Help me; I have to start an IV, and now!
Darmeshia Brunson
Leadership
Mrs. Erica Lue
Fortis Institute

ABSTRACT
Nurses frequently face challenges placing peripheral intravenous (IV) lines in adults and children. Multiple venipuncture attempts can heighten patient anxiety and suffering, delay vital treatment, and increase costs. Numerous factors such as small, fragile or hidden veins can predispose patients to collapsed veins due to dehydration are especially challenging. Several techniques can improve venous prominence, but when IV access cannot be achieved promptly, other routes of administration can be valuable. For rehydration fluids and certain drugs, subcutaneous administration may be a safe and effective alternative, providing cost and ease-of-use advantages.

The word intravenous simply means “within a vein”, but it is usually used to refer to IV therapy. Intravenous therapy is getting fluid directly into a vein. It can be intermittent or continuous; continuous administration is called an intravenous drip. Treatments administered intravenously are often much needed medications. Compared with other routes of giving medications, the intravenous route is the fastest way to deliver fluids and medications to the body. Some medications, like blood transfusions, can only be given intravenously.
I have to put in an IV, my patients’ pervious IV is older than 72 hours and per protocol a new has to go in. Oh, I remember back in nursing school going to clinical watching the more experienced nursing putting in fresh IVs and being horrified at some of the techniques used behind closed doors. One particular clinical a nurse gathers all the necessary material to start an IV. I watched her that tie off the arm above the elbow, clean it and then insert the needle. Standing off to the side being the student that I am thinking, wow she’s so good at IVs she doesn’t even palpate the arm before she stuck them, I so want to get that good that I can do that. Big mistake, before it was all said and done she stuck that patient 5 times using the same method as stated before and walk away without a good IV site. After watching the horror story of needle insertion, I had to go back to the basics. What was I taught in my foundations class about IVs? Why is IV therapy needed? Intravenous therapy is needed to supply fluid when clients are unable to take in an adequate volume of fluids by mouth. To provide salts and other electrolytes needed to maintain electrolyte imbalance. To provide glucose for a patient comes in unconscious with severe hypoglycemia. To establish a lifeline for much needed medications. I remembered the step by step job of putting them in but where was and still remains a little disconnect between what we are taught in school and the work force. Proper step by step instructions for inserting an IV starts with an assessment followed by the follow thru. The client should be assessed prior to anything because without an patent site no medications can be given. Before anything else starting with an assessment of the solution and the client to determine the following:
Assessing the client:
Baseline vital signs
Skin turgor
Any allergies to latex, tape or iodine
Bleeding tendencies
Any disease or injury to extremities
The character of the veins to determine placement of an IV
Assessing the solution:
The type and amount of solution to be infused
The exact amount of any medications to be added to a compatible solution
The flow rate at which the infusion will be completed
The assessment of client and the solution is complete, now what? Implementation of the new IV site is the next step. Upon entering the client’s room I need to introduce myself and verify the client’s identity. Explain the procedure to the client. Explain how a venipuncture can be uncomfortable for a few seconds, but there should be no pain while the medication is flowing. Start with properly washed hands, a 30 second scrub will do nicely. Find a venipuncture site, preferable use the client’s non dominant arm, unless contraindicated by veins injured by a pervious infiltration or phlebitis, side of a mastectomy, dialysis shunt or affected by a CVA, used for lab testing, or near an area of flexion such as antecubital. Try to identify possible venipuncture sites by looking for veins that are somewhat straight, not sclerotic or tortuous, and avoid venous valves. The vein should be palpable, but may not be visible, especially in clients with darker skin. Consider the catheter length; look for a site sufficiently distal to the wrist or elbow that the tip of the catheter will not be at a point of flexion. Place a towel or a bed protector under the chosen extremity to protect linens. Dilate the vein by placing the extremity in a dependent position (lower than the client’s heart). Gravity slows venous return and distends the veins. Distending the veins makes it easier to insert the needle properly. Apply a tourniquet above the venipuncture site. Explain to the client that it will feel tight. Tourniquet must be tight enough to occlude venous flow but not so tight that it occludes arterial flow. Obstructing arterial flow inhibits venous filling. If a radial pulse can be palpated, the arterial flow is not obstructed. Massage or stroke the vein distal to the site and in the direction of venous flow toward the heart. This motion helps fill the vein. Encourage the client to clench and unclench the fist. Contracting muscles compresses the distal veins, forcing blood along the veins and distending them. Lightly tap the vein with your fingertips. Tapping may distend the vein. Now that a useable vein has been located, put on clean gloves and clean the venipuncture site. Wearing gloves protect the nurse from contamination by the client’s blood.
Now it is time to clean the site with topical antiseptic swab. Some may use anti-infective solution such as povidone-iodine. Check for allergies and the facilities protocol. Use circular motions by moving from the center outward for several inches and using a back and forth friction scrub. This action removes microorganisms away from the site entry. Allow the solution to dry on the skin. It may take the Povidone-iodine a full minute to be effective. While the antiseptic dries, prime the short extension tube then apply side clamp. Use your nondominant hand to pull the skin taut below the entry site. This will stabilize the vein and make the skin taut for needle. It can also make initial penetration less painful. Hold the needle catheter at a 15-to 30-degree angle with the bevel up; insert the catheter through the skin and into the vein. Sudden lack of resistance is felt as the needle enters the vein. Once blood appears in the lumen or you feel the lack of resistance, lower the angle of the catheter until it is parallel with the skin and advance the needle catheter.
While holding the needle portion steady, advance the catheter until the hub is at the venipuncture site. The catheter is advanced to ensure that it, and not just the metal needle, is in the vein. Release the tourniquet. Stabilize the hub with thumb and index finger of the non-dominant hand. Remove the protective cap from the distal end of the tubing and hold it ready to attach to the catheter, maintaining the sterility to the end. Carefully remove the needle, engage the needle safety device, and attach the end of the infusion tubing to the catheter hub. Put pressure on the vein proximal to the catheter to eliminate or reduce blood oozing out of the catheter. Attach the syringe and aspirate to see if there is a blood return, if yes, flush normal saline and remove syringe. Apply tape and dressing over insertion site but not over the connection of the catheter and tubing. Loop the tubing close to the cannula and secure with tape to prevent kinking or pulling. Open and prepare the infusion set.
Spike the medication bag. Put on a medication label to the solution container if a medication was added. Also apply a time to label on the solution container. Set up machine, unclamp, take off gloves, clean up and dispose sharps in sharps container. Document the important data, including assessments. Record the start of the infusion on the client’s chart. Include the date and time of the venipuncture. Amount of solution used, including any additives, flow rate, the type, length and gauge of the needle or catheter. Document the type of dressing applied and the client’s general response.
I guess as time goes on, nurses start to get set in their way and fall away from the way they were taught in school. I also realized that facilities have protocols to follow for a reason and they should be followed as ordered. Some patient come in already frighten and afraid of needles, like myself, so no I do not want to be stuck 50 million times until you get it right. All too many patients are getting bruised and battered all for placement of an IV.

REFERENCES

1. Perry, Potter, Ostendorf. Clinical Nursing Skills & Techniques. 8th Edition: Saunders

Elsevier: 2014: chap 28

2. Jacobson, Winslow. Variables Influencing Intravenous Catheter Insertion Difficulty and

Failure: An Analysis of 339 Intravenous Catheter Insertions, Hear & Lung: The

Journal of Acute and Critical Care, Volume 34 Issue 5, September-October 2005,

Pages 345-359