Pediatric Nurse need help with Adult IV insertion

[kheemooy]

Hello there, I'm a NICU/Peds nurse with 4yrs experience and so far I can say that I'm comfortable with IV inserts on peds and neonates. But to be honest, the largest gauge I've used on a peds pt is gauge22.

Anyways, I recently took a casual position on a Pediatric floor that actually receives off-service Gyne patients! I didn't know about this until I was orientated on the floor. To be honest I don't mind taking care of them I'm only a little uncomfortable doing IV sticks on them.

One day, on my orientation we received a patient that needs bloodwork and IV. I insisted to try it out, and my preceptor asked me to use gauge20 instead. Of course I'm not used to this HUGE bore, even a gauge22 is already so big.

I tried on the AC. I saw the vein but it was a little flat, not as juicy but my preceptor recommended to start it on the non dominant arm of the patient. In my mind, this shouldn't be difficult I've started IV's on the smallest veins and why couldn't I miss on big adult veins. And of course, first stick no flashback and I had to fish a little bit got flashback but flow is not good and I knew I missed it! Tried to flush it and of course it's interstitial.

Holy crap! Was I ever frustrated! My preceptor might be thinking how come Im bad with IV's with all that 4yr experience. I'm not used to adult iv inserts. I think I went to superficial, I'm still applying my NICU/paeds tricks on an adult ivs.

Also, I'm so used to having another person with me to assist in IV insert. Like we do in paeds/nicu we got another person to assist me. I guess I'm not used to the independent IV starts too.

I'm kinda frustrated. Now I'm looking into IV therapy course to brush up my adult iv sticks . Anybody had the same experience? Can you give me some tips on how to adjust when it comes to doing adult IV's?

[bebbercorn]

You are psyching yourself out! Did you get every neonatal IV you started right away? I know I didn't... Give yourself 3 more sticks and you will be golden. I had to re-orient to new angiocaths in our new facility, and I am really comfortable with IV's across age groups. You have the concept, just let yourself get the tactile learning in. Hang in there!

[kheemooy]

Thanks bebbercorn! Well yea, I guess I'm psyching myself. Besides it was my first try and I kinda got frustrated right away and just let my preceptor take it away. I was nervous of not getting it the second time. Hopefully I'll get more chances next time.

[Double-Helix, BSN, RN]

I'm a peds nurse as well, although I do see my fair share of teenagers and occasionally adults. The IV's we place are primarily for short term use- sedation/anesthesia, radiologic contrast, blood draws. The only time we need 20g or larger are for certain radiology exams- usually CT angiograms.

Here's a few things I know:

1. 20g's are more difficult to thread than 22's or smaller. Because the bevel is larger, you need to advance the needle a bit more after you get a flashback in order to make sure your catheter is fully within the vein before attempting to thread. Otherwise it will blow.

2. Adult veins tend to roll more than peds veins. They have less supporting subcutaneous fat (this is especially true to hand veins) and it's not uncommon for you to stick a good looking vein and after you stick, the vein just isn't there anymore. You can help this by using your non-dominant hand to tack down the vein above where you're going to stick. You can grab another person to help with this until you're comfortable.

3. Unless it's a very sick patient, and you anticipate giving a lot of fluid/blood, a 22g will work just fine. If you're starting the IV, any size will allow you to draw blood. We draw labs with 24g IV starts all the time. A well-maintained 22g works just fine for repeated blood draws as well. And there is a lower risk of phlebitis from a large catheter in a a vein. So, especially if you're not comfortable with the gauge, there's little benefit of a 20g over a 22g.

4. Adult veins tend to have more rigid valves. When you're looking at a vein, look for areas that appear more rounded, almost like bumps along the vein. That's where you're likely to find a valve, and have a harder time threading the catheter. If you see a valve, go above or a good bit below that spot.

5. My favorite veins for adults are the cephalic vein- from the forearm up to the anticubital space- and the medial ante brachial in the forearm. Hand veins can work as well, just watch out for valves and make sure they are stabilized when you stick.

[LoveMyBugs, BSN, CNA, RN]

You are not alone my friend

Give me a sick neonate I can pop a line in.

Give me a big healthy teenager with big rolly veins and I struggle.......

I once put an 18 gauge in felt like I was putting in a fire hose in the vein.

Try and remember to anchor the vein and breath.

I am sure most adult nurses feel the same as we do if they had to place a line in a little one

[nerdynurse22]

I may not be the best to answer as I am not good with adult IV insertion (I deal with older, malnourished, thin skin etc) and transitioning into peds, so I have not done ped insertions either. I DO KNOW that with this skill it only gets better with experience. I think you went into it thinking "I got this, I've done this so many times on little veins so a big one no problem" but the anatomy of the veins, tissues, thickness of the skin, approach all varies on the ages. Give it more time and more practice and you will be a pro! Hang in there.

[jrt4]

I agree with the above poster that said you are psyching yourself out. It is different but the principles are the same. I find pediatric veins to be easier to access usually just because they are full of valves and scar tissue. I also would caution regarding using a 20G as your standard. Its really not necessary. I worked on the IV team for a short while with some IV therapists. They usually used 22G as their standard but dont be afraid to use a 24G if you are using it for short term hydration. The rule of thumb is to use the smallest gauge possible for the treatment you are giving. Not use the largest gauge that you can get in a vein just because it is "better". Now if you are giving blood or vesicants of course use a bigger gauge. We underutilize PICC lines in the hospital as well. If you are anticipating 7-10 days of antibiotics recommend a PICC!

[rtmike2002]

I have had the same experience transitioning from neonatal and pediatric transport to mostly adult transport. I'll use the advice on this thread to improve my odds. I have had a similar experience drawing adult blood gases. Hitting those huge arteries in patients with A Fib has been a real challenge.

[Double Dunker]

I agree with what's already been said. I usually only insert a 20 if the patient needs contrast or if they have fluids ordered for over 100 mL/hour. I have a lot of older, confused patients, so I tend to avoid the AC as well, as they usually can't remember to keep their arms straight. Just wait until you have to start an IV on an ESRD patient. Still struggle mightily with those.

[apillarofsalt]

I'm staring a new gyn job this week after peds and am nervous about the same thing. I've only ever used 22 and up, but they routinely use it 18s. Ugh.

[JadedCPN, BSN, RN]

I think this is mostly in your head, because if you can put in a 24 gauge on a tiny neonate or toddler than you will certainly be able to put a hose into an adult ;-) I have been peds for my entire 10 year career but a year ago I started working PRN at an adult urgent care that a friend owned to help her out, and I was also nervous about IV starts and lab sticks on adults. Partially because of the bigger size, and also because I was used to using butterflies rather than straight needles for labs. Long story short, I mentally psyched myself out the few times and it was smooth sailing after that.

[meanmaryjean, DNP, RN]

The ONLY way to become proficient at IVs is to keep practicing. Just keep plugging away- you'll get there. (Can you practice on a co-worker?)