By Glenda Dennis, RN, VA-BC, AIMS Founding Member
IV insertion, for the novice nurse, can seem like a frightening dark art–difficult, if not impossible, to master. But, with patience and practice, you can learn to perform IV insertion in ways that minimize discomfort and any long-term side effects for your patient.
The most important concept is to use the smallest gauge IV needle possible to address the patient’s need and insert the needle in the largest peripheral vein.
Areas to Avoid
Avoid areas of flexion, such as the wrist or elbow. Never use the inner aspect of the wrist. Veins there are visible, but many tendons and nerves run through this area and are at risk of damage.
Never use the patient’s feet or legs for IV access unless the patient is a non-ambulatory infant. Although quite visible in many feet and easy to cannulate, the veins dive deeply into the legs, and the irritation caused by many IV solutions can set a vein up for a blood clot, commonly known as a deep vein thrombosis or DVT. If the clot breaks loose from where it has formed, it can travel to the lungs and be caught there causing a pulmonary embolism, a life-threatening complication.
What Size of Needle?
Blood transfusions need not be done with a large-bore needle. Blood will infuse safely through a 24-gauge needle, but it will require more time. If rapid transfusion is required, you will need a large-bore needle, such as an 18-gauge or 20-gauge.
How to Choose a Vein
Start using the most distal veins first. Consider how long the therapy will be needed. If required for days to weeks, start with distal veins, such as in the hand. If the IV inadvertently infiltrates (infuses into the tissue instead of the vein), you cannot use the vein below the infiltration, due to the damaged vein tissue. Therefore, using the most distal veins first will allow you to preserve as much of your patient’s vasculature for future IV insertion as possible.
Choose a straighter vein for the IV insertion. There are valves in veins that help keep the blood flowing back to the heart whatever the patient’s position. These valves can be challenging to penetrate, especially when the valve is at the distal tip of the IV catheter. You will learn to locate these valves in some patients, but, in the very young and very elderly, you may not be able to see where these valves are. They often are located at the bifurcation of the vein, where it divides into two. Try to avoid locating the IV catheter tip in this area.
Tourniquet or No?
Tourniquets are devices, such as tightly encircling bandages or rubber tubes, used to stop bleeding by temporarily stopping the flow of blood through a large artery in a limb. They can be helpful tools in locating a usable vein, but proper use takes time to learn.
The best way to apply a tourniquet for IV insertion is with light to moderate pressure. Avoid putting the tourniquet on extremely tight as you may completely block the flow of blood in the artery, and as a result, the vein will not fill well. If your patient has fragile veins, as is often the case in the elderly, the tourniquet can create enough back pressure to rupture the vein as soon as you try to enter it with your needle.
Minimizing Your Patient’s Pain
The most painful part of IV insertion for the patient is getting through the skin. Many nerves are located just underneath the skin. A small subdermal wheal of bacteriostatic normal saline used prior to IV insertion is a great anesthetic. A ½-inch 27-gauge insulin needle works well for this. The alcohol in the bacteriostatic saline provides the numbing agent.
Once you have applied the anesthetic, cleanse the skin thoroughly, and with gloves on, gently access the vein.
When to Stop Trying
Even the most experienced nurse can occasionally encounter challenging veins. The IV standards of practice clearly state that if you have not successfully canulated the vein after two attempts, you must let another experienced nurse make the third attempt. Do not get discouraged. You will improve with practice.