A nurse colleague on twitter asked me for tips on starting IV’s in pudgy toddlers. This tweet was followed by another, stating “I have trouble with pudgy at any age”. Yes, I agree. Even to the most experience infusion nurse, pudgy is always a challenge and usually means no chance of finding veins or easy venipuncture. Here are 10 tips that I find helpful in any situation, pudgy or not, young or elderly, when peripheral veins are hard to find. These are based on my own experience as an infusion nurse for more than 20 years.
1. Dry heat: Use dry heat to the proposed site. Application of dry heat increases blood flow allowing for good venous dilatation, thus improved vein visualization. To me, heat has been a proven technique and now, as I have discussed in a previous blog entry, has been studied. Dry heat was 2.7 times more likely than moist heat to result in successful IV insertion on the first attempt, had significantly lower insertion times, and was more comfortable.
2. Tapping: Apply the tourniquet. Lightly tapping the skin or area where you see veins will help distend the vessel. Avoid “beating” the skin as it might cause venospasms.
3. Stroking: Stroking the vein toward the hand allow for venous refill.
4. Open/Close fist: Open and close fist during vein assessment but keep arm relaxed during venipuncture.
5. Palpation: Apply the tourniquet. Use your index finger to palpate the veins. Press directly on the vein with your index finger, assessing for vein softness and volume. Then release the pressure slowly without lifting your finger and feel the vein bounce back to your index finger. Repeat as often to ensure you found a suitable vein. Don’t stick without palpating the vein!
6. Skin Anchoring: An important step to the success of venipuncture. Prevent the movement of veins during venipuncture.(especially for “rolling veins”). Pull skin downward below the point of insertion with the thumb of the non-dominant hand or pull skin above the point of insertion with forefingers or pull skin from underneath the extremity.
7. Enter at an angle: Select the smallest gauge and shortest length catheter. Position catheter tip bevel up. Approach angle to skin at 10 –15 degree. Deeper veins need greater angle. Superficial require lesser angle. If parallel to the skin surface, will drag the skin as you puncture it. Lower angle once blood return is observed and advance the catheter.
8. Vein Viewer and Ultrasound: There are devices that can help you find veins. The equipment ranges from transillumination to ultrasound. These are expensive equipment and would require training prior to use. There is increasing evidence that the use of ultrasound for venous access is safe and successful. It’s use perhaps will be a common practice soon.
9. Patience: Take the time to find and assess veins. Some veins are located deep in the superficial fascia and the extra “fatty deposits” doesn’t help. Veins won’t change position just because you are in a hurry.
10. Take a deep breath: Both you and the patient! Let the patient know when you are ready to stick and tell them take a deep breath and blow it out slowly. This will distract them from the stick and help the tension in their arm.