Today in clinical we are learning the fine art of I.V cannulation.
This oughtta be interesting.
Last year I had to just about bite my tongue off when we were taught to aspirate before injecting in IM and SC injections. When I was in nursing school *cough* 11 years ago that had already been turfed thanks to evidence based medicine that demonstrates the only area where this is indicated is in dorsogluteal IM's (even there it is debatable but certainly NOT indicated with SC injections).
Ok well initially I didn't bite my tongue and said it to another student but the bat-like hearing of our clinical skills prof exposed me and I was told in no uncertain terms I would fail the OCASE if I didn't aspirate. Sigh. I muttered something about doing it for the exam and never again. (BAD medical student!! BAD!!!)
Anyway, I am interested to see how the IV starts are going to be taught. I wonder how many I may have done in my career as a nurse? Hard to calculate but based on rough figures...7 years, 200 shifts per year (with great variation in # of starts per shifts) maybe averaging 6 starts per shift...that comes out to 8400 starts. Okay even if that is a gross over-estimation, I am well past the 5000 mark. Hey! That is kinda cool. I never actually figured that out before.
Below is a comment that I left on Rob's blog ages ago when he wrote about learning how to start IV's. They are some of the little tips/tricks I've gleaned mostly from other nurses, much more experienced than I.
I love IV starts. These are some of the rituals I go through when I am starting an I.V.
First off, most people believe that there is a metal needle in their arm. When people are really anxious about it (esp PEDS) I show them how it works with a demo needle that I chuck. It seems to really calm a lot of folks down. I only usually show adults if they are going to have the IV in for a long time, it makes them more relaxed about moving the tethered limb around.
Some tricks I use for tough starts (I am sure you know these already but in case you don't):
-In the elderly with the feathery skin and veins don’t use a tourniquet as you are more likely to have it roll or blow with the induction. Just anchor the vein above the site with the thumb of free hand and go at a very superficial angle. As soon as you get flashback take the needle out and gently advance the catheter.
-For tough starts go for the radial vein near the wrist (usually very juicy as not many people use it).
-Warm people up with either warm blankets or (my personal favorite) 100cc saline bags that you put in the microwave for 10-30 sec. This is great with PEDS also, I warm the bags up then kling wrap the bags to their hands and feet–go off and do some other task and when you return–BAM! the veins are waiting for you. (Just make sure you hold the bag on your own skin for about 10 sec to make sure it is only warm not hot. I think that hot wet towels are a bad idea because as soon as you take them off it cools the limb down a lot and if you get caught up doing something else then you have a cold, wet limb to try and salvage a start out of. Dry heat is better.)
-Drop people’s hands so that their arm is hanging below the chair.
-Don’t slap the veins as sometimes that causes them to flatten out.
-Take your time.
Really. I spend as much time as I need just chatting with the patient while I palpate around for the best vein. The longer I take to find a good one, the greater the likelihood I’ll find one on the first poke.
-Don’t be afraid of small guage needles on hard starts. No matter what they tell you blood *will* run through a #20, even a #22 in a pinch. Not everyone needs a #16 in the pinky to prove your abilities.
-If you hit a valve going in, you can try to gently push through or just pull back a bit and if the line is good just secure it there.
-Tape is our friend. Use paper tape on the elderly, especially if you don't feel like tearing their skin off when you d/c the I.V.
-And finally, feet are sometimes better than you think. Esp in people who’ve had lots of chemo or alternative drugs (ahem) in specific veins.
So there you go blogworld. My free, unsolicited advice on I.V starts. Now I am off to learn how to do it! There may be some major tongue biting today as well, but must go and see what the gold-standard-medical-school-OCASE-way of doing it is.
I won't mention my aversion to gloving with difficult starts!