Department: upFront: I.V. ROUNDS
ESTABLISHING AND MAINTAINING venous access in an older adult can be challenging. In this article, I'll review some common problems and describe techniques that increase the chance for success.
Aging causes changes to the skin, vein walls, and circulation that can create problems with venipuncture for even the most skilled I.V. nurses. The skin loses tone and elasticity and becomes more fragile and prone to bruising. When bleeding occurs under the skin, it spreads out over a larger area, reducing the available I.V. access sites. Also, loss of subcutaneous tissue in older patients makes veins less stable, so they're more apt to wiggle and roll under the skin as you try to insert an I.V. device. All these changes raise the risk of vein tears, “blown” veins, and bruising.
An older patient also is likely to have multiple medical problems and a weakened immune system, putting her at greater risk for infection. Maintain meticulous aseptic technique during I.V. insertion and throughout therapy to avoid introducing bacteria into the bloodstream. And remember to examine your skin preparation technique: Too-vigorous friction on the fragile skin of an older adult can damage surface tissue, opening pathways for bacterial invasion.
In an older patient, signs and symptoms of infection may be subtle and atypical. Be alert for such warning signs as a change in mental status, subnormal temperature, bradycardia or tachycardia, fatigue, lethargy, and decreased appetite.
Here are some suggestions for reducing the risks of venipuncture in older adults.
- Be gentle to avoid bruising or skin tears. If possible, use a tourniquet made of softer material and apply it lightly. (If the veins are dilated well, you won't need a tourniquet at all.) Never put a very tight tourniquet on an older patient; it can cause petechiae, hematoma formation, or venous high-pressure backflow of blood, resulting in vein “blows.”
- Use the smallest catheter possible, in keeping with Infusion Nurses Society standards. A smaller-gauge needle works well with older patients and can be used for administering antibiotics or hydrating solutions by infusion pump.
- Note the depth of the vein to determine the right angle of insertion. Most veins are very shallow in relation to the skin surface and require an almost flat (10- to 20-degree) insertion angle.
- Before penetrating the skin, stabilize the vein by applying traction to the vein below the insertion site. Don't obstruct the vein below; you won't be able to see where to penetrate the vein.
- Insert the catheter directly on top of the stabilized vein. Avoid side access, which tends to push the vein away from the needle.
- Give yourself plenty of time. This reduces the tendency for jerky long strokes instead of short smooth ones. Go very slowly but steadily; make one short stroke through the skin and into the vein. Feel the needle penetrate the vein. Once the needle has penetrated the vein, advance it and the cannula slowly.
- If your I.V. attempt is unsuccessful or bleeding occurs under the patient's skin, apply gentle but steady pressure for a bit longer than with a younger patient. In older adults, a clot may take longer to form, even if they aren't taking anticoagulants. If bruising occurs, apply cool compresses for the first 24 hours to promote hemostasis, then apply warm compresses.
Monitor your patient closely for signs and symptoms of infiltration, fluid overload, and infection. Infiltration may not cause immediate swelling, but it may cause skin color and temperature changes as the fluid seeps under the skin. When appropriate, use I.V. pumps to regulate fluid infusions, making sure the preset pressure limits are low. Auscultate the patient's lungs for crackles, a sign of fluid overload.
Tell the patient to report pain or swelling at the site and teach her and her family signs and symptoms of complications and when to report them. When discontinuing the I.V. device, remove it gently to avoid skin tears or bruising.
Following these tips consistently not only increases your venipuncture success rate but also reduces the patient's risk of complications.
Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs.
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