IV tips and tricks - page 3
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
Jul 6, '04Occupation: RN supervisor and staff nurse. Joined: Apr '04; Posts: 124; Likes: 49[QUOTE=nursbee04]A friend in nsg school had trouble remembering where her veins were once she had rubbed the site down with the alc pad, so our clinical instructor taught her to pick her vein, pick out where she is going to insert the IV and take the end of a skinny ball point pen (not the marking end) and make an indentation at the site (not enough to hurt the pt...), then clean. The indentation will stay long enough for you to stick. Good trick for beginners.
I clean the site with the alcohol pad then leave it on the site. Once you're ready to stick it remove the pad, let dry for a few secs and go.
Jul 6, '04Joined: May '04; Posts: 11; Likes: 1Quote from TraumaInTheSloti agree... even with some patients like the sicklers, you should believe them when they say "that's not a good vein, try this one.."oh, and if a heroin addict says "thats not a good vein" , they are right.
Jul 6, '04Joined: Dec '02; Posts: 1,368; Likes: 997ALWAYS listen to postitve advice like, "They usually have good luck with the one in my left hand." Take advise like, "They always have to call anesthesia to start me," with a grain of salt. I've been successful with a lot of "anesthesia starts."
I like to stick just above a bifurcation (sp?) because it provides a bit of an anatomical anchor.
Look and FEEL...don't just look...it's amazing what you can feel, but not see.
Don't tie your tourniquet too tight on patients with big ropes...you'll risk blowing the vein.
When you don't succeed the first time, try sometime different the second time...change arms, try a smaller cath, move the tourniquet higher or lower...
BTW...I learned on 18s and 16s...can't imagine using anything smaller for a patient who needs blood or a bolus or D50...
Jul 9, '04Occupation: Physician Assistant Joined: Jan '04; Posts: 97; Likes: 12I think the lesson here is that you need to guard against what you don't know. When someone walks into the ED, you don't know what is going on with them until you perform a physical exam and review the appropriate diagnostics. That generalized ABD pain could very well be an atypical presentation of a dissecting aortic aneurysm. Then how are you going to get a large bore cath when they have ruptured and are clamped down so that their antecubital fossa veins have magically disappeared? Are you going to be frantically calling for someone to come start a femoral while the patient crashes through the basement? Taking reasonable steps to prepare for the unexpected is just something that is appropriate when you don't know.
It might be appropriate for smaller guage catheters to be started in non-emergent settings where a patient's condition has been better defined.
Someone mentioned using a bifurcation as a natural anchor. I like to go in right below the bifurction and hit the vein where it splits rather than going on top of the vein. You might have to advance the needle slightly further to get through some valves, but its a pretty sure bet.
Jul 9, '04Occupation: Float RN Joined: Feb '04; Posts: 359; Likes: 14[Q
Someone mentioned using a bifurcation as a natural anchor. I like to go in right below the bifurction and hit the vein where it splits rather than going on top of the vein. You might have to advance the needle slightly further to get through some valves, but its a pretty sure bet.[/QUOTE]
I agree, I almost always have success when I go in below the bifurcation
Jul 9, '04Occupation: R.N. Specialty: 27 year(s) of experience in cardiac, diabetes, OB/GYN ; Joined: Feb '02; Posts: 1,947; Likes: 418We had to learn how to put in an iv with the lights out in the room so you could feel the vein only...Interesting...I still turn on the lights...Also, if people remember granulex or the spray used for decubitus ulcers to increase circulation, that also helps...With autogard brand ivs catheters, you will not feel the pop we feel or felt with quick caths...I agree, so what if a topic has been discussed before. If it is an opportunity for learning, go for it....For my warm compresses, I place a heated face cloth or towel that has been warmed in the microwave or wrap it in a chux as one would for an iv infiltrate and leave the hand down....That usually works for me..AND, as has been said, if someone with bad veins or who is a difficult stick, I believe them...Even in labor and delivery where large gauge ivs are preferred, if I think I will miss with an eighteen I will go for a twenty and, by the way, for those of you using the autoguard brand, their twenty gauge is the size of our old eighteens..AND, if someone has difficult veins, the larger gauge needle can cause more damage, and I speak of autoguard because we use them now....So, I had to attend a conference...
Jul 9, '04Occupation: R.N. Specialty: 27 year(s) of experience in cardiac, diabetes, OB/GYN ; Joined: Feb '02; Posts: 1,947; Likes: 418Actually, through the autoguard, blood runs as well as an eighteen or more....
Jul 9, '04Occupation: R.N. Specialty: 27 year(s) of experience in cardiac, diabetes, OB/GYN ; Joined: Feb '02; Posts: 1,947; Likes: 418A lot of times blood "Hemolyzes" when the lab takes awhile to get to it....We hand carry our specs to the lab on babies or absolutely needed draws...Somehow they NEVER hemolyze then...And , if it is between four or five sticks or a perfectly good twenty gauge, I am going with the patient rather than the anesthesiologist preference. Unless of course, we need two sites or things are more serious....The patient comes first.
Jul 13, '04Joined: Nov '03; Posts: 75; Likes: 7My 20 yen......if a 22 g is all you can get, then use a 22g gage. Run in a little fluid then try again with a bigger needle. If you really need a largebore IV and they have no good access, I frequently have success with an EJ stick. But check with your department guidelines about putting one of these in first.
EJ's are really simple to do. If the patient's condition allows it, stand at the head of the bed and turn the patient head to the opposite side of the body where you want to place the EJ. This will flatten out the neck area making it easier to see the external jugular (or if you're in Michigan, the external "juggulo".....you down with the ?) Locate the external jugular (this is a fairly shallow vein and may or may not be distended depending on a variety of factors). It crosses the sternomastoid in the superficial fascia, traverses the posterior triangle and then pierces the deep fascia to enter the subclavian vein in the chest.
Again, if the patient's condition allows, placing the pt in trendelenburg position can distend the vein, making it more visible. Prep the site and insert the needle towards the heart. Then do the "dirty bird" cause you got a big ole line in that patient!
Now as far as getting lines into people, nothing' worse than spending an hour to get a good line and have the patient pull it out. What do you use to secure the site? Veni-gard? Op-sites? IV-loc? A big patch of tape?
What kind of splints do you use on pediatric patients? My hospital's kinda low-budget so I'm currently using the 3 popcicle and 4*4 guaze method and securing the whole mess above and below the joint/IV site with tape.
This was previously posted on an old thread too, but worth mentioning....you can use a little local anesthetic, buffered lido or EMLA cream to numb the pain of the IV stick and your patient will be very grateful for it.
Jul 13, '04Joined: Nov '03; Posts: 75; Likes: 7Quote from Calfaxpopcicle = tongue depressor, ahem.My hospital's kinda low-budget so I'm currently using the 3 popcicle and 4*4 guaze method and securing the whole mess above and below the joint/IV site with tape.
Jul 13, '04Joined: Jun '04; Posts: 101; Likes: 8I don't want to repeat everything that was said before. My one tip is when you get a blood return, don't immediately advance, go in a hair further then advance. When I first was starting iv's I would advance as soon as I hit the vein and then it would blow. This works for me....usually
Jul 22, '04Joined: Mar '02; Posts: 1,888; Likes: 117Quote from mother/babyRNActually, that's not true--I used to work for BD and taught InSyte Auto Guard to health care workers all over the country. What you MAY be seeing is the fact that IAG 18s come in more than one LENGTH--so you may be seeing an 18 that is LONGER than your previous brand, and perceiving it as BIGGER--that is, looking like a 16. But, IVs are standardized everywhere in the world--18G is green, 20 is pink, 22 is blue, 24 is yellow--regardless of brand. I agree with those who point out that you have to consider the situation and the patient. I trained as a corpsman during the Vietnam era, so we learned on 18s, 16s and 14s--we were learning to address trauma situations. I, personally, like to start large bore IVs, but I have worked with many a fine anesthesiologist who routinely only put in 22s. If the patient needed more fluid, or faster, he could always speed up the drip rate. If more vigorous fluid, or blood, resucitation was needed, or we ran into problems, it only takes a second to start a second, bigger IV., for those of you using the autoguard brand, their twenty gauge is the size of our old eighteens..AND, if someone has difficult veins, the larger gauge needle can cause more damage, and I speak of autoguard because we use them now....So, I had to attend a conference...
When I worked home infusion, they often gave blood through 24 G IVs. Remember, this is not a truama situation, and there is no rush. For those who think it cannot be done, or is "asinine--"--check the INS (Infusion Nurses' Society) standards and guidelines.
I have run into people who say they hate the InSyte Auto Guard. It usually means they have not been trained to use it properly. Let me give you some tips here that might come in handy.
Here are a couple of tricks to avoid blowing the vein, (IAG is sharper than most other IV catheters--the sharper the catheter, the less to the vein accessed)
---Before you start, hold onto the catheter hub where it attaches to the clear flash chamber (just above the button.) You will see a slight notch there. BE CAREFUL NOT TO PRESS THE BUTTON!!!
---With the opposite hand, grasp the clear flash chamber at its base, and twist it--NOT THE CATHETER ITSELF-- to the right, a full circle, (360 degrees) until you hear a slight "click." You have brought it all the way back where you started, to that "notch." (The notch is just above the button; again, be careful not to press the button.)
We taught this step by saying "take it for a spin. " This action will loosen the heat seal between the catheter and the stylet, and allow the catheter to "glide" off the stylet easier. If you neglect this step, the catheter may feel "sticky" when you attempt to advance it off the stylet, and may cause you to inadvertently "blow" the vein when you struggle with it.
---Here is the most important step: Remember, your approach should be LOW AND SLOW.
---Place your thumb and index finger on the little "grooves" on the side of the flash chamber (created for that very reason.)
---Angle the catheter, bevel up, at approximately 15 to 30 degrees above the skin.
---Stick, (just enough to get the catheter tip in) stop, lower the catheter almost flush with the skin.
---As IAG's stylet is sharper than some of the other brands, and thus cannulation less traumatic, you will not feel a POP as you enter the vein as you do with some other brands--that "pop" with other brands is trauma to the vein from a stylet that is not sharp enough.
---It may take a bit longer than some other brands to see the flash in the chamber--but if you have successfully accessed the vein, it will appear. Be patient.
---Now ADVANCE THE ENTIRE UNIT--not just the catheter--approximately 1/8".
---This is important with ANY IV catheter, to make sure a good portion of the actual catheter is in the vein--not just the tip of the stylet.
---Go ahead and thread your catheter off the stylet.
---Push the button, stabilize your catheter, put digital pressure above your tourniquet, (this will cut down on "back-bleeding") and pull your tourniquet. ----Dress IV site according to institutional policy.
FYI: the 22s and 24s have a "divet" cut into the tip of the stylet, which allow you to see a drop of blood IN THE CATHETER before you see it as a flashback in the chamber.
Another FYI: One of the most common reasons for the complaint of "I got a flash, but the catheter won't thread" is failure to advance the entire unit another 1/8" into the vein before threading the catheter off the stylet--it means that only the tip of the stylet is in the vein, and not the tip of catheter itself.
Jul 22, '04Occupation: RN Joined: Feb '02; Posts: 372; Likes: 15stevierae - thanks for the tips. Will try this weekend with a new technique!