On the road to successful I.V. starts

Abstract

PERFORMING VENIPUNCTURE and starting intravenous (I.V.) infusions are among the most challenging clinical skills you'll ever have to master. Yet few nursing schools offer enough hands-on learning, and hospitals typically provide only limited opportunities for supervised practice. If you work in a busy hospital, you can understand why. For an experienced practitioner, it's quicker and easier to perform venipuncture than to coach a less-experienced nurse through the procedure and provide feedback. So the less-experienced nurse never develops the skills to perform venipuncture confidently under all kinds of conditions—which can cause frustration and needless pain for patients. If all this sounds familiar, this special guide will help you increase your knowledge and critical thinking. Use it along with other opportunities to learn. Courses via the Internet, traditional classroom instruction, lab practice sessions using anatomic training arms, and work with clinical preceptors can help build your confidence. To become truly proficient, however, you must perform many procedures on real patients. The learning process will also involve practicing on all types of arm sites. Veins that you can easily see and palpate aren't always available, so you must learn to cannulate more difficult veins too. In the following pages, we'll show you how. Your employer must determine that you're competent to perform these procedures before you work independently. This process usually involves working under the supervision of a clinical preceptor or a more-experienced colleague who likes to teach others. Check the processes outlined in the policies where you work to determine how you must demonstrate competency and what procedures must be included. This may be limited to venipuncture, but it could include I.V. medication administration, use of electronic infusion pumps, and blood administration. Begin by working with patients who are well hydrated without chronic diseases or a history of many courses of infusion therapy. As you work to improve your skills, you're bound to have a few failures. If you make two unsuccessful venipuncture attempts, don't persist on a patient. Call in the I.V. team (if available) or a nurse who's more skilled at venipuncture. Don't let a few setbacks discourage you. With practice, you can refine your venipuncture skills. Then continue using them to keep them current. SELECTING A VEIN When choosing an appropriate vein for venipuncture, you'll consider many factors, including: the patient's medical history his age, body size and weight, general condition, and level of physical activity the condition of his veins the type of I.V. fluid or medication to be infused the expected duration of I.V. therapy your skill at venipuncture. Consider the characteristics of the therapy, such as the osmolarity and pH, and the length of time therapy will be required. If therapy is likely to continue beyond 6 days, contact the I.V. team or vascular access resource group to assess the patient for a midline catheter (MLC) or peripherally inserted central catheter (PICC). Short peripheral catheters are indicated when the therapy lasts 6 days or less, when the fluids and medications have a pH between 5 and 9, and when the osmolarity is less than 500 mOsm/liter. If therapy is expected to last less than 6 days, you'll want to start with the most distal site in the upper extremities and move up as necessary. The Infusion Nurses Society (INS) recommends that each subsequent cannula be placed proximal to the last one. By thinking out cannula placement ahead of time, you can head off problems during therapy. To learn more about the veins most commonly used for I.V. starts, see Mapping out a plan. Exploring the options For most adults, assess hand veins first. Starting with a hand, preferably the nondominant one, leaves more proximal sites available for subsequent venipunctures. But you shouldn't use hand veins in older adults who've lost subcutaneous tissue surrounding the veins or in patients who'll be getting in and out of bed frequently or using their hands for other activities. Infusion of vesicant medications into hand veins is also contraindicated. Vesicant medications cause tissue necrosis, which could result in loss of hand function from damage to tendons and ligaments. Sites in the hand require support on a handboard to reduce vein irritation and subsequent complications such as phlebitis and infiltration injury. Mobility shouldn't be affected if you correctly position the handboard to allow finger movement and provide wrist support. Make sure you remove the handboard at established intervals to check the patient's circulation. Veins in the fingers and thumb may be easily visible when a tourniquet is placed; however, they're prone to complications and can't support a catheter for long periods. Their small diameter allows little or no blood flow around the catheter. The motion of the finger can lead to phlebitis, infiltration, and subsequent tissue damage. If these veins are the only sites you find, ask another nurse to assess your patient. Most adults have many venipuncture sites on both sides of the forearm. Using these veins is usually a good option for short-term I.V. therapy because hand and arm mobility aren't restricted. This is a plus for patients in home care or those who are using crutches or a walker. A patient's weight can also be a factor in your choice of forearm veins. In an obese patient, for example, you may not be able to see veins in the forearm. But you may be able to palpate a healthy vein if you know the typical locations. Don't routinely use veins in the antecubital fossa and above for peripheral catheters. These sites may limit the patient's range of motion, increase the risk of phlebitis and infiltration, interfere with blood sampling, and prevent the use of these veins for midline and PICC insertions. Starting at a distal site and making subsequent venipunctures proximal to the previous sites is crucial. When a complication develops at a proximal site, you can't use veins distal to this site because the fluids and medication would infuse into the damaged site, compounding the problem. Avoid these sites Don't use veins in the wrist for venipuncture because of their close proximity to nerves. Besides the risks of causing pain and damaging nerves, preventing movement at these sites may be impossible, increasing the risk of complications. Although used in infants, veins of the legs, feet, and ankles shouldn't be used in adults. The superficial veins of the legs and feet have many connections with the deep veins. Catheter complications can lead to thrombophlebitis, deep vein thrombosis, and embolism. But if you have no choice during an emergency, the dorsum of the foot and the saphenous vein of the ankle can be used until central venous access is obtained. You can stabilize a foot vein by asking the patient to point the foot toward the end of the bed, then use the same stretching technique you'd use to stabilize a hand vein. Remove catheters in the lower extremity as soon as possible.FigureOther sites to avoid include: veins below a previous I.V. infiltration veins below a phlebitic area sclerosed or thrombosed veins areas of skin inflammation, disease, bruising, or breakdown an arm affected by a radical mastectomy, edema, blood clot, or infection an arm with an arteriovenous shunt or fistula. Evaluating the vein you choose A vein that's suitable for venipuncture should feel soft, elastic, and engorged—not hard, bumpy, or flat. Inspect and palpate it for problems. Some veins that appear suitable at first glance feel small, hard, or knotty on palpation. A vein sclerosed from previous I.V. therapy isn't suitable for venipuncture. To palpate a vein, place one or two fingertips (not the less-sensitive thumb) over it and press lightly. Then release pressure to assess the vein's elasticity and rebound filling. To increase the sensation in your fingers, practice palpating veins on friends or co-workers. Always practice while wearing gloves because gloves must be worn during venipuncture procedures to reduce your exposure to blood. To acquire a highly developed sense of touch, palpate before every cannulation—even if the vein looks easy to cannulate. Although some veins feel and look suitable, they don't take cannulation well because their lumens are irregular and narrowed from scarring. In that case, you'll have trouble advancing the cannula smoothly into the vein. Or you may find that an apparently suitable vein is too fragile and easily damaged. If bleeding through the vein wall occurs, the area will become puffy, bruised, and painful. Although you can't always foresee these problems, expect a patient who's received several courses of I.V. therapy in recent months to have fewer suitable veins. Avoiding arteries Because they're located deeper than veins, arteries are rarely damaged during venipuncture. In the antecubital fossa, however, where arteries and veins lie close together, the risk increases. Before performing venipuncture at any site, palpate for arterial pulsation (which occurs even after a tourniquet has been applied properly) to locate nearby arteries. In some cases, you may also see pulsation. Stay off your patient's nerves Nerves are located close to superficial veins in many locations on the hand and arm, especially in the wrist and antecubital fossa. Never perform venipuncture on the palm side of the wrist and avoid the large cephalic vein at the level of the wrist too. Recent research has demonstrated that the superficial branch of the radial nerve crosses the cephalic vein at least once and up to three times as it extends from the wrist to the forearm. To avoid all these possible intersections when using the cephalic vein, perform venipuncture 4 to 5 inches (10 to 12.5 cm) above the level of the wrist, if possible, depending on the number of available venous sites and the length of therapy. If your patient complains of tingling, a pins-and-needles sensation, or numbness, a nerve may be damaged. Immediately remove the catheter and choose another venipuncture site. Don't probe around after piercing the skin or use a plunging or jabbing technique to insert the catheter. SELECTING A CANNULA Federal legislation in 2001 amended the Bloodborne Pathogens Standard from the Occupational Safety and Health Administration (OSHA), meaning that I.V. catheters with an engineered safety mechanism must be provided. After venipuncture, the stylet is a hollow-bore, blood-filled sharp. Needle-stick injury with this type of device carries the highest risk of bloodborne disease. Catheters with a safety mechanism greatly reduce your chances of being stuck with a contaminated needle. Several brands of catheters are available with various safety mechanisms. They may require a little more practice for you to handle proficiently, but the effort is worth the reduced chance of being exposed to hepatitis B or hepatitis C virus, human immunodeficiency virus (HIV), or other bloodborne pathogens. An over-the-needle catheter and a closed I.V. catheter system with attached tubing are ideal choices for veins of the hand or forearm. Most over-the-needle catheters range from ⅝ inch to ¼ inches; closed-system catheters are between ⅝ inch and ½ inches long. The diameters of these cannulas range from 16- to 24-gauge. After inserting either type of device, you'll withdraw the steel needle, leaving only a flexible plastic catheter in the vein. If you're using an over-the-needle catheter, plan to attach a short, small-diameter extension tubing or use a closed I.V. catheter system with an integrated extension set. This lets you loop the tubing and secure it away from the insertion site. If the tubing gets pulled, this secured loop prevents catheter dislodgment and vein irritation. Another advantage of having this additional piece of tubing or integral extension set is that you'll change the tubing away from the insertion site, decreasing cannula manipulations and the risk of contamination. Avoid steel butterfly-type needles except for short-term duration (1 to 4 hours) or injections of one-time doses. An inflexible steel needle greatly increases the risk of vein injury and infiltration. Never use these devices for any medication that would cause tissue necrosis if it extravasated. Intermediate and long-term therapy options Midline catheters are a good choice when the therapy will last between 1 and 4 weeks. An MLC is inserted via the basilic, median cubital, or cephalic vein of the antecubital fossa and advanced until the tip rests in the proximal portion of the upper arm, level with the axilla but distal to the shoulder. Therapies suitable for infusion through an MLC include those with osmolarities less than 500 mOsm/liter and a pH range between 5 and 9. A PICC is indicated when therapies will be needed for 1 to 12 months. A PICC is inserted via the veins of the antecubital fossa or the upper arm, but the tip resides within the superior vena cava. Solutions with extremes of osmolarity and pH can be infused because the high blood flow around the catheter tip will rapidly dilute the infused solution. Choosing the right size Depending on the vein used, the I.V. cannula should usually be ⅝ inch to ½ inches long. To reduce the risk of phlebitis, the catheter should have the smallest diameter possible so it takes up less space in the vein. This allows better blood flow around the catheter, lessening the risk of phlebitis and promoting proper hemodilution of the fluid. When selecting a catheter, consider the patient's condition and the type of solution you'll be running through the catheter in the next 72 to 96 hours. Using the smallest-gauge catheter in the largest vein possible will reduce the mechanical and chemical irritation to the vein wall. Keep these general guidelines in mind: 24- to 22-gauge for children and elderly patients 24- to 20-gauge for medical patients and postoperative surgical patients 18-gauge for surgical patients and for rapid blood administration. Blood can be infused through smaller-gauge catheters, but the flow rate will be slower. 16-gauge for trauma patients and those requiring large volumes of fluid rapidly. Before inserting any needle or cannula, carefully inspect it for imperfections, such as problems with the catheter tip. Follow the manufacturer's recommendations about adjustments that you should or shouldn't make to the catheter before insertion. GETTING STARTED Obtain the I.V. fluid from floor stock or from the pharmacy. Compare the label on the container with the prescriber's order to confirm accuracy of the type of fluid and any added medications. Additional information can be gleaned from the patient's medical record. Check for allergies, especially to antiseptic agents (iodine, for example) or latex. A long history of hospitalizations is a clue that your patient has had many I.V. catheters in the past, possibly decreasing the number of venous sites available now. A history of vasovagal reactions indicates he's at risk for this reaction during venipuncture. Gather the equipment you'll need and prime the I.V. tubing before you enter the patient's room—especially if you're relatively inexperienced. With privacy, you'll have time to get organized, look over the equipment, and plan your approach without making your patient anxious. If you're working with a preceptor, devise a system of communication ahead of time so that the preceptor will know when to step in and perform the procedure. This may happen if you don't feel comfortable performing the procedure because of the patient's veins or his attitude toward the procedure. When you enter the room, wash your hands or clean them with an alcohol-based hand rub, identify the patient, and introduce yourself if you're meeting for the first time. Take a few minutes to explain the procedure. Encourage the patient to ask questions and answer them with direct and complete information. Avoid using words that might add to his apprehension, such as "needle" or "stick." Instead, you might say, "I'm going to put this soft plastic catheter in your arm to deliver your medication." He may relax a little when you show him the equipment. As you talk, note whether his skin is cool or diaphoretic: If he's anxious, vasoconstriction could make veins hard to find. Acknowledge his feelings with a comment like, "I can see you're a little nervous," and do your best to put him at ease. If he's never had an I.V. catheter inserted before, for example, assure him that he'll be able to use his hand and arm after venipuncture. If he's nervous, chilly, or hypotensive, expect to spend a little extra time dilating and distending the vein before venipuncture. Make sure you're in a comfortable position by raising the height of the bed to prevent unnecessary bending. Make sure that lighting's adequate for accurate vein assessment and I.V. catheter insertion. The patient should be supine with his head slightly elevated (unless and with his arm are at an risk for vasovagal reaction if they're up during venipuncture. the patient's nondominant arm first to allow him to use his hand the tourniquet and assess his veins. If they these his arm below level or his arm to filling. him to and close his several sure his is during or his arm to the his arm with for to minutes to by increasing blood flow to the a tourniquet the tourniquet 5 to 6 inches to cm) above the venipuncture site. veins in a patient should within a few may take in elderly or patients. Use a tourniquet because can be a of To it as as possible, avoid or the it enough to venous blood in the lower veins without with arterial If you can't feel a below the tourniquet if the patient complains of it's too As the veins the skin below the tourniquet will become slightly from venous Make sure the tourniquet the patient's the of the tourniquet toward each so that one the the and then use two fingers to the under the Make sure the point away from the venipuncture site. Use this technique to stabilize the the tourniquet and the skin and tissue away from the venipuncture site. 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By the solution or below the vein, you can avoid the into the vein. about to of the length to a superficial you may have to deeper for a deep vein. up the needle tip slightly so a can be you the the small superficial veins may require only of with deep veins, you may have to the to a about the size of a the needle. 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If you know the site is at once with If you use a the patient to him to in and out as you insert the the cannula at a to depending on the vein's the cannula up to reduce the risk of piercing the vein's wall. your fingers so you can see blood in the or extension Some catheters and closed catheter are to provide or of which will improve your on the first the vein the cannula through the skin and vein with one Don't always expect to feel a or for blood in the cannula tubing or to you that the vein may if the stylet through the and out