For which reason would the nurse stabilize the catheter with the nondominant hand and release the tourniquet while performing a venipuncture?

COLLECT THE FLUID container from floor stock or supplied by the pharmacy. Compare the labels to the prescriber's order to confirm accuracy of the fluid and medications. If multiple medications are prescribed, check for compatibility before giving the medications together.

Additional information can be gleaned from the patient's medical record. Check for allergies such as antiseptic agents (iodine, for example) or latex. A long history of hospitalizations is a clue that your patient has had many I.V. catheters in the past, possibly decreasing the number of available venous sites now. A history of vasovagal reactions indicates the patient is at risk for this same reaction during venipuncture.

Gather the equipment you'll need and prime the I.V. tubing before you enter the patient's room—especially if you're relatively inexperienced. With privacy, you'll have time to get organized, look over the equipment, and plan your approach without making the patient anxious.

If you're working with a preceptor, devise a system of communication so that the preceptor will know when to step in and perform the procedure. This may happen if you don't feel comfortable performing the procedure because of the patient's vein or skin condition or his attitude toward the procedure.

When you enter the room, wash your hands or clean them with an alcohol-based hand rub and introduce yourself to the patient if you don't already know him. Take a few minutes to explain the procedure. Encourage the patient to ask questions and answer them with direct and complete information. Avoid using words that might add to his apprehension, such as “needle” or “stick.” Instead, you might say, “I'm going to put this soft plastic catheter in your arm to deliver your medication.” He may relax a little when you show him the equipment.

As you talk, be sure to touch his hand and arm reassuringly. Note whether his skin is cool or clammy: If he's anxious, vasoconstriction could make veins hard to find.

Acknowledge his feelings with a comment like, “I can see you're a little nervous,” and do your best to put him at ease. If he's never had an I.V. line before, for example, you might need to assure him that he'll be able to comfortably move and use his hand and arm after venipuncture.

If he's nervous, chilly, hypotensive, or experiencing vasomotor changes, expect to spend a little extra time dilating and distending the vein before venipuncture.

Make sure you're in a comfortable position by raising the bed or by sitting next to the patient. Check the lighting to ensure that you can see the vein, patient armband, and fluid container labels. The patient should be in a supine position with his arm supported. Patients are at an increased risk for vasovagal reaction if they're sitting up during venipuncture. Assess the patient's nondominant arm first to allow freedom of the dominant hand.

Apply the tourniquet (see below) and assess his veins. If they fill poorly, try these tips:

• Position his arm below heart level or hang his arm down to encourage capillary filling.
• Instruct the patient to open and close his fist several times, but make sure his fist is relaxed during venipuncture.
• Gently rub or stroke his arm to warm the skin.
• Cover his entire arm with warm packs for 5 to 10 minutes to trigger vasodilation.

APPLYING A TOURNIQUET

Apply the tourniquet 5 to 6 inches above the intended venipuncture site. Peripheral veins in a well-hydrated patient should distend within a few seconds. Venous distension may take a longer period in elderly patients or those with a history of numerous peripheral venipunctures.

To apply the tourniquet as painlessly as possible, avoid pulling hair or pinching the skin. Pull the tourniquet tight enough to trap venous blood in the lower arm capillaries and veins without cutting off arterial flow. If you can't feel a pulse below the tourniquet (or if the patient complains of discomfort), it's too tight. As the occluded veins distend, the skin below the tourniquet will become darker from venous congestion. Single-patient-use disposable tourniquets are preferred because reusable tourniquets can be a source of cross-contamination.

If not discarded, tourniquets should be cleaned after each use. Be aware that tourniquets are also a source of latex contact, so assess for allergies.

1. Make sure the tourniquet lies flat against the patient's skin. Bring the ends of the tourniquet toward each other, so that one overlaps the other.
2. To tie the tourniquet, lift and stretch it; then use two fingers to tuck the top tail under the bottom, as shown on the next page. Make sure the tails point away from the venipuncture site.

Figure

Figure
3. Use this technique to stabilize the veins: Lift the tied tourniquet and stretch the skin and underlying tissue away from the venipuncture site. Then gently lower the tourniquet. You may be able to retract several inches of skin and tissue away from the site with this maneuver, which is especially helpful with older patients (who have less collagen and elastin than younger patients) and patients who've lost a lot of weight recently.

When the tourniquet is in place, ask the patient to clench his fist tightly several times. This encourages the veins—which are normally elliptic in shape—to become turgid and more rounded.

After identifying a desirable vein, you can encourage it to enlarge with a light tap of your finger (hitting it too hard will cause vasoconstriction). The vein should become as engorged as possible to create a bigger target and provide stability. Gently palpate the vein (don't stroke it) to see if it feels elastic and has rebound resiliency. When you depress and release an engorged vein, it should spring back to a rounded, filled state.

If the vein won't distend sufficiently, remove the tourniquet and let the vessels refill. Sometimes, veins fill better on the second try because of a rebound effect. If necessary, use one or more of the techniques described on the previous page to engorge the veins. (Apply warm packs, for example.) Then reapply the tourniquet and stretch the skin as just described. Make sure the tourniquet is tight enough to occlude the veins; a tourniquet that's too loose is a common reason for inadequate vein distension.

Note: Some clinicians prefer to use a blood pressure cuff instead of a tourniquet—especially for elderly patients, whose fragile veins are more likely to rupture when engorged if a tourniquet is applied too tightly. Inflate the cuff, then deflate it to just below the patient's diastolic pressure to make the vein visible without engorging it excessively.

PREPARING THE SITE

Once you've selected a vein, don gloves and prepare to clean the site. If the site is excessively hairy, you should clip the hair as recommended by the Infusion Nurses Society (INS). Never shave the site because of the potential for causing microabrasions. Always clean visibly dirty skin with soap and water.

Next, apply an approved antimicrobial solution. Chlorhexidine gluconate solution is the preferred agent, according to the Centers for Disease Control and Prevention; tincture of iodine 2%, 10% povidone-iodine, 70% isopropyl alcohol, and combination povidone-iodine/alcohol agents are also acceptable agents. Don't use aqueous benzalkonium-like compounds or hexachlorophene to prepare the site.

Figure

The procedure that you use to apply an antimicrobial solution for site preparation is crucial to achieve effectiveness. This process has now changed from a circular motion to a back and forth motion, which increases the friction and allows the antiseptic solution to penetrate the lower layers of the epidermis.

Although the surface area for prepping depends on the size of the extremity, in adult patients an area 2 to 4 inches in diameter is generally accepted. Never blot excess solution at the insertion site. Let the solution air dry completely. Much of the solution's germicidal action takes place during this time. Chlorhexidine gluconate achieves its antimicrobial action within 30 seconds; povidone-iodine requires 2 to 3 minutes to adequately kill the organisms on the skin. Never apply 70% isopropyl alcohol after a 10% povidone-iodine prep because this may irritate the skin.

Figure

If a patient has a known allergy to iodine, the prepping solution of choice is chlorhexidine gluconate or 70% isopropyl alcohol. When you use 70% isopropyl alcohol, you should apply it with friction for a minimum of 30 seconds or until the final applicator is clean.

The INS recommends that you use single-unit containers of antimicrobial solution. Be sure to discard the containers after use.

IMMOBILIZING THE VEIN

Superficial veins have a tendency to roll because they lie in loose, superficial connective tissue. Prevent rolling by maintaining the vein in a taut, distended, stable position. Because the wrist and hands are flexible, hand veins are generally easier to immobilize than arm veins. Hand veins may also be easier to cannulate because they're usually surrounded with less fatty tissue. But remember, there's a greater chance of nerve injury in the hand and wrist area.

Use the following techniques to immobilize hand and arm veins.

Figure

1. To immobilize a hand vein, grasp the patient's hand with your nondominant hand. Place your fingers under his palm and fingers, with your thumb on top of his fingers below the knuckles. Pull his hand downward to flex his wrist, as shown here, creating an arch. To maintain the proper angle, make sure his elbow remains on the bed. Use your thumb to stretch the skin down over the knuckles to stabilize the vein. Keep a firm grip throughout venipuncture.
2. To stabilize a vein on the forearm, encircle the patient's arm with your nondominant hand and use your thumb to pull downward on the skin below the venipuncture site.

USING A LOCAL ANESTHETIC

If ordered or permitted by hospital policy, you may use a local anesthetic before venipuncture to reduce the patient's pain and anxiety. Follow your employer's policy regarding documenting your competency to perform this aspect of the procedure. Although intradermal injections prior to insertion are controversial (and not recommended for routine use by the INS), using an anesthetic may make venipuncture easier on everyone because the patient will be less inclined to tense up and pull away. In most institutions, the anesthetic of choice is 1% lidocaine (Xylocaine) without epinephrine or contact your pharmacy to obtain buffered lidocaine, which helps remove the sting from this procedure. An alternative choice is an intradermal injection of bacteriostatic 0.9% sodium chloride. The preservative benzyl alcohol acts as a local anesthetic. You might also consider using topical anesthetic creams, but keep in mind that these creams must be applied 1 hour before the procedure and may cause vasoconstriction, which could make it difficult to cannulate the vein. Iontophoresis, a method of delivering local anesthesia to the skin using a mild electrical current, is another possibility. To learn more about these options, see the Photo Guides “Touching on Topical Anesthetics” (Nursing99, November, page 56) and “Electrifying News about Iontophoresis,” (Nursing2000, January, page 48).

If using lidocaine, make sure you have a health care provider's order or standing orders before you begin; then ask the patient if he's ever had an allergic reaction to lidocaine.

You'll administer the anesthetic after cleaning the skin, while the tourniquet is in place and the vein is immobilized. This will help you give the anesthetic at exactly the same site you've chosen for venipuncture. Follow this procedure:

• Put on gloves. Using a U-100 insulin or tuberculin syringe, draw up the solution.
• Position the syringe and needle at a 10- to 15-degree angle over the site where you plan to insert the cannula. Hold the syringe with your thumb behind the plunger to prevent the needle from wiggling and causing discomfort once it's under the skin.

Figure
• With the bevel up, introduce the needle tip into the skin slightly to one side or below the vein as shown. Take care not to penetrate the vein wall. By administering the solution beside or below the vein, you can avoid accidentally injecting the drug into the vein.
• Insert about one-fourth to one-third of the needle's length to anesthetize a superficial vein; you may have to go deeper for a deep vein. Lift up the needle tip slightly so a wheal can be formed.
• As you depress the plunger, watch the small intradermal wheal rise. Very superficial veins may require only 0.05 ml of solution; with deep veins, you may have to inject the entire 0.2-ml dose to produce a wheal about the size of a pea.
• Withdraw the needle. To hasten absorption and prevent the wheal from obscuring the vein, gently massage the wheal with an alcohol sponge. Allow 5 to 10 seconds for the anesthetic to take full effect.

HOW TO APPROACH THE VEIN

An I.V. cannula can be inserted in several ways. The choice depends on cannula length, vein location, and your preference. No matter which method you use, though, the cannula should enter the skin at such an angle that the needle punctures the vein wall and enters the lumen without piercing the opposite wall. Here are three ways to do this:

Figure

1. Approaching the vein from the top. Insert the cannula at a 5- to 15-degree angle (depending on vein depth; for example, use a 5- to 10-degree angle for a superficial hand vein). Take care not to insert it too far into the lumen or it may penetrate the back wall.

2. Approaching the vein from the side. Position the cannula tip adjacent to the vein, aimed toward it. This method, which is preferred if you've injected a local anesthetic, reduces the risk of piercing the vein's back wall.

Figure

3. Approaching a vein that's palpable and visible for only a short segment. This technique may help you cannulate a vein that extends into deeper tissues, where you can't see or feel it. Insert the cannula about 1 to 2 cm below the vein's visible segment, then tunnel the cannula through the tissue to enter the vein. Tunneling may reduce trauma to the vein wall on insertion.

Figure

Note: Avoid performing venipuncture in areas where valves are palpated or where two veins bifurcate. The insertion site should be proximal to a valve or a bifurcation, according to the INS.

INSERTING THE CANNULA

Before performing venipuncture, stretch and immobilize the vein as shown earlier. Press the vein lightly to check for rebound elasticity and to get a sense of its depth and resilience. Palpate the portion where the cannula tip will rest, not the point where you intend to insert the cannula. If you touch the insertion site, you'll have to reclean the skin.

To insert the cannula, follow the steps shown here.

1. Using your dominant hand, grasp the cannula or the cannula's wings (if using an over-the-needle butterfly). If you previously administered a local anesthetic, its effectiveness will extend for only ¼ to ¾ inch (0.6 to 1.9 cm) from the injection site. Touch the spot with the cannula tip and ask the patient if it feels sharp. If he says no, you know the site is properly anesthetized. Proceed at once with venipuncture. Note: If you didn't use a local anesthetic, encourage the patient to relax. Tell him to breathe slowly in and out as you insert the cannula.

Figure
2. Insert the cannula at a 5- to 15-degree angle, depending on the vein's depth. Insert the cannula bevel up to reduce the risk of piercing the vein's back wall. Position your fingers so you can see blood backflow in the flashchamber or extension tubing. While keeping the vein immobilized, advance the cannula through the skin and vein with one quick motion. Don't always expect to feel a popping or giving-way sensation. Look for blood backflow in the cannula tubing or hub to tell you that you've entered the vein lumen. Note: Backflow may occur briefly if the stylet passes through the lumen and out the opposite wall. But the blood flow will stop when the stylet leaves the vein lumen.

Figure
An alternative is to enter the skin and pause slightly to position the cannula tip over the vein wall. Then insert at least one-fourth of the length of the cannula into the vein.

3. Upon visualization of backflow, lower the cannula almost parallel to the skin and advance it slightly to ensure the cannula tip is in the lumen of the vein. While immobilizing the vein, push the catheter off the stylet and advance it completely into the lumen of the vein. Refer to the manufacturer's recommendations for further details on this step. (Also see Advancing the Cannula: Three Options.)

Figure
If the initial insertion isn't successful, you can try repositioning the cannula as long as you don't remove its tip from the skin. A deeper or more superficial approach to the vein may work, but don't excessively probe the area, which could damage the nerve. If necessary, tighten the vein stretch to prevent the vein from rolling. Then make one or two more attempts to enter the vein without removing the cannula from the skin. If you're still unsuccessful, remove the catheter and try again with a new catheter at a new site—preferably on the opposite arm. Never reinsert a stylet back into a catheter. This can shear off a piece of the plastic. Never reuse the same catheter; catheter-related infection can occur.
Start the infusion or flush the catheter. Watch carefully for signs of infiltration, which would indicate that fluid is leaking from the vein. If infiltration occurs or if the patient complains of an unusual tingling or burning sensation, remove the catheter immediately.

4. Release the tourniquet, apply digital pressure beyond the cannula tip, and stabilize the hub. Activate the safety mechanism to house the needle. With the safety device shown here, push the white activation button to shield the needle. Dispose of the barrel immediately into an approved sharps container. Be sure you're familiar with the techniques unique to the device you're using.

Figure

SPECIAL CONSIDERATIONS FOR DEEP VEINS

Although a deep arm vein is a challenge to cannulate, sometimes you have no choice because it's all that's available. Cannulating an arm vein also has the virtue of freeing the patient's hand so he can move around easily.

When you stretch a deep arm vein to immobilize it, it may seem to disappear because stretching may flatten it slightly. So you must be able to “see” it by palpating it with your fingers. To cannulate a vein that's palpable but hard to see, follow these steps:

1. Palpate the vein and use anatomic landmarks to situate the vein in your mind. Do not palpate the site again after the skin antiseptic has been applied. Ask the patient to relax his fist as tight muscles can compress veins.
2. Use skin traction techniques by encircling the patient's arm with your nondominant hand and stretching the skin downward with your thumb. Using moderate pressure, retract the skin away from the insertion site to stabilize the vein.
Grasp the cannula with your fingers, touching only the hub, so you can easily see blood backflow. Aim the cannula tip at the vein you visualize by the anatomic landmark and insert it in one smooth motion.

3. Use your nondominant hand to maintain vein stretch. Lower the cannula angle and continue advancing the cannula until you see blood backflow in the hub, indicating that the cannula tip has entered the vein.

SECURING AND DRESSING THE CATHETER

Adequate catheter securement is crucial to reducing complications and ensuring adequate dwell time of the catheter. In the following photos, you'll see how to secure and dress the catheter.

1. Tape placed under a transparent dressing should be clean, preferably strips of tape from an I.V. start kit. It shouldn't be taken from rolls of tape moved between patient rooms, from other procedures, or from nurses' pockets.

Figure
Attach the administration set or extension set to the catheter hub. Place a ½-inch-wide strip of tape across the catheter hub; it shouldn't cover the puncture site. Then place a ½-inch-wide strip of tape under catheter hub, adhesive side facing up. Fold the tape strip around the catheter hub. If you're using a catheter hub with wings, fold the tape strips across the wings rather than the hub.
Cover the venipuncture site and catheter hub with the transparent dressing but don't cover the hub/tubing junction. Fold a 2x2 gauze in half and cover it with a 1-inch-wide tape strip. Place under the catheter hub-tubing junction. This prevents skin breakdown from tubing taped directly to the skin.


Figure
Finally, curl the tubing to the side. Place a 1-inch-wide tape strip over the tubing directly on top of the tape under the hub.
Catheter securement devices are available for purchase and have been demonstrated to reduce complications and increase the catheter dwell time.
A transparent dressing lets you observe the insertion site for phlebitis, infiltration, and infection without disturbing it. Also, because it's waterproof, you won't need to replace it routinely unless it loosens. Apply it directly to the site without stretching it (which may make the patient's skin itch). It should cover the catheter and part of the hub. Follow the dressing manufacturer's instructions for specific application technique.
Make sure no tubing extends beyond the hand, where it could catch on something. Also, the hub should be positioned to let you change the tubing away from the insertion site.

2. You may want to use stretch netting to cover the entire I.V. site. It prevents accidental dislodgement while allowing easy site access.
Catheter insertion sites affected by the motion of a joint should be supported on a handboard to avoid the risk of infiltration or mechanical phlebitis from motion of the catheter inside the vein. Even though these catheters are made of soft plastic materials, vein damage is still a very real possibility.


Figure

If you apply restraints to an arm with an I.V. line, first wrap a washcloth folded in thirds around the arm where the restraint will go. This prevents the restraint from sliding and dislodging the I.V. cannula. It also helps prevent edema.

ADVANCING THE CANNULA: THREE OPTIONS

There are several ways to advance an over-the-needle cannula into the vein. Once you find the way that works best for you, stay with it. With any method, insert the cannula with a smooth, aggressive (but not jerky) motion as you advance the needle through the skin and into the vein. You should adapt your techniques based on manufacturers' recommendations for each product.

Method 1: “Floating” the cannula into the vein

With this method, you'll remove the stylet before fully advancing the cannula. It's a good technique to use if you're inexperienced: You'll be less likely to puncture the vein's opposite wall because you'll advance the catheter only after you see adequate blood return. Also, fluid flow helps “float” the catheter into place.

Figure

• Perform venipuncture and advance the cannula about one-third to one-half its length into the vein or until you see blood flashback.
• Place a protective pad or sponge under the hub to catch any blood that escapes when you remove the stylet. Prevent contact between the shaft of the plastic catheter, the skin, and the pad or sponge.
• Release the tourniquet and activate the safety mechanism.
• Attach the tubing and start the I.V. infusion at a slow rate. This technique requires flowing fluid to work.
• Use one hand to maintain vein stretch while advancing the cannula with your other hand.
• When the cannula is fully advanced, adjust the I.V. rate.

Method 2: The two-handed technique

• Insert the catheter into the vein until blood backflow is visible.
• Lower the angle and advance about ⅛ inch into the vein to ensure that the entire plastic catheter is inside the vein lumen. Continue to hold the stylet hub with your dominant hand.
• Release the skin traction held by your nondominant hand. Move your dominant hand to the plastic catheter hub and hold the stylet hub with your nondominant hand. Separate the plastic catheter from the stylet by pushing the catheter into the vein slightly.

Figure
• Continue to hold the plastic catheter with your dominant hand.
• Reestablish skin traction with your nondominant hand. Advance the plastic catheter with your dominant hand until it's inserted completely. Be careful to avoid moving the stylet back into the catheter lumen. Remove the tourniquet.
• Activate the safety mechanism according to the manufacturer's instructions. Attach the I.V. tubing or attach a short extension tubing with an injection cap.

Method 3: The one-handed technique

With practice, you can learn to advance the catheter off the stylet with one hand, while the other maintains vein stretch. If the vein is small, leave the tourniquet on to increase the vein size during catheter advancement. You should release the tourniquet before removing the stylet to avoid excessive blood spillage.

• Advance the catheter into the vein and check for blood return in the flashchamber.
• Using a push-off tab on the plastic catheter hub, push the plastic catheter off the stylet and into the vein.
• Use your nondominant hand to hold skin traction during the entire catheter advancement.

Figure
• Activate the safety mechanism according to the manufacturer's instructions. Connect the I.V. tubing or short extension set.

REMOVING THE DRESSING AND CANNULA

1. Turn off the I.V. infusion, remove all tape, and put on gloves. Moisten the transparent dressing, tape, or catheter securement device with alcohol or adhesive remover, following the manufacturer's recommendation. Then, while stabilizing the patient's hand as shown at right, lift one corner of the dressing and stretch it upward and away from the skin.

Figure

Figure
2. Apply a folded gauze sponge over the insertion site and hold it lightly with your thumb. Then grasp the wings and withdraw the cannula in one smooth motion.

Figure
3. After the catheter has cleared the skin, apply pressure to achieve hemostasis. Tape the gauze pad in place and elevate the patient's arm. Apply direct pressure for 1 to 2 minutes. (Depending on his condition, the patient may be able to do this himself.) If he's going home, tell him how soon he can remove the bandage and tape (usually within 6 hours).
4. Inspect the catheter removed from the vein to ensure that the complete length has been removed.