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An IV start should be a little pinch, not a big ouch, a minor procedure, not a major ordeal. Patients dread surgery's necessary evil — and your nurses might, too. Here are expert tips to get it right on the first try to avoid having to stick the patient multiple times.
1Put patients at ease
Your first attempt at the IV start may very well be your best chance of success. Once you miss a vein, the odds diminish with each subsequent attempt. Make patients comfortable before proceeding with the IV, says Denise Gallagher, RN, BSN, a retired nurse with more than 10 years' experience on IV teams throughout her career.
Laying patients down allows them to settle in and relaxes them and can make for better blood flow to the vein. By consistently using this position, you get used to the same angle of holding and inserting your catheter, says Ms. Gallagher.
"Also ask the patient not to watch. Explain that by lifting their head to look, they automatically retract their arm, and this can cause you to lose the insertion site," she says.
Ask the patient to slide over to the railing on the far side from you, which will allow more room for the arm on which you're working. Laying the arm flat on the bed will stabilize it and works better than having the arm hanging off the edge of the bed.
"The goal is to position yourself distally to the vein and keep the catheter aligned with the vein," says Ms. Gallagher.
Because no 2 arms are shaped alike, you can use a rolled blanket or pillow to straighten the arm. The hand should hang off the end of the blanket or pillow, which gets the knuckles out of the way if you're using a hand vein. Having to hold the catheter over the knuckles can change the entry angle of the needle, which can cause you to go too deep and miss the vein. For bigger patients who fill the stretcher, you can also use the bedside table to straighten out the arm and create more workspace for yourself to insert the IV. Adjust the table to lift or lower the arm to a more workable and comfortable angle, says Ms. Gallagher.
2Tourniquet etiquette
When applying the tourniquet, be aware of the hair on the patient's arm. Instead of putting the tourniquet directly on a hairy arm, put something between the arm and the tourniquet so you don't pull on the hair. You can use a sleeve, wrap a piece of gauze around the arm before applying the tourniquet, or even use a blood pressure sleeve and set it on IV start, says Nikolaus Gravenstein, MD, professor of anesthesia at the University of Florida College of Medicine in Gainesville.
3Sights and ultrasounds
Some veins aren't visible to the naked eye. Instead of going in blind with your stick, you can use infrared or ultrasound to locate veins. Infrared vein finders expose superficial veins nearest to the surface. But some people with bigger arms might not have any superficial veins that are visible. With ultrasound, you can find a vein that is deep to the skin, ones that aren't visible to the naked eye or even a vein finder. Ultrasound is especially helpful when you're going into an upper arm or anywhere you have more soft tissue between the surface of the skin and where the vein is located, says Dr. Gravenstein.
4Target practice
Once you've identified the target vein — either visually or with a vein finder — you want to make the target as big as possible. Sharply tapping the vein with your fingers temporarily stuns the blood vessel nerves, which makes the muscles in the vein wall unable to receive a nerve signal to contract. The larger your target, the better chance you have of hitting it on the first stick with less pain to the patient, says Dr. Gravenstein.
"Once I use the lidocaine, I'm willing to say that 75% of the people that I stick tell me that they did not feel the IV catheter go in."
— Chris Lippert, RN, CAPA, Avera Queen of Peace Hospital in Mitchell, S.D.
5Lidocaine to ease pain
Early in his career, a nurse anesthetist suggested to Chris Lippert, RN, CAPA, that he use lidocaine on his patients before IV starts. It ended up being sound advice.
"It was amazing to me how patients suddenly didn't get upset with me over starting their IVs," says Mr. Lippert, OR director at Avera Queen of Peace Hospital in Mitchell, S.D.
Inject lidocaine just under the skin with a small (27-guage) hypodermic needle to anesthetize the tissue around where you're going to place the IV. Then you can go in with a larger catheter (18-guage) and the patient will have less discomfort with the IV start because the skin is already numbed.
"Once I use the lidocaine, I'm willing to say that 75% of the people that I stick tell me that they did not feel the IV catheter go in," says Mr. Lippert.
You can give lidocaine as a patch (put it on the patient 45 minutes to an hour before the IV start), a topical cream that takes 15 to 30 minutes to take effect — apply the cream to 2 or 3 areas of the skin in case you can't find the vein you want — or as an injection.
"When you inject local anesthesia into the skin, you are creating a space where there was none, and you have to create a space in the tissue," says Dr. Gravenstein. "So, inject it slowly."
You can also use a needle-free jet injection device, which you press against the site where you want to insert the IV. It uses carbon dioxide instead of a needle to propel aerosolized lidocaine through the skin. It works immediately, "but it makes a loud, hissing sound, like you're opening a can of soda which can make patients anxious," says Sulpicio Soriano, MD, FAAP, endowed chair in pediatric neuroanesthesia at Boston Children's Hospital and professor of anesthesiology at Harvard Medical School.
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