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Do you want a clumsy, painful IV start to be your patients' lasting memory of their surgical experience? Of course not. Here are some tips to improve your IV start success rate.
Talking them through it
A physician once reassured a needle-nervous patient that I could start an IV through a grapefruit's thick skin. I don't know about that, but I do know that most patients at our GI center are very dehydrated from their bowel preps, making their veins difficult to locate and IVs difficult to start.
What to do? Talk to the patient. There's no better way to distract and relax a patient than to talk to her. Introduce yourself and establish some rapport with her. Tell her everything you're doing, as you're doing it, so she's prepared and never surprised.
Keep the patients talking, especially about themselves. Ask them, what do you do? Do you have children? What did you do on your last vacation? Have we ever met before, because you look familiar? Getting them to tell you a story will make them feel more relaxed and make them feel like you're their friend, not just a nurse. Humor is a great icebreaker. Tell them a joke (even a groaner like the grapefruit line). It's an excellent relaxation method. It's hard to be tense when you're laughing.
Placement pointers
The next step is deciding where to place the IV. This will depend on each patient's anatomy and surgical situation, as well as how long the catheter is intended to remain in place. You can learn a lot about the effectiveness of IV sites by paying attention to your OR workflows and by asking your anesthesia providers how they work within the perioperative process. For instance, all of our gastroenterologists are right-handed, so all of our patients are positioned on their left sides for their procedures. As a result, we put the IV into the right arm so it doesn't end up underneath the patient. Since a patient positioned on his side tends to bend his elbow, the antecubital is not an ideal site, as the catheter may kink.
For younger, muscular patients, the upper arm presents a usable site, especially since the blood pressure cuff is going to be wrapped around the lower arm. But I particularly favor the wrist. It's very accessible and doesn't interfere with surgical equipment or instruments. If the catheter is staying in for any length of time, you want the patient to be able to use her hands and bend her arms. An IV in the wrist provides the patient with a full range of motion.
Another reason the wrist is my favorite placement site: If you find yourself chasing a rolling vein, you can easily immobilize it by hyper-extending the wrist, which will stretch the vein and hold it in place. If it still rolls after you do this, move the needle under the skin to the other side of the vein and insert it from that side. This "back door approach" may sound strange, but it works quite well.
Preparing the site
Raise the gurney and stand to start any IV. This offers several advantages. There's better lighting on the site and the patient's extremity is closer to your eyes. It lets you move freely, to quickly retrieve or run for supplies or fluids. Plus, for patients who tell you they feel faint or have a vasovagal response, you'll be able to move the patient into the Trendelenburg position using only one hand.
Directly warming the site with a compress or a gel pack can help to bring veins to the surface, but don't forget the blankets or patient warming devices. Body warmth helps to dilate blood vessels. Plus, patients tend to remember shivering in pre-op the same way they remember a painful IV start.
Here's a helpful hint: When applying a tourniquet to bring up veins, place it over the patient's gown. Then it doesn't feel as tight and doesn't pull their hair when released. Forget about having the patient squeeze their hand or make a fist. Think about it: When you're inserting a needle through the skin, it's going to be more painful if it also has to penetrate a tightened muscle. Instead, you want them to be totally relaxed.
Get tactile with the veins beneath the skin. The best way to raise a vein is to tap it with your finger, hard. I make sure to warn the patient that it may sting a little, but it almost always causes the vein to go into a spasm and fill tautly with blood, making a small vein look very inviting.
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With IV Starts, Practice Makes Perfect |
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Training is key to keeping your staff's IV skills fresh and sharp. Annual training not only builds nurses' skill levels, it also builds their confidence — a quality that is crucial to getting a successful IV start. "The best way to reduce the pain of an IV start is to be assertive when inserting the needle through the skin," says Shanon Malone, RN, CNOR, director of surgical services at St. John's Hospital in Lebanon, Mo. "One smooth, quick motion will take the needle through the skin and into the vein, reducing the pain associated with the needlestick. A slow, unsure stick will cause pain every time." And the more confident your nurses, the less anxious your patients will be when they see that needle heading toward their arm. Offer initial training for new hires and annual competency training for all staff who start IVs at your facility. Ask more experienced nurses or anesthesia providers to give in-services or mentor newcomers having difficulty with IV starts. If you're at a smaller facility with limited in-house resources, consider sending staff to a local hospital or college for refresher courses on IV therapy. The device reps who supply your IV delivery systems can also provide training. Make sure your staff education covers the anatomy of the arm and hand (to assist with vein location), proper antisepsis when starting an IV, how to work the IV systems used at your facility and any other technologies or techniques you employ, such as lidocaine injections. At Mid Coast Hospital in Brunswick, Maine, all RNs, regardless of their experience, receive an IV therapy packet during their orientation. The packet contains a competency-based orientation tool, the facility's IV therapy policies and a post-test. "The employee then needs to demonstrate competency in starting 5 successful vein punctures," says Lynne Pinkham, RN, BSN, nurse manager in the hospital's surgical services department. In addition, all RNs must attend an IV therapy skills fair (offered 4 to 6 times a year) for annual re-education, which becomes part of the annual employee performance evaluation. The hospital also offers in-services throughout the year to cover changes in practices or equipment, or specific skill areas identified by staff or patient satisfaction feedback. — Irene Tsikitas |
Comfortably numb
I highly recommend administering a topical or local anesthetic to the IV site in order to numb the area before you insert the needle and catheter. It's so much more comfortable for patients, especially if their veins are difficult to find, if their veins roll, if they're dehydrated or if they say they're afraid of needles. In fact, I don't let any member of my staff start an IV unless they're willing to pre-treat the site with lidocaine 1% first. I teach all of my nurses how to use it. If they don't wish to use it, they're not assigned to pre-procedure cases. But they all learn quickly, because they all enjoy pre-procedure assignments.
We use a 27-gauge needle and 0.1ml of lidocaine. We let the patient know there's going to be a tiny little stick and that they might feel a slight sting. Then we inject the lidocaine subcutaneously, right next to the selected vein, in order to avoid obscuring the vein or puncturing it and causing it to bleed. The injection should be done very slowly so as to minimize any sting the patient feels.
When we remove the lidocaine needle, we flick it up through the skin to "mark the site." This makes the injection site a little bit larger (without causing much bleeding), allowing easier insertion of the larger needle and catheter in the same site. Then the patient only gets punctured once, and you know you're injecting in the area you've already numbed. All the patient feels is a little push.
Another advantage of using an injection site next to the vein is that putting the needle through the side of the vein makes it less likely that you'll puncture all the way through it. If you ap-proach from the side, however, be sure to turn the needle in the direction of the vein as you advance the catheter.
When you're inserting the IV, keep in mind that just seeing a flash of blood doesn't mean that you're in the vein. The tip of the needle is longer than the catheter sheath, so when you see blood, you must continue to advance the needle slightly further in order to ensure that both the tip and the sheath are in the vein. If you fail to introduce the catheter sheath into the vein, any attempts to thread the catheter will result in the sheath actually pushing the vein off of the needle.
Should you actually go through the other side of the vein, you still may be able to save the site. Simply remove the needle and very slowly start removing the catheter. When you see a good blood flow, attempt to advance the catheter again. If it slides easily, there's a good chance you're in the vein. Attach a syringe and flush with saline. If you don't see any infiltration, congratulations! — you saved the site.
Basics to build on
I'm a big believer in teaching my nursing staff the techniques I've found to be successful. With IV starts, as with anything, each nurse may discover her own innovations on these basic steps, but she has to start somewhere, and I want my nurses to do the best job they can. Something as small as an IV injection site may be visually undetectable by the time your patient is discharged, but as with all aspects of patient care, it ultimately reflects on your center.
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