Zen and the Art of IV Maintenance

It is the most common nursing procedure in the ER that frightens patients. The insertion of an intravenous catheter for the purpose of providing fluids and/or administering medicines, the IV start is a nursing psycho-motor skill that must be mastered.

What it IS and is NOT

Myth #1: "I hate the idea of a needle in my arm"

An IV catheter is a small-bore plastic tube about one and a half inches long that surrounds a smaller hollow-bore metal needle. Once the catheter is inserted into the vein, the needle is retracted so only the tube remains. Because the catheter is plastic and thin, it is flexible. If inserted in an antecubital vein in the fleshy anterior aspect of the elbow (a.k.a. the crook of the arm), patients can still move and bend their arm without any further sharp instrument pain.

Myth #2: "It's going to hurt"

Actually, this isn't a myth at all. A nurse cannot put a sharpened piece of metal through a patient's skin without the patient feeling some discomfort. This should be explained because (1) the "pain" patients fear is more than the amount they will feel--in fact, it is fear more than pain that the patient experiences; and (2) there are some patients who believe that nurses can do this procedure without causing any pain whatsoever.

The nurse must help minimize the patient's fear, then, in order to minimize pain. To do this the nurse MUST: (1) be honest with the patient about the procedure, specifically, why it is necessary, what will happen, and what the likely outcomes will be (i.e., fast pain relief from re-hydration or pain medication); (2) distract the patient with constant banter; and (3) act quickly and confidently.

A good nurse demystifies the experience for patients so they know what to expect. Pain that one knows will occur is never as bad as the pain one has no idea is coming.

Myth #3: "I have bad veins"

I hear this all the time. In fact, this and "my veins roll" are the most often repeated phrases I hear from patients when I prepare to start an IV. My immediate response is usually, "you don't have bad veins; you've just had bad nurses!"

Veins are not good or bad, they are merely easy or difficult to access. These qualities are complicated by certain disease conditions (e.g., dehydration) and previous interventions (e.g., chemotherapy which makes veins frail), but the most common problem is obesity. Excessive subcutaneous fat makes veins difficult to locate and access.

Myth #4: "It'll hurt less if you use lidocaine"

For some reason, many patients have become accustomed to getting small shots of lidocaine, a numbing agent, before nurses attempt to start IVs. There is no evidence that this actually decreases the discomfort of IVs. It may decrease momentary sharp instrument pain, but one has to experience momentary sharp instrument pain and the burning sensation of lidocaine in order to achieve this benefit.

As well, the long-term discomfort of less immediately painful but poorly placed IVs can be worse than a momentarily painful but well-placed IV. The numbness caused by the lidocaine, in essence, provides a fishing license to the nurse who can't access a vein. In this case, the nurse might misconstrue a patient's momentary lack of discomfort to mean the nurse is not doing damage by rooting around with the needle, damage that may be very painful later.

Myth #5: "There's an air bubble in my IV line!"

If it weren't for television, no one would ever die of air bubbles in IV lines. And that's usually what I tell patients, "Yeah, those air bubbles'll kill you if you watch too much television."

And then I go on to explain that (1) venous blood can absorb air; (2) IV tubing is 72 inches long because that is the amount of air that the average adult can absorb without injury; and (3) television is evil.

Placing IVs well and least painfully is an art. It is a creative activity that nurses must put effort into in order to develop their craft sufficiently.

But just as there are myths, there are also truths, and the most important truth is, IV starts represent the one thing most patients fear most about ER visits. It is up to nurses to attempt to dispel this fear.