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 vein", would be greatly appreciated. (and if you have a few that are not to be taken entirely serious those would be welcome as well).
Please answer me directly - no need to clutter up the board with this. I will post the text once it is finished.
Don't be mortified! It's a great question. And using your critical thinking skills, you have arrived at the answer. More reasons include that arteries are usually pretty deep and harder to find. Plus, you would have to tourniquet distal to the site you are going to stick.
Great thinking--a very good skill for a student nurse!
I know that in nursing school they are anal retentive about getting absolutely every bubble out of your IV tubing but in actuallity it's not totally critical just recommended.
And patients never quite believe you when you say it doesn't matter, they (and their families) just watch the slow march of that little bubble.
I have thought it takes less time to evacuate the bubbles by priming properly than to try to reassure people that it is OK for you not to have to.
It doesn't take much to learn to prime a line really well.
If you are "pouring" that blood in a short time frame, then I would agree to have a larger lumen catheter, however, most of the elderly can not take blood infusions at a fast rate, and usually it's infused over 3-4 hours.
A 22 gauge IV catheter is quite appropriate in this situation. Perhaps your ER manager can check out references that review that fact in the AABB (American Association Of Blood Banks) manual and then subsequently your policies can change to reflect the appropriateness of care.
Our hospital system policy is 20g for blood and IV contrast CTs. Because we never know who's going to get contrast or blood when they enter we usually just opt for 20g to be safe. I've only ever used 22 a handful of times. I don't even know where we keep the 24s as no one uses them. In the beginning I opted to use 22s on a couple of pts. One ended up needing adenosine (so she got an 18g anyway) and the other ended up needing a CT with IV contrast (so she got a 20g). I hate to stick people multiple times so now, like most of my coworkers I go to large bore usually 18s when I can. Nothing smaller than a 20.
You can't remember using anything smaller than an 18g? really? wow.... #1 I'm not impressed....unless u are a trauma junkie, flight nurse, or medic why the obsession....I will certainly use from 14 to 18g in a TRUE emergency...but the average pt does not need that...yikes....
Regardless, we have the opportunity to teach someone something, so lets take that opportunity.
IV's just take practice, stick everyone you can until you feel comfortable. soon you will be able to do it with your hands tied behind your back. however, we all have our days when we cant miss and then theres days we couldnt hit a cannon with an angio cath.
the first thing i tell everyone is that selecting a vein is never ever something you do with your eyes. you have to do it by feel. one vein might look good, but it is too frail. get to know your veins.
a lot of people are afraid to use the bigger 18 and 16 gauges in the beginning. im the exact opposite, i cant remember the last time i used anything smaller than an 18 gauge. the needle is firmer and doesnt give as much.
stay away from thick veins right below a bifurcation (where the thick vein turns into two small veins, like a junction in the road, these ivs almost always blow in the first hour)
women have the "rule of thumb". theres almost always a vein that comes off of the thumb where the forearm begins. look around, youll see im right.
any patient, and i mean any patient who has even the slightest chance of being a surgical patient, be it an AP or abd pain or trauma, should have a large bore iv 18g or less. the anesthesiologist will put a second larger line in if you dont.
anyone receiving anticoagulant clot busting therapy like TPA or equivalent should have three lines, one 18 or 16 gauge for blood draws before the med is given. pop away.
even if you dont know what you are doing, try and make it seem like you do. be professional, dont let your hands shake, and read your patient. their eyes can tell you alot.
TIE THE TOURNIQUETTE TIGHT. DONT FORGET TO TAKE IT OFF!
Don't shake...that like telling someone-- dont be hungry. suggestions??? shaking is my huge problem.
Is your shaking due to nerves? I would say that the more you can make a routine of the whole process, the easier it will get. Set up your supplies the same way everytime. Palpate with the same finger everytime. Make the same sort of soothing comments (explaining what you're doing) to the patient everytime. Then the actual getting the IV into the vein will also start to feel part of the routine and you'll get faster and faster.
When I was first starting, I would get blood return, get the IV in there, and say "very good!" to the patient while I finishing things off. They seemed to like it, but secretly I was congratulating myself on a good stick. Well.... I still sometimes do this. :)
Specializes in Emergency/Trauma/Critical Care Nursing.
I beg to differ about the sizes of cannulas listed above. It used to be a trend years ago to throw the biggest IV into the patient that they can handle. Not so anymore. Chances of phlebitis increases with increased sizes of IV cannulas.
I cannot imagine putting 16ga IV's into a patient in an emergency room. If this patient is a victim of multiple trauma or multiple GSW or stab wounds maybe. Usually those come in with larger bore IV's anyway.
Our hospital has now become very adamant about not starting large bore IV's. Even our pre op patients go in with a #20 in. I can give any med (including blood) through a #22 if I need to, and believe it or not. A #22 is the recommended size to prevent phlebitis. We use #20's for CTA of chest and cardiac caths, and sometimes you cant even get a #20 in them. Go with whatever you can get.
In my ER you generally get "the biggest that you can", not to say we throw 16g is people, but if you CAN do an 18g you do, however i work in downtown detroit where a large number of my pts are dialysis or IVDA with crap for veins and you get the best that you can. 18g, 16g and very rarely 14g are the goal in any trauma resus we get.
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chris_at_lucas_RN, RN
1,895 Posts
Don't be mortified! It's a great question. And using your critical thinking skills, you have arrived at the answer. More reasons include that arteries are usually pretty deep and harder to find. Plus, you would have to tourniquet distal to the site you are going to stick.
Great thinking--a very good skill for a student nurse!