Consider the key factors!
The patientâs medical history and current medical stateÂ
If the patient is critically ill or if they could âgo southâ quickly, vein preservation is crucial. These patients are most likely to require rapid administration of fluid and/or rapid access to a vein for bloodwork in an emergency setting. Ensure that IV access is obtained from the most distal site first and moving upward with alternating sites as required.
Patients with a history of multiple hospitalizations or chronic illness where IV access has been an ongoing requirement often know their veins very well and will not hesitate to tell you what areas never work!! Although their insight is incredibly useful, always assess BOTH arms regardless before making your decisionÂ
Age, body size and weight, skin and vein condition, level of activity
If possible, try to initiate the IV on the non-dominant arm to reduce the risk of losing the IV during patient activity.Â
Confused patients who are prone to pulling at tubes are often âtrickedâ by IVs that are placed in hidden spots like the ventral forearm with a light sleeve to cover the area. Remember it is never appropriate to cover an IV site with gauze and tape, you should always be able to quickly assess the site especially during continuous infusion.
Elderly patients lose subcutaneous tissue as they age, their distal veins are frail and roll easily and are prone to blowing. These patients will also experience worse complications if infiltration or phlebitis occurs at a distal site. The general rule that I use for the elderly is to try to find the straightest distal vein that is available, usually in the forearm.
Obese patients may not have veins that are visible. Practicing identifying veins by touch first may help you to improve your IV access skills on heavier patients where visualizing veins is challenging.
The type of IV fluid or medication to be infused
IV fluid or medications with a high osmolality or low pH will require a larger vein that can tolerate the infusion
Vesicant medications cause tissue necrosis and can damage surrounding tendons and ligaments in the hands/distal forearm. These medications should ideally be administered at a more proximal site with a larger IV.
It is also important to ensure that there is adequate blood flow around the IV site to carry fluids and medications into circulation, especially if they are vesicants.
Consider this: Vancomycin has a pH of ~3.9. Lemon juice has a pH of 2.5-3. When administering Vanco through a peripheral IV, not only does the site have to be large enough to tolerate the drug, but there has to be enough bloodflow AROUND the catheter to carry the drug into circulation and prevent local damage.
The expected duration of I.V. therapy
If the patient is expected to receive IV therapy for less than one week, start with the most distal site in the upper extremities and move upward. This is extremely important for vein preservation and keeps vein selection high if IV access is lost.
If the patient is expected to receive IV therapy for longer than a week, and/or requires frequent blood work and intermittent IV meds but has poor venous access, discuss the option of a central line/peripherally inserted central line as a more appropriate alternative with the medical team and/or venous access support team at your work
Your level of experience -Â If the patientâs veins are a level 4 or 5, consider observing a more experienced nurse insert the IV until you have become more comfortable with your skills, or have them guide you through vein selection.
Consider the vein level! The lower, the better.
Consider where NOT to poke!
Veins below (DISTAL to) a previous I.V. infiltration or phlebitic area
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.
Avoid veins in the wrist for venipuncture as they run in close proximity to nerves. The cephalic vein on the lateral (thumb) side of the lower forearm/wrist is right next to the radial nerve, I always avoid this site and consider it a last resort for this reason.
Avoid valves. Where two veins conjoin into one there will be valves. Valves can also be visualized as distinct bumps along a straight vein during vein engorgement. You cannot pass an IV catheter through a valve. It will be met with resistance and it will be painful for the patient.
Consider appropriate gauging!
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.
Consider useful techniques!
Warm the arms for 3-5 minutes prior to searching for a vein
Position the arm at or below the level of the heart to encourage blood flow
Use a blood pressure cuff in the elderly. The tightness of a tourniquet can actually blow a punctured vein and a cuff is much more pressure sensitive against the skin of these patients
Use moist compresses or rub the site to encourage blood flow
When cleaning the site, apply good pressure, this can really help you to visualize the vein better immediately prior to puncturing it
Stabilize the vein throughout the IV insertion. Pull downward on the skin distal to the puncture site with your non-dominant hand and maintain that stabilization UNTIL THE CATHETER IS IN. Before puncturing the skin, make sure you are stabilizing far enough down the arm or hand that you can get a low enough angle to go into the vein and not through it.
Insert the catheter with the needle bevel up at a low angle. When blood return is observed, lower the angle level to the arm and advance the unit slightly to confirm placement. Blood return should continue during advancement, at which point the catheter should advance smoothly while the needle is retracted.
Learn to insert the IV holding it with your thumb and middle finger. This eventually allows you to advance the catheter with your index finger while retracting the needle with your thumb and middle finger.
Once the IV is in, follow the two T rule: Transparent Dressing and Tourniquet. As soon as the dressing has secured the site the tourniquet should come off.
It is okay to instruct the patient to clench their fist during IV initiation, this helps with venous filling. However this should be avoided if the IV site is being used to draw blood on insertion (often seen in ED) and should always be avoided with blood work. Fist clenching can result in inaccurate lab results due to hemolysis and excessive local muscle contraction.
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