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The Starting Line
Lisa Fisher
Publish Date: October 10, 2007   |  Tags:   Patient Safety

Starting intravenous lines is second nature to most nurses, but problems can still occur when performing even this most basic of tasks. A patient who's repeatedly poked, pricked and stuck during misplaced attempts will remember that unpleasant experience far longer than the smiling receptionist or great surgical outcome. So with the safety and comfort of your patients in mind, here's a refresher on starting safe, painless and efficient IVs. After you're through reading, pass this article along to all of your staff who start IVs.

Proper planning prevents poor performance
v Starting efficient IVs begins with proper preparation. Have all supplies readied before contacting the patient. Having the required supplies opened and within arm's reach puts the nurse at ease and relaxes the patient, who takes comfort in knowing the IV is being administered by a trained and prepared clinician. You can either buy basic supplies in commercially produced IV starter kits or organize them with individually packaged items. Here's what's required: gloves, angio or butterfly catheter, alcohol swab, tape, gauze (4x4 or 2x2), tourniquet, patient label and IV tubing.

Following patient safety guidelines isn't reserved for the OR; once you've washed your hands and opened and organized the supplies, properly identify the patient. Introduce yourself, understanding that patients are often fearful of needles and the IV start, perhaps even more than of the surgery itself. Be sure to explain the IV-start process to patients and ask about their history of IVs. Multiple IV starts, whether because of past surgeries or intravenous therapy, can scar veins and make starts difficult in typical target areas.

Finding the vein
Here are tips to help bring a suitable vein to the skin's surface:

  • Apply a tourniquet to the patient's upper arm and palpate the arm to help identify the target vein.
  • Have patients pump their fist or drop the arm to their side, below heart level.
  • Tapping on the vein itself can also make it more visible and suitable for an IV start.

Challenges in locating a suitable vein can occur in geriatric patients, who often have small and rolling veins. The thickness of obese patients' arms can also cause difficulty in locating suitable veins.

Once you've identified a vein, swab the target area with alcohol, working in concentric circles and from the inside out. Some facilities also require application of betadine as an extra cleaning protocol. Next, choose the catheter size. Larger gauges, between 14 gauge and 16 gauge, allow for rapid transfusion in trauma situations. Suitable adult catheter sizes in non-emergency surgical cases range from 18 gauge to 21 gauge. Pediatric and geriatric patients have smaller veins, and therefore require a smaller catheter, typically a to 24 gauge.

Getting in
The fewer attempts needed to start an IV, the better. Using your thumb, hold traction on the target vein below the insertion site to keep the vein from rolling. Then enter the skin with the needle and angio catheter at a 30-degree to 40-degree angle with the bevel of the needle up. A quick, focused push is more effective in reducing the patient's pain than slow, searching insertions. After the skin has been punctured, a slight amount of blood appearing in the clear chamber of the catheter signifies that the catheter has entered a vein. A further push into the skin is required at this point, followed by a leveling of the catheter and a lowering of the insertion angle.

With the catheter flush to the skin, hold the needle steady as the catheter slides off the needle and into the vein. Release traction on the arm, remove the tourniquet and apply pressure above the insertion site as you pull the needle from the catheter. Once you've removed the needle, connect the catheter to an IV adapter or IV tubing. Flush the line to ensure it's functioning properly.

After successfully starting an IV, record the time, the date and sign your name to the label that was included in the pre-IV supplies. You can either affix the label over the insertion site or fold it around the IV tubing.

Keeping infection control in mind
From an infection control standpoint, it's important that you don't deviate from the proper insertion technique. For instance, the angio catheter becomes contaminated if it slides across the glove during insertion. Also, never recannulate the needle, as it could shred the catheter on the first pass, resulting in the potential for pieces of plastic to enter the vein.

Protect yourself from blood-borne pathogens by wearing barrier protection and following proper insertion techniques. Another safety factor is measured more indirectly. The fewer times you handle sharps, the fewer opportunities exist for a sharps-related incident. In addition to ensuring that you review and understand proper IV starting technique, consider the use of safety IV catheters that limit exposure to sharps and therefore offer you and your staff further protection.