“Nurse, I hope you're good at this; they always have trouble with my veins.”
This is the last thing you want to hear when you approach a patient to insert a peripheral intravenous (I.V.) catheter, but it's an all-too-common complaint. Peripheral I.V. insertion is a difficult skill to master, and you must perform venipuncture frequently to keep skills sharp. You can also improve your success rate by considering how your patient's age, size, and even cultural background can influence the outcome, then modifying your techniques accordingly.
In this article, I'll describe principles of site selection for I.V. placement and a few tricks for cannulating difficult veins. I'll also discuss how to make choices and modify your approach for certain challenging patient populations so you can perform a “good stick” even in difficult circumstances.
The I.V. line you start is only as good as the vein you cannulate, so make sure you choose the right site and vein for the therapy you'll be administering. Select a site that's stable and a vein that's large enough to accommodate the size catheter necessary for the infusion and allow adequate blood flow around the catheter. The two assessment skills you'll use again and again are inspection and palpation.
While developing your venipuncture skills, stick with the veins you can see. This may be more difficult in obese, edematous, or dark-skinned patients. Apply the tourniquet and look for bumps and bifurcations, indicating venous valves. Take care not to attempt venipuncture at a valve; damaging it could cause blood to pool in the distal part of the extremity and increase the risk of thrombosis.
Using newer technologies to locate veins can greatly improve your chances of success, especially with patients whose veins are hard to see. Try a transilluminator, which is designed to show a vein's size and direction of travel, or portable ultrasound, which is becoming routine in many institutions. Both these devices come with sterile probe covers so you can see the vein in real time as you insert the cannula.
Always palpate a vein before attempting cannulation, no matter how promising it looks. With practice, you'll come to trust your fingers even more than your eyes as you assess the vein's condition and suitability to house a catheter.
To palpate a vein, rest one or two fingertips (not the less-sensitive thumb) on the vein and press lightly. Feel for a “bounce” in the vessel—the sign of a suitable vein. It shouldn't feel hard, bumpy, or flat. Even if you can't see it, this vein may be healthier than a visible vein with multiple previous venipunctures.
If the vein is hard or scarred, try for another; even if you can cannulate this vein, blood flow may be impaired through sclerosed and scarred vessels. Forcing a cannula into a hardened vein can fray or kink the cannula, damaging the vein lining.
Because you can't always be sure what you're feeling is a vein, make sure that it isn't pulsatile, which would indicate that the vessel is an artery. Also make sure it doesn't stretch during range-of-motion movement of the forearm, indicating that the structure is a tendon.
Learning what good veins feel like takes time, especially when you're wearing gloves that may diminish your sense of touch. For more on basics of starting an I.V. line, see Tips you can stick with in any situation.
Now let's look at some tried-and-true tips for finding a suitable vein in certain challenging patient populations.
- Remember developmental stages. Consider a child's age and emotional maturity as well as her physiologic size. Even healthy children reach developmental milestones at different times and in different ways; those with chronic diseases or therapies that retard growth may appear younger than their chronologic age. Remember, too, that children tend to regress developmentally when hospitalized or receiving care for a serious illness or injury, so you may need to make your explanations simpler or use distraction.
- Go to a neutral place for venipuncture. An adult may be fine with having venipuncture in his room. But to a child, the room is a safety zone, so try to avoid performing painful procedures there. In many facilities, children are moved to a treatment room for procedures such as I.V. starts.
- Restrain only p.r.n. Avoid restraints whenever possible. But if you must restrain a child to safely perform venipuncture, use therapeutic hugging—a secure, comfortable holding position, usually performed sitting, that provides close physical contact. Give parents the option of being present for support, but don't ask them to restrain the child.
- Use distraction for nonpharmacologic pain control. Have the child blow bubbles or take a deep breath when you puncture the vein, to “blow the hurt away.” Counting and singing are other good distractors for a preschool or school-age child. Tell her she can sing or count louder if she feels any pain.
- Keep the child warm. Have a blanket available and expose only the limb being cannulated. This is important for neonates and premature infants, who are especially susceptible to hypothermia.
- Know age-appropriate sites. Familiarize yourself with the veins appropriate for your young patient's age. Although not appropriate for routine use in adults or older children, a leg or foot vein can be a good choice for a child who isn't yet walking. Try not to insert an I.V. device in the child's dominant hand or the hand the child uses to suck his thumb.
- Protect your site. Naturally curious, a child may want to explore her I.V. site. Secure the catheter so it's not easily removed, but remains visible for assessment. Transparent site protector devices are available in various sizes and configurations. You can also use flexible stockinette bandages to protect the site; make sure they don't interfere with circulation or site visualization. If the I.V. site is near a flexion area and you use an armboard to stabilize it, make sure it's sized appropriately and padded well. Remove it at regular intervals and perform gentle range-of-motion exercises.
- Anchor the vein. With aging, the subcutaneous connective tissue that anchors superficial veins thins, making the veins more likely to roll when you attempt venipuncture. To firmly anchor an older adult's vein, try pulling the skin taut toward you with your nondominant hand and anchoring the vein with your thumb. Or use your index finger and thumb to spread the skin so that it's taut, anchoring the vein above and below the desired site. You may need to draw very loose and thin skin downward from underneath by using your hand in C-clamp fashion. Whichever anchoring technique you use, take care not to compress the vein above.
- Reduce the angle of insertion. An older patient's veins are likely to be more superficial than those of a younger person, raising the risk that venipuncture could penetrate the vein's back wall. Rather than starting at a 10- to 30-degree angle for the initial entry into the vein, reduce your angle. Once blood flashback confirms entry into the vein, further reduce the angle until the device is almost parallel to the skin.
- Minimize pressure from tourniquets. Use low tourniquet pressure to avoid damaging an older patient's fragile skin and veins, especially if he's taking an anticoagulant or corticosteroid. Or avoid the tourniquet altogether, if possible, by compressing superficial veins with your finger above the insertion site. If you must use a tourniquet, try applying an upside-down blood pressure cuff instead of a tourniquet, which could tear thin, fragile skin. Inflate the cuff to just below diastolic pressure for even, effective compression. This lets you regulate pressure and encourage venous pooling without compromising arterial flow. To avoid bruising the patient's skin, release the cuff as soon as you see blood return.
Edematous or obese patients
- Displace edema and extra tissue. You may need an assistant to help hold extra or edematous tissue out of the way while you insert an I.V. cannula. For a patient with pitting edema, hold firm finger pressure over a spot where you're likely to find a vein and try to see or feel one in the depression. (This also works for displacing adipose tissue, which may be compressible.) Before preparing the site, make an indentation on the skin with finger pressure or mark the spot using a sterile skin marker. Or simply have your prepping solution and catheter ready to use quickly.
- Don't make edema worse. Avoid applying tape around the arm to anchor the catheter, which can further impede venous return and cause venous stasis, pooling of I.V. fluid, infiltration, or extravasation. Minimize the amount of time a tourniquet stays on an edematous limb, to avoid exacerbating the edema.
- Use multiple tourniquets. To distend veins, apply tourniquets progressing distally from the most proximal joint toward the site. This also holds edematous or excess tissue out of the way.
- Shed some light on the subject. Use a vein transilluminator to show the vein's location and size. Vein transilluminators have disposable, sterile covers to minimize the risk of contaminating a prepared site and can help stabilize the vein in obese or edematous patients. (A flashlight or otoscope can fill in if you don't have a transilluminator.) No matter what instrument you use, take care not to burn the patient's skin by using it for a prolonged time.
- Observe anatomic landmarks to avoid problems. Most patients have a superficial vein on the thumb side of the wrist. In a patient who wears a wristwatch, which has a mild tourniquet effect, you may see a vein in the indentation left by the watchband. Because of the risk of nerve injuries and extremely painful venipuncture, use a wrist vein only in an emergency when no other veins are available.
- Try for more superficial veins. As a last resort, the back of the hand or inner surface of the forearm is likely to be less edematous or at least have less underlying tissue obscuring veins.
- Use a longer cannula. Accessible veins may lie below the reach of the standard I.V. catheter. You may need a catheter longer than 1 inch (2.5 cm) to traverse overlying tissue or extracellular fluid. Make sure you can insert enough of the cannula into the vein to avoid dislodgment and infiltration or extravasation because these complications can be very difficult to detect in an obese or edematous patient.
Patients who've had multiple episodes of I.V. therapy
- Ask the patient about past experiences. He probably knows his veins better than anyone else.
- Conserve the veins that are left. To avoid the need for additional venipunctures, consider using a syringe or needleless vacuum tube system adapter to draw ordered blood specimens when you insert the I.V. device. Because this technique could lead to the loss of the vein, however, weigh the benefits versus the risks of obtaining the specimen from a second venipuncture site.
- Avoid collateral veins. A patient who has vein damage from I.V. therapy, surgery, or injury may have developed collateral circulation to facilitate venous return. Usually small in diameter, these vessels don't accommodate an I.V. cannula well and are associated with pooling of infusates at the site.
- Look for an “out of the way” location. Consider infrequently used veins, such as the basilic vein on the back or ulnar side of the arm, or the cephalic vein in the upper arm, which may be visible over the bicep.
- Limit routine site rotations. The Centers for Disease Control and Prevention's guidelines for preventing catheter-related infections recommend restarting peripheral I.V. sites every 72 to 96 hours in adults to prevent phlebitis, unless an earlier restart is clinically indicated. If, however, a patient has limited venous access and already has a well-running I.V. line that's free from complications, consider extending the dwell time. Document your findings to support this decision and obtain a prescriber's order to extend the dwell time. Continue to monitor the site closely and discontinue the I.V. line immediately if you detect any sign of complications.
- Believe your patient if he says he's afraid of needles. About 20% of adults experience mild to intense fear when confronted with injections, blood, injury, health care providers, and hospitals. About 10% of adults have such a profound fear of needles that they have clinical signs and symptoms of “needle phobia”: immediate anxiety and a vasovagal response that can lead to bradycardia and hypotension. Fear also leads to vasoconstriction, making an I.V. start more difficult in these patients.
- Acknowledge his feelings. A supportive approach, combined with reassuring touching of his arm or hand (if you sense this will be welcome), helps the patient relax and preserves his dignity.
- Distract him from the procedure. Try engaging him in a pleasant conversation or having a family member or another staff member distract him. Guided imagery, deep breathing, and listening to music are other distractors that help some patients.
- Choose your words carefully. Remember, the patient is probably embarrassed by his fear of needles, so make sure your comments are supportive and nonjudgmental. Avoid the words needle and stick, which may heighten his perception of pain. Instead, use such terms as insert and soft plastic tube to describe an over-the-needle cannula. Make sure he understands that the painless plastic cannula is all that will remain in the vein when you're finished.
- Supine positioning. Before you start the procedure, have the patient void and lie down in a comfortable position, with his arm supported comfortably on the bed. Patient comfort goes a long way toward promoting relaxation, which will encourage vasodilation and improve your chance of success. A supine position also promotes his safety; if he becomes hypotensive, he won't fall. Maintain this position until the catheter is secured and a dressing is in place. Assess his response to the procedure, help him to a sitting position, and don't leave him unattended when he sits up.
- Consider using local anesthesia. Common agents used for local anesthesia are intradermal injections of 1% lidocaine, 1% buffered lidocaine, 0.9% sodium chloride with benzyl alcohol as a preservative, and topical eutectic lidocaine preparations. Newer needleless injectors or electronic iontophoretic devices also are options. Assess your patient's allergy history and know your facility's policy regarding use of these anesthetics.
Patients from various cultures
- Establish communication. Use words appropriate to your patient's education level and fluency with English. Use a medical interpreter if necessary and avoid medical jargon. Watch for nonverbal cues and be sensitive to ways in which your patient's cultural background may influence such factors as loudness or softness of speech, touching, eye contact, personal space, and reflective silence.
- Be aware of body language. Where you stand in the patient's room to address him, when and how you touch him, and the meaning of eye contact and body movement can vary from culture to culture. This may be particularly true if you and the patient are of opposite sexes or if there's a wide disparity in your ages.
- Know the social organization. Some cultures place a high value on the decisions of family or elders, so you might need to speak to other family members, as well as the patient, about invasive procedures such as I.V. insertion. Make sure you have the patient's permission to speak with family about his treatment.
- How does the patient view time? Cultural attitudes toward time can be particularly relevant when you work with patients in an outpatient setting; they may not place the same value on punctuality that you do.
Meeting the challenge
Starting an I.V. line can be especially challenging in patients with special needs. Try applying the tips I've discussed here to polish your skills and deliver top-notch I.V. care even in the most demanding circumstances.
Tips you can stick with in any situation
Try these general tips for easier I.V. starts.
- Review the patient's medical history. In general, you'll want to avoid using an arm affected by hemiplegia or with a dialysis access. Also avoid an arm on the same side as a mastectomy, sites near infections or below previous infiltrations or extravasations, and veins affected by phlebitis.
- Put gravity to work. Dangle the patient's arm over the side of the bed to encourage dependent vein filling.
- Make sure the patient's comfortable. Pain and anxiety stimulate the sympathetic nervous system and trigger vasoconstriction and vasovagal reactions. Have the patient void before you start the I.V. line, make sure he's warm enough, and administer pain medication as ordered before the procedure. Help him into a comfortable prone or semi-Fowler position for the I.V. insertion.
- Warmth encourages vasodilation. Apply warm compresses to the site for 10 to 15 minutes before you attempt venipuncture. Unless contraindicated, the patient could take a hot shower or drink warm fluids before I.V. insertion.
- Avoid hand veins. Because of the risk of nerve injuries, hand veins should be a last choice, especially in older patients whose skin is very thin.
- Choose the right device for the ordered therapy. If the ordered I.V. medication is irritating to veins and therapy is expected to last more than a few days, consult with the I.V. nurse or medical team to determine whether the patient is a candidate for a midline catheter, a peripherally inserted central catheter, or another type of central venous access device.
- Use the smallest gauge cannula that will accommodate the therapy and allow good venous flow around the catheter tip. For example, for routine hydration or intermittent therapies, use 22- to 27-gauge catheters; for transfusion therapies, 20- to 24-gauge; and for therapy for neonates or patients with very small, fragile veins, 24- to 27-gauge.
- Use good body mechanics. Raise the bed or stretcher to a comfortable working height. Sit, when possible, and keep all equipment within reach. Stabilize the patient's hand or arm with your nondominant arm, tucking it under your forearm if necessary to prevent a moving target.
- Display confidence in your own abilities. When you approach the patient, don't say, “I'm here to try to start your I.V. line.” Instead, confidently state, “I'm here to insert your I.V. line.”
- If you miss. Offer an honest explanation in a matter-of-fact and friendly manner. Think about what you can do to improve your next attempt, explain what you'll do differently (if anything). Most important, limit your attempts to two. If you're not successful after two tries, ask another nurse or an anesthesia provider to try again a little later.
Kelli Rosenthal is president and chief executive officer of ResourceNurse.com, a division of Nurses-Station.com of Oceanside, N.Y.
The author has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.
SELECTED WEB SITE
Wong on Web. Guidelines for atraumatic skin/vessel punctures.
Last accessed on April 5, 2005.
Intravenous Nurses Society. Infusion nursing standards of practice. Journal of Intravenous Nursing
. 23(6, Suppl.), November/December 2000.
, August 9, 2002.O'Grady NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report
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Tailor your I.V. insertion techniques for special populations
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Weinstein S. Plumer's Principals and Practices of I.V. Therapy
, 7th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2001.