to stick for IV access. If the pt is dehydrated and nothing is showing up much I have used a 24 just until we can get them rehydrated enough for something else. I have put 24's in fingers, 20s in thumbs and 14's in AC's. I hate sticking kids although I have to do it all the time, something I'll never get used to. Good luck, practice makes perfect.

Long Term Care Columnist / Guide · Dec 22, 2003

I'm another one who often gets called in for the hard starts, but I have days when I can't hit the broad side of a barn! Try to keep it in perspective, and don't be so hard on yourself.......that NEVER helps.

There have been many good suggestions here......experiment with different methods, and don't be afraid to use the little "tricks of the trade". As an inexperienced IV starter, you might want to use gravity and warm packs for EVERY stick for awhile; it gives you both an advantage in getting the veins to plump up, and time to think through what you're going to do.

Another thing some beginners do is forget to take off the tourniquet before attempting to flush the newly cannulated IV site......I used to blow perfectly good veins before I got the hang of this! Now, I rarely use tourniquets on frail, elderly patients (BP cuffs work well if you really need the occlusion), and I do give pts. the option of Lidocaine.....it can distort the vein, but it also gives me a visible starting point. Speaking of visibility........sometimes all you need to do is turn on all the lights!

Scis · Dec 22, 2003

Lidicaine is helpful to us on our end, but speaking from the end of the receiver, Lido is painful!! The one time someone (an anesthesiologist) started an IV on me using Lido it stung like a son-of-a-gun, hurt much worse than the IV stick. The MD told me he gave it to "numb up the area" where he was starting the IV!

Good try! Of course he had no idea I was an ER nurse!

:eek:

BRANDY LPN · Dec 22, 2003

I blew em all the time when I first started and it was because I wasnt advancing the needle far enough before I threaded the cath. so try to advance farther before you thread and see if that helps. One of the new RNs I work wiith had this prob. too and this really helped her too. Also not using a tourniquet is really helpful if you can see the vein w/o it.

Dont be too hard on yourself, beleive you can do it and you will be able to:kiss

FlyingED · Dec 24, 2003

My 2 cents in particular Large people.

BP cuffs work well just remember you need a good pulse below the cuff (no blood in no pressure build up:D ). Remember your anatomy, where should a vein be, the AC is first choice. The close your eyes and feel, muscle, fat and fluid have different densities and once you get used to the feel you are golden.

I find with a lot of new ED nurses they are tentative in the initial insertion of the needle. Have you ever cut yourself on a very sharp knife and not realy felt it. It is probably because it was a quick cut. The same should be with an iv start, quick but controled, don't be afraid of going to deep. It helps to visualize in your mind that the vein you are looking at is as deep as it is wide. A 1/4 inch wide vein is normally 1/4 inch deep, so if you insert the catheter an 1/8 of inch you should be golden.

Loosen the catheter from the needle. BD catheters need to be loosened prior to insertion to advance smoothly.

One quick mess saving tip: I attach my syringe to the Heplock prior to the start. So once I have my IV in all I have to do is attache the Heplock with syringe and draw the needed blood, remove the syringe and fluch. The fewer times you have open access to the vein the less mess you will make.

Blown veins from a flubbed start. Veineous tissue will close quickly from a needle stick, normally. So, in a EMERGENT situation I don't mess around pulling the catheter out if it is acting like a plug in the vein. I then quickly prep a new site above the missed site and try again. If I am successfull I do what I need to do and then pull the failed catheter and dress the site.

All this is subject to change, there will be a time when everything I have just said is inappropriate and should not be done. But, there are times when it comes in handy.

One war story before I leave:

50 something WM hx of ETOH and IVDA with extensive hx of IDDM and PVD. PResents to ED vomiting blood. I was scared to death, Medics could not get IV access. Three nurses working to start an IV, I was the first to get access on the top of his foot with a 16g. It hurt like hell when I put in, but we had access. Actually he screemed twice, I missed the firt time.

GO BIG OR GO HOME!

ScarlettRN · Dec 24, 2003

I like to get a firm grasp of the skin from the bottom of the arm when it is an old person with loose flesh. This also anchors the vein so it doesn't move as much. Going in fast helps with rollers...I feel like I am tricking the vein if I go in fast.

I personally don't like to use the AC unless I positively have to, because when they go to the floor, it is almost impossible to keep the flow running due to arm bending.

While I am thinking of this, how many of you refer to a heplock/saline lock as an INT? I have always called it a heplock until I went travelling and the facility I worked in at the time called it an INT....which no one knows what INT stands for! Is that a regional thing, or is someone just extremely rural?