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.
I 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
, 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...
Actually, 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.
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.
Giving blood through a 22 guage catheter is one of the most assinine things I have ever heard.
~~
that, and using a knuckle vein, or the veins on the inner wrists! if that's all you have, you need to be discussing a jugular line or central line with the er doc.
you do NOT win a prize for getting a 22 in a knuckle!
i'll add that each pt and their problem is different. a copd-er will be fine with a 20 to get his solumedrol.
cp will need at least 1- 20. if the ecg is positive, you're going to need at least 2 more lines that are 18s. if you can get a 16 in the a/c get it. why? bc once they get their tpa...that's it. all labs come from your lines. think ahead.
abd pain should also get an 18 if possible. they could be anything like a gi bleed.
just last week i had a man hit by a car. i put a 16 in him right away. another nurse was like...' 16?' yes, a 16. his veins were huge, it wasn't a problem, and he sustained trauma. think about it.... it's a no brainer.
in the er, it's not all about comfort. sure, you don't want to torture someone with a 16 if there's no good reason for it, but if it's logical to go with an 18 or larger, don't hold back either.
in the er, it's not all about comfort. sure, you don't want to torture someone with a 16 if there's no good reason for it, but if it's logical to go with an 18 or larger, don't hold back either.
And it only tales a second to put in local--if you don't want to take the time to make an intradermal wheal with buffered (with NaHCO3) 1% Lidocaine, then use 0.5 % Lidocaine (plain)--makes access a bit les traumatic for them.
Of course, as stated by tridil, in the ER, with people coming at them from all angles poking and prodding them (trauma patients, I mean) IV access, with or without local, is just a transient minor pain that is over in a flash, and then it's on to other things--like a trip to the operating room, where their pain will be gone soon enough--
1st - All great veins run medial to the arteries. Personally, I don't think you should ever have to rely on sight, but rather go with a what you feel.
2nd - If all else fails (other than a central line or EJ), palpate the brachial artery, then insert the catherter just medial to where you feel the pulse.............
In our ER, we tend to go for the 20's all the time...unless it is known that the pt is a potential GI bleeder, TnKaser, etc then we go for the 16's/18's. Pretty much every nurse grabs an 18 and a 20 when going to start an IV...but we accept22's all the time...if all they need are pain meds, or solumedrol, or antibiotics...why torture them with something bigger? I agree large bores are needed in SOME patients in the ER, but not all...and from experience, an 18 hurts A LOT more than a 20...We give blood through 20's all the time...it flows plenty fast, gave a guy a unit of blood in less than a hour via a 20 the other night...I've heard about using 22's for blood, but our hospital policy is no less than a 20 for blood. We get a lot of drug users, and its true if they say to go for a specific vein go for it...and sometimes you will be unable to get anything bigger than a 22 or 24 in these guys (yes I said 24g)...but unless they are in a potentially life threatening situation (and come on ER nurses, your instinct usually knows), then an EJ or central line may not be necessary...while we don't make it a habit, if all they need is a little fluid and pain/nausea meds, and a 24 is all we are able to get (normally the 24g wouldn't have been the 1st attempt), then by all means make the patient feel a little better, and then reassess the need for something bigger! I found people's veins are getting worse and worse, and sometimes the large bores aren't feesible or just aren't necessary, and if its really not indicated than all your doing is causing extra pain.
I'm a new nurse so this is a super thread for me! I saw a new one several weeks ago.... Many nurses took a stick at a guy with *nothin* for veins. Nothing could be seen or felt - even with all the usual tricks - even the "IV queen" of the unit couldn't find anything to stick. So she tells the doc 'hey, i need an order for nitro paste'. Sure enough, a pea-sized dab and the vein popped right up. She nailed it on the first stick.
bam_bam
93 Posts
I 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
Beth