Thursday, March 6, 2008

Venipuncture Techniques

I found this article on for those of you practicing venipuncture...this is a lot of help.

Always use universal precautions and aseptic technique. Avoid needle sticks.

Excess hair may be removed to enhance site preparation and to facilitate catheter insertion, taping, and dressing adherence. INS advocates use of scissors for this. Extremely dirty skin should be cleaned with soap and water before an anti-microbial solution is applied. Skin cleansing solution should be applied in a concentric circle, from the center to the periphery of the intended site to be accessed. Solution should be allowed to air dry before proceeding. The area that is prepped should extend beyond the size of the dressing used. Alcohol is applied first, allowed to dry, and then Betadine is applied unless the patient is allergic to iodine/Betadine. Extra alcohol wipes should be used in case of patient allergy to Betadine. The site is considered clean when the last alcohol wipe used comes away clean. Alcohol is an anti-microbial agent. It kills staphylococcus epidermis. It also removes oil from the skin. Additionally, the alcohol rub applied over the vein dilates the vein. Much of the Betadine’s germicidal action takes place in the first minute after application. It is effective for up to six hours after drying. Blot the Betadine dry with a sterile 2X2 gauze to allow for better visibility of the vein.

Preparation for Venipuncture

Success at the first stick depends on proper preparation. If rushed and nervous, failure of the cannulation attempt is likely. The nurse should put him/herself and the patient at ease. The patient needs an explanation of the procedure in appropriate, understandable terminology. The patient needs to have confidence in the clinician. The clinician should determine the patient’s history with I.V. therapy.

A patient may have a history of needle phobia. Needle phobia is an inherited vasovagal response and/or a learned reaction as result of previous I.V. sticks. The symptoms prior to insertion are tachycardia and hypertension. On insertion bradycardia and a drop in blood pressure occurs with signs and symptoms of pallor, diaphoresis, syncope and in rare occasions, asystole and death. The onset of vasovagal response is usually immediate or sometimes it can occur five to thirty minutes after the stick. Patients with needle phobia will avoid medical help at all costs. Techniques for managing patients with needle phobia are reassurance, education, keeping needles out of sight until the last minute before use, distraction, elevation of legs, use of valium (diazepam), or topical anesthetics (Emla, ice, or lidocaine 1% without epinephrine.)

Tourniquet Application

Before applying a tourniquet, the nurse should look for blue lines (veins) on the arm or rounding out of veins under the skin starting with the hand and moving up the arm. To obtain a maximally vein, a tourniquet should be applied correctly and the selected vein should be tapped lightly. Care should be taken to not pinch the patient’s skin in the tourniquet. Use of blood pressure cuff at 30 mm/hg will also provide a dilated vein.


1. TAKE YOUR TIME when choosing the right vein!

2. TAKE YOUR TIME performing the venipuncture!

3. Think: Purpose->Appropriate Access->Appropriate Catheter Size->Appropriate Site

4. Apply tourniquet 6 to 8 inches above the selected puncture site.

5. No veins: Let arm hang down for a while-the “praying position” for venipuncture.

6. No veins: Apply warm towels over several minutes.

7. Bad filling: Some people swear on “milking the vein”-gently stroke from distal to proximal.

8. No veins: Some people swear on double tourniquets-one high on the arm, one 4 inches above the puncture site.

9. For low blood pressure: Use a BP cuff, not a tourniquet.

10. For well filled, but fragile veins: Try puncture without using a tourniquet.

11. In patients with hypovolemia: Use larger veins as small veins collapse quicker.

12. When a patient’s upper extremities are grossly edematous, apply a tourniquet for a few minutes to create an “indentation”; after removal a vein can usually be seen in the well of the indentation.

13. Apply warm towels on the cannulated arm if an irritating medicine is being infused.

Discussion with the patient about his/her I.V. history at this juncture will provide the R.N. with information to become the patient’s advocate. Venous status or patient’s condition may suggest the use of a central line instead of a peripheral line placement. At this point you should also inquire whether the patient is allergic to Betadine, lidocaine, tape, or latex. Most hospitals allow the I.V. therapist the option to use lidocaine intradermally to numb the skin prior to a needle stick.

Lidocaine 1%, without epinephrine, should be offered to each patient prior to an I.V. stick, if the patient reports no allergies to the Lidocaine. A dosage of 0.02 cc to 0.03 cc in a 1 cc T.B. syringe should be administered at a 5’ angle intradermally over the vein to be cannulated. The exact spot where the angiocath enters the skin should be numbed. The site will be immediately numbed and will remain numb for up to 15 minutes. If too much Lidocaine is administered (e.g. 0.1 cc), the skin and vein will constrict and accessing the vein will become more difficult. In patients with loose skin, i.e. the elderly, the medicine may diffuse under the skin, possible resulting in less effective numbing. The nurse should be aware of this possibility and compensate accordingly.

A high number of individuals with spina bifida or congenital urological abnormalities tend to have latex allergies or may be predisposed to developing such allergy. Latex allergy can lead to anaphylactic shock. Latex is found in yellow tourniquets, I.V. bag ports, Y-sites on I.V. tubing, tops to medication/N.S. bottles, to name a few. If the patient has a latex allergy, cover the tourniquet with stockinet. Healthcare workers are also at risk for developing latex allergies. Good hand washing is required and use of non-latex gloves is advocated.

Cannulation Supplies

1. Favorite tourniquet (or two) 2. Appropriately sized angiocath 3. I.V. extension tubing 4. 2 packages of 2X2 gauze 5. Tape 6. 4 alcohol wipes 7. 1 Betadine wipe 8. Needle and syringe 9. N.S. bottle 10 cc 10. Supplies for doing blood work as needed 11. Warm pack consisting of a warm, wet towel in a plastic blue chux 12. Magic marker to label dressing

Steps in Cannulation Techniques

After having found or made a vein large enough for cannulation

1. Use the top approach

2. Use lidocaine 1% to numb the skin prior to insertion of a 22 or larger gauge needle (remember that only the wall of the vein where lidocaine is injected intradermally will be numb but if the R.N. rides along the vein with the needle and accesses the vein away from the lidocaine injection site, the patient will still feel discomfort of the stick. Use of too much lidocaine will obliterate the vein.) CHECK FOR PATIENT ALLERGIC RESPONSE

3. Hold angiocath with bevel facing up at a 10 to 20 degree angle on top of the skin over the chosen vein.

4. Pull skin taut (but not so taut that you flatten the vein). If cannulating on hand, have the patient loosely close the hand.

5. Using a continuous, slow motion, advance angio through the skin. Round out angio slightly while under the skin.

6. With continuing slow motion, advance the cannula a minimal amount to pass it through the wall of the vein (you should now see the beginning of a “flashback”) and you should have felt a “pop” as the needle penetrated the vein wall (DO NOT CANNULATE THROUGH THE OPPOSITE WALL!) Lower the angle of the cannula as you continue to minimally advance the angio into the center of the vein. The flashback will continue. Now loosen the tourniquet.

7. Once in the center of the vein, slide the angio further into the center of the vein and off the stylette. Pull the stylette back a minimal amount. Flashback will now be observed in the cannula, which remains in the vein.

8. You should now be able to easily advance the cannula up the center of the vein. Continue to watch for flashback. If the cannula is stuck (it could be hung up on a valve within the vein), advance it by flushing it up the vein with N.S. The entire process of accessing a vein should be done with one slow, continuous motion from start to finish.

9. Loosen the tourniquet for sure at this point (if not done earlier) and SMILE!

Patient education is an important part of I.V. cannulation placement. Instruct the patient to report ANY signs and symptoms of soreness at the I.V. site and remind the patient that once an I.V. site is sore, it will not get any better. This soreness is irreversible until the I.V. is removed. Document that the nurse/medical technician has instructed the patient about reporting soreness.

Challenging Veins

Veins with valves are recognized as having little bumps along the track of the vein. Weight lifters, sculptors, and construction workers tend to have more valves in their veins than the average person. If unsuccessful in advancing an angiocath up such vein, use a floating technique to open the valves and subsequently advance the angio up the vein. This floating technique is accomplished by attaching a primed extension tubing to the cannula and flushing that tubing with N.S. via a syringe.

Some patients will have arms and hands the shape of which will interfere with the placement of the cannula by the nurse. In these cases, use a sterile cap to slightly bend the tip with the bevel facing up and then approach the vein. This will change the angle and facilitate accessing the veins of the inner arm.

Bifurcated veins are recognized by an inverted “V” shape. These veins are less likely to roll; however, the vein should be accessed below the bifurcation for the highest probability of cannulation success.

Accessing large, “ropy” veins, often found in the elderly, should be done without the use of a tourniquet because the veins are less structurally sound and tend to rupture easily.

Similarly, use of hand veins in the elderly is not recommended because they, too, tend to rupture easily.

Basilic veins located immediately below the elbow, particularly those in male patients, are large and attractive for venipuncture; however, the accessing is difficult for two reasons: 1) the angle of approach for the nurse is awkward and 2) they tend to roll easily and therefore require significant attempts to stabilize them.

Troubleshooting Insertion Technique

Success of I.V. placement is VERY DEPENDENT on the nurses own confidence level, the nurse’s relaxation level, and of rapport with the patient. Success also depends on proper tourniquet placement and the selection of a proper, well-rounded vein. Tourniquet pressure is critical; too loose, and the vein will not round properly, too tight, it can result in a ruptured vein that turns into a hematoma.

Consider the following problems when troubleshooting your insertion technique:

1. An improper tourniquet placement

2. Failure to release tourniquet once angiocath is in the vein

3. With a tentative start and stop approach, the vein disappears

4. Failure to recognize when a cannula has gone through the vein; resulting in a hematoma

5. Stopping too soon after insertion can cause a hematoma or a disappearing vein

6. Inserting a cannula too deep and missing the vein altogether is generally a result of too steep an angle of approach for the depth of the vein

7. Failure to penetrate the vein is generally a result of a dull angiocath or a sclerosed vein

8. Getting stuck in the wall of the vein is usually the result of not advancing the angiocath far enough in towards the center of the vein. Signs of this condition are a positive flashback with the inability to advance the angiocath with ease.

9. A difficult to advance angiocath is generally indicative of not being in the center of the vein. Advancing the angiocath a small amount will generally place it in the center of the vein.

10. A ruptured vein on insertion is generally a result of the use of too large an angiocath for the size of the vein

11. Pain during insertion can be a result of touching a nerve ending. Start over at a new location and document that the I.V. therapist has possibly hit a nerve. If the cannula is left in place, this nerve will continue to be triggered and will result in a painful I.V. site for the patient.

12. Improper taping of the I.V. tubing across the cannula and the vein beneath it will later cause pain during infusion. Tape the tubing away from the cannula site.

DO NOT PROBE FOR VEIN UNDER THE SKIN! Very seldom will an incorrectly placed angiocath end up properly in the center of the vein. This action will cause damage to the vein and surrounding tissue.

The aim of I.V. placement is to make a direct, clean stick into the vein and to do so slowly.


Documentation provides a means for recording and retrieving information. It also provides information about the patient’s clinical outcome. Information provided through documentation can help the medical professionals decide upon the best vascular access device for that particular patient. Documentation should include date and time of I.V. insertion, specific vein chosen, gauge and length of inserted device, solution(s) and medication(s) infused, the rate of infusion, and any comments made by the patient about the insertion. Document any difficulties encountered while inserting angiocath. If R.N.s who care for the patients afterwards are aware of specific difficulties, it will assist them in providing better patient care, avoid unnecessary pain for the patient, and save time.

With I.V. therapy lawsuits on the rise, it is very important to have complete documentation of I.V. angio placement including verbal and written consents obtained prior to the procedure. The consents should be obtained from the patient, the family, or the patient’s power of attorney.

A tip for nursing documentation. DON’T DOCUMENT WHAT YOU DON’T SEE. In other words do not use phrases such as “no swelling, no redness, no leakage observed”. These phrases have not held up in courts of law. Use instead, “No signs and symptoms of I.V. related complications observed,” if that is the case.

Site and Catheter Care

I.V. site checks should be made at least every two hours and every time the nurse sees the patient in-between. Chart these observations.

Angiocaths placed while the patient was in an ambulance or in the field should be changed within twelve hours of arrival at the hospital or as soon as the patient is stable. This also applies to re-accessing implantable port-a-caths. With each new admission, inquire about the place and time of the V.A.D. placement and document the findings.

Change an I.V. site every 72 hours or if redness, tenderness, swelling, pain, streaking, palpable cord, purulence, and/or leakage around the insertion site is observed. A large gauge cannula, placed pre-operatively, should be changed as soon as the patient is stable after the procedure. If a patient is immuno-compromised, the cannula should be changed every 48 hours or as needed (P.R.N.) Follow the facilities procedures. These patients are at risk for developing a potentially life threatening inflammation of the vein.

Dressing changes on peripheral lines should be done ONLY if the patient refuses to have the cannula site changed or if the patient is to be discharged the next day and if there is no sign of complications. If the patient refuses to have the I.V. site changed, the nurse must explain to the patient that there is risk of soreness and complications.

During site assessment, the R.N. should check for dressing and taping security, for date, angio length and gauge, for wet dressings, and for signs and symptoms of phlebitis, hematoma, and infiltration. The I.V. site should not be covered with tape, as tape does not allow moisture to evaporate (a greenhouse effect). When fluids that support the growth of bacteria collect under the tape, the patient may contract life threatening, blood borne infections. Use gauze over the insertion site.

An alert and oriented patient should be asked about soreness in the I.V. site and the site should be gently palpated during assessment.

Site Complications

Potential complications are many. Contributing factors for complications to occur are:

1. Age of patient 2. Patient’s medical condition 3. Skin integrity* 4. Site of infusion 5. Duration of infusion 6. Method of infusion 7. Line maintenance 8. Activity of the patient 9. Insertion technique

*The patient who is on steroids and who is a diabetic usually have compromised skin and veins. Thin skin impairs the local skin defenses.

Potential local complications are:

1. Hematoma 2. Phlebitis 3. Clotting 4. Thrombophlebitis 5. Infiltration 6. Extravasation

Hematoma is the most common complication of a routine venipuncture. A hematoma is due to leakage of the blood under the skin during or after a venipuncture. The cause is a through-the-vein venipuncture and because of needle displacement. A hematoma can also be a result of the re-application of a tourniquet after an unsuccessful stick. Symptoms of a hematoma are tenderness, ecchymosis, and inability to flush or advance the cannula. Treatment of a hematoma is to remove the catheter, to apply pressure, and warm soaks. Document circumstances leading up to the hematoma. Most malpractice suits related to I.V. therapy are due to hematomas.

Phlebitis is defined as an injury to the vessel wall. Transient mechanical phlebitis appears in the first 48 to 72 hours after insertion. The incidence is higher in women than in men by a ratio of 15 to 1. Phlebitis occurs more frequently with larger gauge needles, traumatic insertion, and with glove powder. To reduce the risk of phlebitis, the angiocath should be as small in diameter as possible, thus taking up less room in the vein and allows for better blood flow around the catheter. The area’s circulation is not compromised and medications get diluted as they enter the vein. Treatment is started with cool compresses to relieve pain, then warm compresses for twenty minutes every four hours until improvement is evident. Elevation and mild exercise are also recommended. Signs and symptoms of infusion phlebitis are redness, swelling, and tenderness. About 60% of all hospitalized patients develop infusion phlebitis between 8 to 16 hours after insertion. Presence of pain at insertion site may be the precursor to phlebitis and may require removal of cannula. Once and insertion site is sore, the soreness will only get worse if the cannula is left in place. Removal of cannula does not terminate the development of phlebitis. Monitor the I.V. site after removal of cannula and document your observations.

There are three types of phlebitis: mechanical, chemical, and bacterial.

The causes of mechanical phlebitis are the use of too large a size of cannula, improper taping, cannula’s location near area of flexion, size and condition of the vein, and the technique of the clinician. Tips to avoid the onset of mechanical phlebitis are:

1. Do not use area of flexion 2. Anchor cannula well 3. Use aseptic technique 4. Use cannula smaller than vein 5. Use a smooth insertion technique

The cause of chemical phlebitis is:

1. Using solutions of >300 mEq/liter 2. Solutions of a high pH 3. Solutions with a large amount of particulate matter

These solutions cause pain at insertion site and irritation to wall of vein. Sufficient dilution of medicine can help this type of phlebitis. The addition of lidocaine 1% to solution or medicine can help prevent irritation to the vein. A doctor’s order is required for this.

The most common cause of bacterial phlebitis is a contaminated catheter hub as well as add-on devices and a fibrin sheath. Bacterial infections in immuno-compromised patients can lead to septicemia. Septic phlebitis can be avoided by using a new cannula for each insertion attempt.

Follow the facilities policy and procedures as far as writing out incident reports should phlebitis, hematoma, or infiltrates occur. Phlebitic events can be reduced by changing I.V. sites every three days or P.R.N. and by performing an excellent skin preparation. Proper skin prep can reduce the growth of microorganisms and the formation of a fibrin sheath.

Some control measures in relation to phlebitis are:

1. Conformation to established policies and procedures 2. Hand washing 3. Proper site and device selection 4. Site preparation 5. Product integrity 6. Cannula placement 7. Occlusive dressing 8. Minimal handling of dressing and I.V. site 9. Frequent inspection 10. Catheter stabilization 11. Using sterile technique 12. Routine changes of dressing, site, and tubing

Thrombophlebitis is caused by injury to the vein during the venipuncture. It can also be cause by a sluggish flow rate as this allows a clot to form at the end of the catheter. Thrombophlebitis is a thrombus plus inflammation. Contributing factors are:

1. Duration of infusion 2. Osmolality and pH of infusate 3. Site of infusion, e.g. areas of flexion 4. Small veins 5. Venipuncture technique

Clotting is caused by any injury that roughens the endothelial cells of the venous wall. The anti-coagulant property of this endothelial layer gets destroyed. Endothelial damage causes inflammation through fibrin, protein, and platelet deposits (a thrombus forms) to which bacteria adhere. White blood count and anti-bodies “come to the rescue”. Bacteria secrete a slime to protect themselves. This layer of slime is called a biofilm. Bacteria will leave this biofilm and enter the blood stream, potentially causing septicemia.

Thrombosis occurs when a local thrombus obstructs the circulating blood. Thrombus prevention can be obtained through a smooth, efficient cannula insertion and removal technique.

Infiltration is caused by an inadvertent administration of a non-vesicant medication/solution into surrounding tissue through an improperly placed or dislodged cannula. Signs and symptoms of infiltration are swelling, tenderness, and decreased skin temperature. Treatment consists of removal of catheter, elevation, and cool/warm compresses.

Extravasation is an inadvertent administration of a vesicant medication/solution into surrounding tissues. A vesicant is an agent that is capable of causing pain, necrosis, and sloughing of tissue. The onset of symptoms can be immediate or delayed. Morbidity is dependent upon the type, amount, and concentration of the medication/solution and upon the location of the infiltrate. Signs and symptoms are discomfort, erythema, blistering, necrosis, swelling, burning/coolness, blanching, and ulceration. Call the pharmacy if there is a question whether the drug being administered is a vesicant and ask about the antidote available. Best results are achieved if treatment is administered within one hour of the acute extravasation occurrence. Treatment of extravasation consists of stopping the I.V. infusion, pulling back on tubing to extract as much of the medicine/fluid as possible. Then remove the I.V. catheter unless the needle is to be used as a path to infiltrate the tissue with an antidote. Estimate the amount of extravasated solution and notify the physician. Administer the appropriate antidote following the physician’s order and the pharmacist’s instructions. Elevate the extremity. Apply either ice packs or warm compresses to the affected area for a 20-minute period every 4 hours until improvement is evident. The choice of the latter should be discussed with the pharmacist. Take a photograph of the site if indicated. Document the site of extravasation, the drug, time and date, and approximate amount infused. Document the patient’s symptoms and complaints and the appearance of the site. Indicate nursing treatment and the doctor’s notification and outcome. An incident report should be filled out and acted upon per institutional policy.

Potential Systemic Complications

Systemic complications may develop quickly and insidiously. Septicemia, pulmonary edema, speed shock, allergic reactions, and occlusions are all potential systemic complications.

Septicemia has been previously covered.

Pulmonary edema is a result of too rapid infusion of fluids, which increases the venous pressure and dilates the cardiac muscle. Overloading the circulation is especially hazardous to the elderly patient and patients with impaired renal and cardiac functions. Signs and symptoms of pulmonary edema are venous dilation with engorged neck veins, increased blood pressure, rapid respiration, and shortness of breath. To correct the situation, slow down the infusion and notify the physician.

Speed shock is a term used to denote the systemic reaction that occurs when a substance, foreign to the body, is rapidly introduced into the circulation, flooding the organs rich in blood (heart and brain); as a result sycope shock and cardiac arrest may occur. It can be avoided by not playing catch-up and by avoiding free flow by gravity.

Allergic reactions to medications may occur from the first to the fifteenth dose. Treat as needed.

There are three types of occlusions: mechanical, thrombotic, and precipitate.

Mechanical occlusions are due to kinks in tubing. Trouble shoot the I.V. line from the insertion site to the I.V. bag.

Thrombotic occlusions can be avoided by eliminating irritation of the wall of the vein and by not allowing the I.V. bag to run dry.

Check I.V. solutions for precipitates and use filters when appropriate. A 0.2-mm filter is an absolute bacteria retentive and air eliminating filter. Particulate matter is a mobile, undissolved substance unintentionally present in parenteral fluids, such as rubber, glass, molds, and drug particles. Studies have shown that particulate contamination is present in all I.V. fluids and administration sets. The vascular route of infused particles is as follows:

Particles introduced into the vein -> right atrium of the heart -> tricuspid valve -> right ventricle of the heart -> pumped into pulmonary artery -> branches decreasing in sizeĆ  particles trapped in massive capillary bed of lungs as well as the brain, kidneys, and eyes.

Infection Control by Handwashing

Infection control is achieved through hand washing. Gloves do not preclude hand washing. Gloves do not just prevent nosocomial infection, but they also protect the nurse from blood borne pathogens, such as HIV, Hepatitis B, and Hepatitis C.

The skin offers a fertile medium for bacterial growth. Staphylococcus Aureus cause one-third to one-half of all I.V. device infections. Gram-Negative Bacilli are rampant on the skin of hospitalized patients. Ten thousand organisms per square centimeter can be found on normal skin. Blood stream infections have tripled over the past ten years and nosocomial infections are the fourth leading cause of hospital deaths in America with annual costs exceeding $4.5 billion. Persons with a high probability of acquiring I.V. infections are: the elderly with less elastic skin, patients with heart disease, diabetes, and HIV, patients receiving steroids, and patients whose immune systems are compromised and who have received chemotherapy.

Sources of cannula related infection are the hands of medical personnel, hematogenous seeding from an established organ infection, contaminated disinfectants, and from the patient’s own skin contamination introduced into the vein via the catheter.

Termination of I.V. Cannula

Termination of an I.V. cannula occurs upon a doctor’s order, prior to discharge, with signs and symptoms of infection, after placement of a functioning central line, and after three days in the vein. Documentation should consist of writing down the following observations:

1. Catheter intact 2. Application of pressure dressing 3. Appearance of site after catheter removal

If upon removal, the cannula is not intact, apply a tourniquet above cannula site, call the doctor, and check the circulation of the extremity. If a cannula is to be sent to the laboratory for culture and sensitivity, the following action should be taken:

1. Scrub the insertion site around the cannula with alcohol to remove exudate 2. Quickly remove catheter onto a sterile gauze 3. Cut below hub with sterile scissors 4. Let drop in sterile container 5. Label per the facilities policies and procedures 6. Send to laboratory

Nursing Responsibilities Regarding I.V.Therapy

In general, the nursing responsibilities regarding I.V. therapy are:

1. Know the protocols and procedures related to access device used. Follow them. 2. Know the medication or solution to be infused, the desired actions, untoward actions, side effects, and normal dosage. Report the patient’s reactions and measures to prevent complications. 3. Be aware of osmolality, pH of drugs and solutions. 4. Make sure that medications and solutions are stored properly and are not outdated. 5. Make sure medications, which are infused simultaneously, are compatible. 6. Change I.V. tubing and central lines dressing per protocol. Label them. 7. DO NOT INFUSE MEDICINES SIMULTANEOUSLY WITH BLOOD TRANSFUSIONS! 8. Clarify unclear orders 9. Documentation is crucial–REMEMBER, IF YOU DIDN’T DOCUMENT, IT WAS NOT DONE! 10. Know your abilities and show confidence.

As you work to improve your I.V. skills, a few failures should not set you back. Practice leads to improvement. Good Luck!

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