Starting IVs on old sick people

  1. Hey,

    I've read tons of info on starting IVs and used to start them quite frequently a fews ago but now am having problems. Am working at a new job where we do our own IVs and not having good success. I have only tried on a few patients but the patients have been severely sick, old, with bad skin, and possibly in renal failure.
    Two of the people have been sick old women, one with COPD. I tried to get the vein but the flash is none. I think i'm rolling it but I'm not sure. After I take the catheter out (a failed attempt) I look at the puncture whole is right over the vein, like I was in the right spot. I'm I going to deep, are these veings in skinny old people a lot more superficial than I'm anticipating?
    Any advice would be appreciated as I refuse to be one of those nurses who isn't good with IVs!!!

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    About zacarias

    Joined: Oct '01; Posts: 1,352; Likes: 83
    RN; from US
    Specialty: 14 year(s) of experience in tele, stepdown/PCU, med/surg


  3. by   sbivrn
    Those are hard ones, no doubt. You are dealing with poor skin tugor, probable dehydration, and poor venous status. Just make sure you are not using a catheter that is too big. A 22 gauge catheter is plenty big for most infusions. Forget what they told you in nursing school about that. INS standards are to use largest vein with smallest catheter possible for prescribed treatment. Sometimes a peripheral IV is just not possible. In those cases ask the MD for an appropriate central line. (picc, IJ, Sub clavian) This will also cut out lab sticks for these hard to stick little old folks.
  4. by   PICC ACE
    Two clues in what you wrote. First,when you say you take out the failed angio and the site is "right over the vein",that's a possible problem. Try going in the SIDE of the vein,not the top.Next,bad skin. Fragile skin goes hand in hand with fragile veins: skin is epithelium and connective tissue,both of which tissues go to hell when you get old and adding steroid tx's for COPD only hastens the process. Veins are epithelium on the inside,then a little muscle layer then epithelium and connective tissue. Not much you can do about that of course except to anticipate that the vein walls will be very thin and easily damaged (i.e. "blown").
  5. by   canoehead
    If blown veins are an issue try going without the tourniquet.
  6. by   zacarias
    Hey guys, thanks for all the tips and tricks! I was wondering something. The other day I tried an IV and got it but to get a flash I had withdraw the needle a little bit like I had gone through and past the vein with the first thrust.
    Again, I think that these old folks with horrible skin actually have extremely superficial veins and I think I need barely insert the angio and then go deeper if needed. I will try going from the side but that method always scares me for some reason.
  7. by   bettycat
    I have been an IV nurse for 20 years. You said the viens roll from you, this is a problem that a lot of nurses have, the secret is to make sure you have good tension of the skin which will hold the vien in place. I never have a problem with rolling veins using this technique. I lhave always loved starting IVs in old people with fragile viens. You have to stick very gently like you are sticking an egg shell. Also have you ever tried sticking with the bevel down, this works will with older people with fragile veins.

  8. by   CritterLover
    Quote from bettycat
    i have been an iv nurse for 20 years. you said the viens roll from you, this is a problem that a lot of nurses have, the secret is to make sure you have good tension of the skin which will hold the vien in place. i never have a problem with rolling veins using this technique. betty

    Quote from canoehead
    if blown veins are an issue try going without the tourniquet.

    i second both of theses techniques.

    sometimes, i will haved a second nurse (or a cna) hold traction on the patient's skin above the stick site, and i will hold traction below the stick site. i especially do this when i have to use a tourniquet.

    as for not using a tourniquet, i frequently do this for patients with thin, fragile skin. on these patients, if i can see the vein, then i skip the tourniquet.

    for the dehydrated folks, somtimes you need to go slow (i know, this hurts more) and pause once you get a flash before advancing the cannula. it is difficult to describe the rationale, but i often stick using ultrasound. i have seen often in dehydrated folks, that the needle completely compresses the vein when you are sticking. if you try to advance the cannula then, you will either hit the back wall of the vein ("the catheter won't thread") or you go through the back wall of the vein ("the vein blew"). however, if you pause when you get the flash, and allow the vein to recover (bounce back) then you can usually thread the cannula. tough to get the timing down, but it does work.
  9. by   CRNI-ICU20
    Here's some tips from an IV Queen....
    1: if you warm the arm with warm packs....or if you have a blanket warmer in your unit....put a warm blanket around each arm.....
    this will bring the veins more to the surface of the skin where you are able to palpate them...
    2: I don't go so much by visual as I do by palpation.....
    I may take a couple of mins. (if time allows) to 'feel' the vein....
    some people come in so dehydrated, this is hard to do...
    In that case....I go for an antecubital site because the goal is to get high volume of fluids in quickly .....then once they have some fluids on board, the site can be re-located where it isn't in the bend of the arm...
    3:After preparing the skin in accordance with your facility's policy, I again run my finger, (gloved) over the venous tract....getting it clear in my mind where I plan to access it...
    4: I usually don't 'attack' from the top....because if people have rolling veins, this will surely make that happen...I usually 'attack' from either one side or the other, depending on the site...
    5: if you can, pick a site where there is a little more 'meaty' tissue surrounding the, avoid that thin onion skinned place on the back of little old ladies hands.....inevitablely the weight of the catheter and the iv line will pull that sucker right out....because the skin will just tear....
    6: I agree that a 22 ga. is plenty large enough for whatever you might need to infuse.....
    7. A small amt. of tension COUNTER to the attack site is helpful....
    Then insert the cath, bevel up, into the skin and direct the tip toward the side of the for flashback....
    8: once you see a bit of flashback...give the cath just a little teeny tiny 'grab' hold of the vein....then slide the cath into the vein....and withdraw the needle....being sure to hit the needle closure button as you withdraw....this can be done with one hand, while the other puts just a smidgen of pressure on the vein just accessed so you don't leak all your patient's blood all over while scrambling to insert a J-loop or lock, or whatever your facility uses...
    9: don't tear off your tape and put it against a nasty dirty bed rail....
    because now you have just put contamnated tape on your patient's open IV site....better choice: tear your tape and leave enough to hang OFF the table or bedrail..., and tear off that portion that was in contact with the bedrail or whatever....better yet, have someone tear the tape off as you with tegaderm, or whatever your facility uses....and secure the iv line so the tension is on the line....not on the site...

    Often, dehydrated patients as well as those who have poor vascularization, will often have a flash back....but then nothing comes out when the needle is withdrawn...this doesn't mean you aren't in the could be poor perfusion....(bad heart patients do this all the time), or the vein is spasmed around the catheter, impeding blood flow, or they are just so dehydrated or anemic, no blood comes out....DON'T PULL OUT YOUR CATHETER!!, you could be in the vein.....just push a little saline, and see if it flows, or bubbles up....if you get a tissue bump, you aren't in the vein....if you get easy push flow, you most likely are in, just give it a min to stop spasming...
    I hope I have helped you...
    IV insertion is one of the hardest skills for some of us....but in time, you will get the hang of it....just don't give up....or get frustrated...
    Take the time to learn from someone who is a good 'sticker' and observe them.....then see if you can mimic their technique....
    Good luck....
  10. by   maryloufu
    Thanks everyone= i am not the OP- but there is alot of good stuff in here for me too! (Especially me rethinking all of the AC sticks that come from the ER- get some fluids in and try a better spot!) Once again thanks!
  11. by   tridil2000
    Quote from maryloufu
    Thanks everyone= i am not the OP- but there is alot of good stuff in here for me too! (Especially me rethinking all of the AC sticks that come from the ER- get some fluids in and try a better spot!) Once again thanks!

    just so you know why we do what we do....
    any chest pain complaint gets, at the very least, 1 20g or larger to the ac. if they need a ct angio, the tech will only inject dye into that. IF they're a real mi, they will need at least 2 iv sites with 20gs or more as well.

    abd pain also gets a 20g or more.... also preferably in the ac. if they're an acute surgical abd, they may need fluids or bloods quickly. hence, the choice.

    just an fyi.... there is a method to our madness
  12. by   dknunges
    A couple of tricks I have learned from starting IV's on people with fragile veins, no SQ tissue or rolling veins:
    Instead of using a tourniquet, I use a blood pressure cuff pump up to 20 below diastolic pressure. This makes for an even distribution of pressure and will be less likely to cause veins to blow.
    Stabilization of veins and keeping skin taught is key. I do this by wrapping my hand around the underside of arm which also allows to enter vein at a low enough angle by not having to work around my own fingers or thimb
    Using the indirect method of starting an IV works well. This is done by entering the skin to the side of the vein, taking a breath, then angling needle towards the vein slowly until you get a flash.
    When you are using a tourniquet make sure you do not leave it in place for longer than 2 minutes. If it is left on for longer, it can cause over extension of the vein which cause veins to "go flat". So place the toruniquet on to locate the vein, release but leave in place while you prepare for veinpuncture. Re-apply just before you are ready to access the vein.
    Try to avoid the AC because this is a frequently used site for drawing blood as well as IV starts in ED. With that being said there is scar tissue that has formed there which is very difficult to thread a catheter through.

    Just my two cents
  13. by   vamedic4

    I primarily work in peds...but we do get some older patients every now and again.
  14. by   zacarias
    Thanks for all the tips. What do you mean "cause the vein to go flat?" Also, One more question. I notice when I apply a lot of tension under where I'm going to poke, the vein suddenly becomes flat and I lose my feeling of how deep to go etc or where exactly it is because it's flat. How do I keep it there to not roll yet still have a vein that's not obscured or flattened by my tension? THANKS!!!