IV start on obese pt

MAISY, RN-ER, BSN, RN · Nov 13, 2008

I say lucky patient.....there is never a reason to torture a patient. If you felt nothing, you did the right thing. As for the others giving you the eye...everybody misses.

Most obese patients are very difficult, the wrist is the easiest spot. Why the 18 unless they were emergent? Is this your facilities base insertion?

If so, perhaps they need to be enlightened. Part of doing no harm is using the size that is minmally invasive for the task at hand. Fragile veins, especially in sick people do not require an 18g at every admission-the iv should match the potential treatment.

I know this has been a contentious issue in the past, but evidence based practice speaks volumes, just because we always did it that way,does not!

My hospital has a number of autoimmune, dialysis and cancer patients with horrible veins! We use doppler and our practice is to insert what you need in the foreseeable future. Obviously, if an 18 g is required than do it....but...if all you can get is a 22g, you can always use that to sedate the patient as the central line is inserted : ) Catch my drift?

Maisy

TraumaNurseRN · Nov 13, 2008

What was I doing wrong? I get this very obese lady the other day. I cannot see a vein ANYWHERE let alone feel one. I have been a nurse for 10 months and do okay at IVs. Well, I couldn't even ATTEMPT this IV because if I can't see or feel it, forget it. So I get this other nurse to come help me, I had to leave the room (I had wanted to watch) to assist another pt. Well, the other nurse got an *18* in her wrist and says to me, "She had huge veins". I felt like a fool, plus "huge veins"? Hardly.
Lately I have been blowing the veins (call me the hematoma queen) or I get in but can't advance the catheter. And you know those tiny veins that look as thin as a pencil line? Other nurses can get IVs into those apparently, but not me. My confidence now sucks. At the last hospital I was at I had a lot more younger pts so I was more successful (I also had better IV supplies). At the facility I just transferred to I have a lot of very old pts who are bruised up on coumadin (with crepey purple arms), a lot of dehydrated pts. Ugh....

Don't take it personally.....Sometimes we can't get them....sometimes we can......It's not the end of the world!....she got an IV

mama_d, BSN, RN · Nov 13, 2008

I'm usually great at IV starts, but there are times I couldn't hit the broad side of a barn. There have also been times when another nurse has asked me to try on a hard stick, I've put the tourniquet on, seen a great vein, popped it off to leave the room to get supplies, come back in, and the vein that was just there is nowhere to be seen. Sometimes for whatever reason veins just don't cooperate with us, but will for other nurses.

As far as the not being able to advance, I find that oftentimes "floating" the catheter in with a saline flush helps. And be sure to pop the tourniquet off before flushing after you have the catheter in.

morte, LPN, LVN · Nov 13, 2008

http://en.wikipedia.org/wiki/Anatomical_snuff_box

even if you cant see it, feel it.....it is there the cephalic vein......

Gabe's GirlLVN · Nov 14, 2008

obese pt's in tx are usually hard sticks. after a couple of nurses attempts and a charge nurse attempt we called the house supervisor who got it on the second try just last week. keep having faith in yourself.

iluvivt, BSN, RN · Nov 14, 2008

The nurse that started the IV for you picked one of the worst places to put an IV....so do not feel bad (especially if she put it in the volar wrist. HALF of ALL IV related complications occur at areas of flexion (that includes the ACF. That is a pretty high number so try to avoid if possible or go above or below the area of flexion. I have been instructing nurses for 22 years on how to start IVs and although there are many mistakes or misses that can happen,,,I will give you my opinion on the ones I see over nad over again.

1. Do not pierce the skin with a too sharp angle..usually all you need is a 20 30 degree angle. Once you hit the vein...immediately drop your angle flush to the skin and advance the catheter as a unit about at least 1/8 of an inch. This is critical for your success as your needle can be in the vein (since it is longer) and not the catheter, If you do not advance it once you get your flashback and then pull your needle back all you did was puncture a vein and then pull out the needle.

2. Select the shortest smallest catheter that will meet the patients needs

3. Do not underestimate the power of a heat pack or warm bath blanket. OK to use a BP cuff set slightly below pts diastolic

try these things and see if your success improves and try to be very specific about why you are failing and I can give you more tips. What catheter are you using as some will require some slight modification in you technique.

bisacat · Nov 14, 2008

Thank you iluvivt for your advice. :)

iluvivt, BSN, RN · Nov 15, 2008

You are welcome. Try to always do the easy ones and then once you get really good at the easy ones push the envelope even more and begin to try harder ones. What device are you using so I can give you some more tips? Believe me ....I have lots and lots. The next thing is always ask yourself why you missed so in similar situations you will not make the same mistake....that is how I always advanced my practice and my reputation in the process (that was an added benefit....I just did it to be a better nurse and get the job done!!!)

MedicalLPN, LPN · Nov 20, 2008

Does your unit have a Venoscope you can use to aide in hard IV starts? Our unit has one and oh god it is the best device that was ever made, I'm on an oncology unit and our patients of course practically have no veins but using the venoscope most of the time enables me to be able to get an IV of some sort in them. I'm thinking about actually purchasing one for myself simply because I work per diem at a facility where we don't have one of these gadgets available. Here's a link where you can learn more about them if you like http://www.venoscope.com

crb613, BSN, RN · Nov 20, 2008

I just hate it when someone is having a hard time with something.......you need a little help......then you have a big mouth that delights in trying to make you look incompetent......or themselves look superior. Forget it & them.....we all have bad days......have faith in yourself, keep your head up and just keep trying to learn......... you will get better. If you can find someone that is well rounded & likes to teach/support new nurses.......you will learn so much.......been there! Good luck:wink2: