IV tips and tricks - page 14
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
May 8, '06Specialty: med/surg, telemetry, IV therapy, mgmt ; Joined: May '05; Posts: 15,027; Likes: 8,980Quote from Woman_in_loveIt should be nearly flat. Picture this. . .a long stick fitting into a long tube. That, in essence, is what you are trying to accomplish. If you bring the needle into the vein at, let's say, a 45 or 60 degree angle, your chances of the tip going completely through the vein and out the underside of it are much greater. Then, you'll get a blown vein and probably a good sized hematoma. So, keep the needle as low to the skin as you can, bevel up, and thrust it forward quickly.What angle do you insert the needle? Should it be completely flat, parallel to skin?
May 8, '06Occupation: Staff Nurse Specialty: Med/Surg ; From: US ; Joined: Sep '05; Posts: 803; Likes: 530Quote from rn4booboowhat's an ad nauseam?Nurses eat their young is ad nauseam- seems like you have it down pat though?
May 9, '06Specialty: med/surg, telemetry, IV therapy, mgmt ; Joined: May '05; Posts: 15,027; Likes: 8,980Quote from Jess1983ad nauseum is a Latin phrase that means "to such a degree or extent as to produce nausea" (from Taber's Cyclopedic Medical Dictionary, 18th Edition)what's an ad nauseam?
May 9, '06Joined: Apr '06; Posts: 406; Likes: 943To respond to the post about EMLA. I work in peds and although EMLA is wonderful, it vasoconstricts and makes big, juicy veins hard to stick. It is great for lumbar punctures, accessing PAC etc. We did use EMLA for some IV starts, you just had to pick the right vein. Also, EMLA takes an hour to work, so if you need access immediately, you cannot use it.
May 9, '06Occupation: RN/LMFT Specialty: 7 year(s) of experience ; From: US ; Joined: Nov '03; Posts: 3,081; Likes: 233Quote from DaytoniteYou hear it in reference to something repeated over and over to the point where you want to throw up.ad nauseum is a Latin phrase that means "to such a degree or extent as to produce nausea" (from Taber's Cyclopedic Medical Dictionary, 18th Edition)
May 9, '06Specialty: med-surg/ortho for now ; Joined: Mar '05; Posts: 89; Likes: 2Great thread, I am always learning something new on this site
May 15, '06Occupation: Paramedic Specialty: 23 year(s) of experience in Peds Cardiology, Peds Neuro, PICU, IV Jedi ; From: US ; Joined: Jul '05; Posts: 1,084; Likes: 466Here are a few things I've learned in the last 12 years of starting IVs on all ages...mostly the young.
. If the baby's asleep and wakes when you flush the IV...it's probably bad.
. If the left arm has an IV infusing and it's twice the size of the right arm (assuming no preexisting conditions)...it's probably bad. But check the TAPE JOB. Too tight on the tape will send an IV south very quickly.
. If you're having trouble with an IV, break it down - take the tape off CAREFULLY and try to find out if the catheter is still in the vein - or in the skin for that matter. Sometimes over time the catheter can kink, especially with active children. Reflush, retape.
. Flush your IVs frequently when establishing them. Both right when you hook up your tubing, and during the taping/securing process. You have no idea how strong little arms and hands can be and they can wiggle that catheter out of that vein like nobody's business.
During an attempt at an IV on a little one, you have to have someone who knows how to effectively immobilize a little one. You have to pretty well immobilize little ones - and that can be difficult. Swaddle the baby and leave out only the extremity you're working on, if possible.
. CHECK YOUR IVs FREQUENTLY!! "It looked fine this morning but I didn't flush it...umm..duh!!
. Try your best not to "overtape" your site. It is a royal PITA to tear down all that tape 20 minutes / 2 days after you started it. Less is more...as long as it's secure.
. Use a padded board to immobizilize the extremity. Tape securely but not tight enough to occlude circulation - it's easy to do (taping too tightly, that is).
. Double side your tape for patients with sensitive skin (babies) / patients with tons of hair. In this instance, use your tape mostly on the skin directly around the insertion site, if you need it at all. We use a Tegaderm and silk tape for a chevron, if necessary.
. Discretion is necessary when establishing an IV. Don't put a 24 gauge in a kid who's 10 years old, has great veins, and is gonna get gentamycin for a week. Use common sense. If he can tolerate a 22, or even a 20, give it to him.
. Use whatever pre IV anesthetics your institution allows. We have cold spray and EMLA cream. Both work well, but be advised EMLA has a tendency to make veins disappear -and it gives the skin a "waxy" feel, which can make palpating a vein you found 1 hour earlier a very tricky ordeal.
. IF THE SITE IS COLD, YOU'RE GONNA BE HARD PRESSED TO FIND A VEIN. Warm the area up with a warm pack first if necessary. Cold extremities = no veins.
. Start distally. Look for IVs in the patients hands before moving up the arm. Try to avoid the AC if at all possible, unless it's critical and you need fast access, or if the patient just doesn't have anything else...it happens more often than you know.
. Don't put an IV in a 16 year old girl's right hand IF SHE'S RIGHT HANDED unless you just can't find anything anywhere else. This goes for ALL children/ adults who are at the age where the dominant hand does most of the work. Also true of infants who suck "that thumb". Again, unless you have no other options.
Be aware that some infusions, like Potassium, sting when infusing, especially to small veins. Antibiotics like gentamycin are caustic to veins as well. Keep this in mind when assessing your patient's response to therapy.
Look everywhere for the best access. A large vein in the saph is better than a small vein in the hand, at least for the purposes of the attempt. It's far easier to his a large target with a small needle than to try and force a catheter thru a tiny vein.
If your patient may require fast acting meds (Adenosine), or if they're in any way unstable, try to establish an IV as close to the heart as possible. Closer to the heart means faster action...and if your patient's HR is 220..they're not exactly Kings of Perfusion.
If you're going to be the one starting the IVs and you don't have much experience...practice on your coworkers before you come in and stick my child. Also, if you have the option - start small...work with the healthier kids before moving on to attempts on the truly sick ones. That way I don't have to worry about you blowing 2 veins I could have used for access.
Last but not least, know your limits!!! If you stick twice and aren't successful - FIND SOMEONE ELSE. Preferably someone with more experience/ or someone you trust.
Children's - Dallas
May 15, '06Joined: Jul '05; Posts: 169; Likes: 55[Quote]2. When removing a needle from someones arm - dont put pressure on site until the needle is out. Some lab techs have put pressure on the site before they remove the needle - this will not only tear the vein its in - but it really hurst and leaves major bruising
To the previous poster about most painful sites to stick - in my experience its usually the top of the hands. But every one is different.[End Quote]
From a patient with LOTS of experience being on the receiving end of IVs, AMEN, RN92, AMEN! I really hate the hand sets as the most uncomfortable. If they are going to be in any length of time at all I'm not wild about the inside of the elbow. I'm gonna be using that arm and bending that elbow!
And - even for just a blood draw, most definitely, please, get the needle OUT BEFORE applying pressure. Thanks to all you for being so caring and so diligent.Last edit by CrohnieToo on May 15, '06
May 15, '06Joined: Jul '05; Posts: 169; Likes: 55Quote from Angie O'Plasty, RNIs this the case w/all CT contrast procedures or just w/CT angio? Thanks for the tip about the AC or higher. In the future I will ask for higher.I was told that it's because the force of the injection will blow small veins. The contrast can cause necrosis to the tissue if it extravasates.
Therefore, our hospital will only do a CT Angio with no less than a #20 to the AC or higher.
May 25, '06Joined: May '06; Posts: 65I am in shock here...NURSES are putting in central lines!!!!! WOW not in my part of town. We just clean them...
May 28, '06Joined: May '06; Posts: 570; Likes: 1,902Quote from CrohnieTooMost people don't realize or even think about what's on an IV catheter. When you're removing it, there's probably few days worth of biologic detritus coating that catheter. When you remove it, putting pressure on it would strip the catheter of all that schmutz and expel it into the patient. Additionally, there is a real danger that if the person who put in the catheter had partially transected it, putting pressure on removal may complete the transection and you'll have a catheter tip embolus (in this case apply tourniquette right away, then call for help)....2. When removing a needle from someones arm - dont put pressure on site until the needle is out. Some lab techs have put pressure on the site before they remove the needle - this will not only tear the vein its in - but it really hurst and leaves major bruising...
From a patient with LOTS of experience being on the receiving end of IVs, AMEN, RN92, AMEN! I really hate the hand sets as the most uncomfortable. If they are going to be in any length of time at all I'm not wild about the inside of the elbow. I'm gonna be using that arm and bending that elbow...
Elbow, or antecubital vein IV's have be a patient's bane of existence since the invention of IV's. However, in the emergency setting, it is absolutely the best place for the following reasons:
1. it's not a long term solution, so it's no big deal
2. it's a big vein, it allows for good blood draws at the time of insertion, allowing for one stick does all.
3. it's a big vein, good for variable required rate contrast injection.
4. it's a big vein, meaning it's normally a size 20ga cath, allowing blood transfusions.
5. it's a big vein, meaning you can't miss.
For the few hours of inconvenience in the ER, it is by far, the best site, bar none.
May 29, '06Occupation: RN staff nurse Joined: Dec '04; Posts: 485; Likes: 168Quote from Angie O'Plasty, RNGood answer our facility they only require a #18 in AC for ct chest otherwise they are ok for #20's on CT's elsewhere. Per our CT tech: The reason for the #18 angio for a CT chest is that they shoot 120 cc at a rate of 4cc/sec over contrast is 115 cc at 2cc/sec in less then a minute. If you do not have a big vein and a big needle the pressure can blow the vein.I was told that it's because the force of the injection will blow small veins. The contrast can cause necrosis to the tissue if it extravasates.
Therefore, our hospital will only do a CT Angio with no less than a #20 to the AC or higher.
Hope that answers your question satisfactorily.
My previous facility in the ED,except in a code the only time you can use the AC is for a chest CT, and after 3 failed attempts anywhere else. they reccommend you start on the hand or wrist first. When you do use the AC you must document why because the IV will report you and you will have to explain otherwise. (do not think I agreed with this in the least I just had to follow protocol.)