Published Aug 6, 2001
Situation: A elderly women had a stroke,and is non responsive,taking nothing by mouth. Supposedly the dr. spoke with family and they decided no IVs. After 8-9 days of no food or liquids family wants Ivs.
The women got stuck probably 10 times over a shift period of time,,before veni-puncture was successful,very dehydrated.
I felt that this many iv attempts was inappropriate, and called the dr. after the 4th attempt,but my the other rns didnt,nor did the doctor think so.
My question is...what is the limit,the parameter,to how many iv attempts should be made?
Also the dr. made a remark that he wanted more experienced nurses working on the floor,meaning the rns did not know how to start ivs cause so many attempts were made. Wasnt luck involved rather than skill,which got the iv?
Well...its all situational dependant. Sometimes...you know the patient won't make it without an IV. How much time do you have? Many docs don't want to unecessarily start a central line if it can be avoided due to complications, like infection, pneumothorax, etc.
The family ultimately has the decision.
Sometimes it is luck.....but not the majoraty of the time. Some people are just tough sticks, because the bottom line is, they are not peripheral vascular goldmines.
After 8 - 9 days without hydration, of course she would be a hard stick, no matter how skilled the nurse--she was in vascular collapse secondary to hypovolemia. Why was this allowed to go on so long without the docs explaining to the family and pressing for an IV? Or at least dropping a feeding tube to keep her hydrated?
P_RN, ADN, RN
I was a very good sticker. I hardly ever needed more than one try. Personally I'd stop at two. Maybe one more IF it were necessary because of patient movement. This lady was totally dry though. I wonder if the family rethought their decision on code status.
It sounds as if the doctor didn't want to be bothered with any more family meetings. If there is a next time, perhaps you have a clinical specialist or supervisor who could intervene and help the family understand the rationale. Lay people don't understand physiology.
My dad had a terminal brain tumor. Everytime he'd start to get hydrated, he'd have cerebral edema and seizures. His doctors recommended no IV. I agreed. I had to explain it to my sisters and to my mother. It hurt me terribly to see him like that but when he died just a day later, he died peacefully and not in the middle of status epilepticus.
I work on a renal unit, so many if not most of our patients are very hard sticks. Our hospital has an 'IV team' which is a group of nurses that do only IV, TPN, PICC lines, etc. On my floor most of us will try to start the IV once before calling the IV team. The IV will usually try until they get it, but they are great at their jobs and it only takes them 1-2. But if the IV team has to stick multiple times and it is obvious that the pt has no veins, the IV team puts them on the 'Hit List' meaning that they will no longer come to stick them for IV. They then write a note in the doctor's notes telling the MDs that they should consider central line placement.
We run into this problem a lot with our elderly CHF and COPD pt's. The facility that I work at doesn't have an IV team. The last Hospital I worked at did have an IV team. We floor RN's were NOT allowed to attempt to start IV's there. Only RN's in peds, ER, L&D and ICU were allowed to start IV's(and the members of the IV team).
Now that I work at a hospital that doesn't have an IV team, I have had to do my own and I think venipuncture is a tough skill to learn, one of the toughest skills in my 4 years experience. I am by no means a master IV starter and probably wont be for a while yet. I limit myself to 2 attempts(per our policy) and then I get another RN to try for me. Usually our pt's come to us via the ER and have had a line started in the ER or in the ambulance. After 3 different RN's have tried, then I call the MD who usually says well get an ICU RN to try.. Which I think is totally a$$inine.
Mediports work well. They last a long time and prevent frequent flyers from repeated IV starts.
As Rick said--some folk are just bad sticks!
I work oncology/chemo so we have to be proficient in IV therapy. We will try 2 or 3 times, then ask one of our "transfusion nurse experts" if they are around. If they can't get it, they call for an anesthesia order and if THEY can't get it either; they call the doc for a picc or central line order. By the time anesthesia has tried the pt has been stuck about 9 times, I don't know of any "official limits" but that does seem like a lot.
At our facility, each nurse is allowed 2 attempts. Obviously, if the patient desperatley needs an IV then I will be sure that someone gets the IV in. Usually, though someone gets the Iv in either the second or third person that tried. And being on a cardiac unit an IV line is a must cause god forbid the patient code and NOT have any venous access!
Stargazer,Im not sure why she went without fluids for so long,I think the dr. really didnt explain the options,of the family ,guardian,didnt understand the ramifications of comfort measures only.
When a pt is referred to Hospice and has been declared a DNR many times hospice stops all iv fluids and tube feedings, depending on the pt/family wishes. Generally a person dies before 7 days without any fluids, there have been studies and research that they are not uncomfortable and many times it is the patient who chooses this.
Apparently in this particular instance under discussion, the family changed their mind.
We have an iv tream, if 2 of them decinde they can't start one (they are very good, it's all they do for 8 hours) the MD is called and has the choice of doing it themselves (havn't seen it happen yet) or having radiology put in a picc.
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