I have been a nurse for 2 years and work in a stepdown unit. Most of my patients are elderly, have chronic diseases like CHF, CAD, DM, COPD. Many of them have had numerous hospitalizations for exacerbations of these diseases. They are usually what we call a "hard stick" and several IV start attempts are necessary. Sometimes 6-9 attempts! I feel so sorry for these people, and I feel sorry for the nurses too. It seems that nearly half the time I try to start an IV, I fail, and I wonder sometimes if it's me or their bad veins. I take into consideration their age, the condition of their veins (most of the time they are small, rolling, or hard, or they have so much edema on their arms, it's difficult to see the veins or reach them), etc.
I guess it's another issue that we deal with all the time, this one causes my stress level to rise, because I feel bad for the patient, don't want to hurt them, and inevitably do because they've been stuck too many times, and they feel bad anyway! It's also a confidence-stealer for me. I like to walk out of their room feeling confident because I have skillfully and professionally started the IV after only one attempt, with minimal pain. But 75% of the time, that's not the way it turns out.
I guess I'm wondering if anyone else working with similar patients is having similar problems with IV starts. Do I need some more education or training on IV's? (My gosh, I have done so many, and I've watched probably hundreds) Any and all honest suggestions are welcome.
It's so much better for our patient's to be proactive...Think ahead to what type of venous access device is the most appropriate. At our 300 bed hospital we've developed an Early Vascular Access program. The patient gets stuck twice, if unsuccessful then or if the patient isn't able to keep a PIV for the 72 hours we can insert a midline without a MD order. The patient is so much happier, meds aren't delayed and venous damage is limited. Venous damage increases the risk of Upper extremity DVT (VTE), so we don't do the patient any good to "keep trying"!:)
The hospital that I work at has somewhere around 400 beds. We DON'T have a program like yours, but I will certainly bring it up in the next staff meeting as an FYI.
I guess I'm wondering if anyone else working with similar patients is having similar problems with IV starts. Do I need some more education or training on IV's? (My gosh, I have done so many, and I've watched probably hundreds) Any and all honest suggestions are welcome. Thanks, PCUSheryl
I have been a nurse just over a year now and if it's any consolation, I still get nervous when I start IV's but I am gaining confidence daily. Used to be, I would just go get a veteran RN and not even try to start an IV if a pt had bad veins (which most of ours do!), then slowly, but surely, I would make myself at least try once before I gave up One of my co-workers (9 yr veteran RN) has been on a "losing streak" recently with starting IV's and drawing blood and she has been coming to get me to try for her. Pay back for all those times I came to get her when I first graduated nursing school last year!! Another confidence builder for me is that I got 2 out of 3 last weekend for her!
Our floor is similar...we're oncology, so if these folks don't have a port, chances are their veins have been torn up. (As an aside...I love ports. Love love love. Makes the patient's life SO much easier.)
I'm pretty new, so if I look and don't see anything within reason, I'll go grab someone experienced. Our hospital does have a fabulous IV team, and usually we end up calling them, but if it's truly time-critical (ie the blood's on the floor but the IV just blew, or the chemo needs to be given NOW and you can't find a blood return even if you stand on your head) we'll try once or twice ourselves.
Hi- A midline is a catheter that is inserted around the antecubital area and extends to the axillary vein(armpit area). The beautiful thing is it can be placed using ultrasound and most often can even be used to draw blood. The technique we use is the same as inserting a PICC, the cath is usually a 4 Fr. Groshong and the dwell time is up to 4 weeks. No chest xray is needed following insertion-it can be used immediately! Can't be used for vesicants or TPN but is so helpful in those patients who have deep veins etc. and the patients and nurses love them!
I understand you getting upset about the difficulty of getting IVs in the "hard sticks". I used to work in a high volume Level 1 trauma ER. The hardest thing about that job was that we were incredibly busy and it sometimes took a lot of time to get an IV started on those spider veins in these patients. We have the same 2 sticks per RN protocol but unfortunately due to how busy we were that was not always followed. Even though it was a teaching facility our docs were reluctant on going forward with central/PICC access unless they were extremely sick. We didn't have anything like midlines but we were allowed to do external jugular IVs. Usually and 18 or 20 guage and it gave a great return and flushed well. No need for xray either due to the short catheter. But keep your head up and keep sticking!
Welcome to the club! I worked in a hospital since I graduated with mainly geriatric pt's on a telemetry unit. I got to be pretty good at IV's. Then I moved and started working in a facility where we had to draw our own labs and I suck at using vacutainers! Now I work home health and sometimes it seems like I can't hit the broadside of a barn! A lot of these pt's are "frequent fliers" or "professional patients" and they are hard sticks. It makes it difficult if I can't get in max of 3 sticks - that pt has to be rescheduled and a billable visit is wasted. A couple of tips: Use a warm cloth (most nurses I sought to help me relied on this), make sure tourniquet is tight enough, tie off above chosen site (e.g. don't tie off at antecubital if you're trying the hand), look on the "backside" or distal side of the forearm - and PRAY
Specializes in ICU, CCU, Trauma, neuro, Geriatrics.
Find a vein, does it bounce easily when you touch it? if so it is a viable vein, one that is hard or does not bounce to touch has probably been abused already with antibiotics and will not be a good access vein this week.
Look at both arms, if you find nothing then so be it. Look again in an hour or two if this is not a life threating episode. I have an IV team but dont use them unless I have to. They are wonderful as they assess and restart 3 day old IV sites.
In my experience when dealing with someone with a chronic illness and/or terrible veins (also someone really dehydrated), sometimes it is worth a second stick with a butterfly to draw labs in order to not lose precious IV access. Several times I have been ever-so-proud to get the IV catheter in, great blood return, then hook up the vacutainer adapter and it just sucks the life right out of the vein. Many of my colleagues feel the same way.
Of course I try to draw the labs whenever possible. But if someone only has one or two sites that look like they will accomodate a 20-gauge or larger, is it worth blowing one of them? So I decide on a case-by-case basis about trying to get the labs.
Of course I am talking ER here. But 2 sticks per person should be the max in any setting.
And of course, everyone, even the best stick out there, will have those days when they just can't hit anything.
I trick I use on "tough sticks" is to use two tourniquets. It seems to work very well. I am also a big fan of 1% LIDO (we have a standing order but no one uses it but me) when placing peripheral IVs. Ejs are also an option if you are in a pinch. They are usually easy to find but take some practice to cannulate well. I live in New Mexico and we have a very high rate of heroin use in this state. The result is a large number of the patient population has "bad veins". Some times it just takes a new set of eyes on the patient. PLEASE DON'T BLAME PATIENTS FOR YOUR LACK OF SKILL!!! The veins are there, you just have not been able to hit them. I don't know how many people I have seen who think it is their fault that a nurse can't get their IV.
Specializes in ER/SICU/Med-Surg/Ortho/Trauma/Flight.
I have worked in sicu and er for awhile and the best trick to do on a tough stick is to use a bp cuff instead of a tourniquet, put it rite above the ac if your going to use the ac or the forearm, put it on the forearm if u decide to use the hand or wrist, pump it to about 140 to 160, also use a warm cloth first and lido if possible, I learned this technique on the IV team.
sabRN2b05, BSN, RN
121 Posts
The hospital that I work at has somewhere around 400 beds. We DON'T have a program like yours, but I will certainly bring it up in the next staff meeting as an FYI.
Stupid question but what is a midline?