Since entering the field of nursing 13 years ago , I have watched nurses, anesthetists, doctors, NPs, PAs, etc...employ different techniques to facilitate IV insertion. Recently, I have observed hand slapping or flicking of veins to promote vein dilation. I spoke to my nurse manager, a doctor of anesthesia and two nurse anesthetists about the situation. I suggested that it could be misconstrued as assault and battery, as well as cause harm to an aging population. My suggestion did not go over well. One anesthetist flat out refused to stop the practice, the other anesthetist argued that so long as the patient was told that their hand would be slapped, and why, was sufficient and the doctor of anesthesia was talking about suing for defamation of character-and I do not think I ever saw him slap a hand. At my nurse managers suggestion, I sent an email to the doctor with the explanation that I was trying to change IV insertion practices for the safety of both staff and patients, as well as sending him the guidelines from the Infusion Nurses Society standards of practice about IV insertion techniques. For some reason, furtherance of evidence based science, which has really become pertinent as research has come to fruition on some topics, is not readily welcomed. People want to do what they have always done regardless the evidence. To say that I am discouraged is an understatement. I just graduated as a family nurse practitioner, but, previously, spent five years on an IV team and am board certified in vascular access. Patient anxiety over getting stuck with a needle is not helped by poor insertion techniques. At this point, I am wondering what I can do to help promote better practices? Below are the guidelines from the Infusion Nurses Society that I copied and sent pertaining to IV insertion.
"Use of a blood pressure cuff or tourniquet applied in a manner to impede venous flow while maintaining arterial circulation. Loosely apply tourniquet or avoid its use in patients who bruise easily, are at risk for bleeding, have compromised circulation, and/or have fragile veins. 1,2,7 (I A/P)"
"Use of gravity (positioning the extremity lower than the heart for several minutes), having the patient open and close her or his fist, and lightly stroking the vein downward. 1,2,7 (I A/P) 3. Use of warmth. The use of dry heat has been found to increase the likelihood of successful peripheral catheter insertion. 11-14 (IV)"
"Make no more than 2 attempts at short peripheral intravenous access per clinician, and limit total attempts to no more than 4. Multiple unsuccessful attempts cause patient pain, delay treatment, limit future vascular access, increase cost, and increase the risk for complications. Patients with difficult vascular access require a careful assessment of VAD needs and collaboration with the health care team to discuss appropriate options. 7 (IV)"
Thank you,
Diana
Lightly tapping the vein might cause distention, however the primary reason for avoidng a hard slap is stimulation of local nerves that causes venous constriction. A few years ago I had this same discussion with an anesthesia resident and I was the patient!! They did not pay attention to me though. I can understand how they may have misintrepreted your liabiity approach and put up their defenses. For superficial veins in the hand, forearm, stimulation of the sympathetic nervous system causes venous constriction. Research this in the A&P literature and use the science to convenience them. If that fails, go through your risk management and medical QI to change this practice. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you. These are excellent suggestions. I will start with the education and go from there. I shall post again with the results, and whatever fall out from my initial suggestion.
Diana L. Atwell, MSN, RN, NP-C, VA-BC
I would encourage the use of ultrasound guidance (or infrared) if they are having that much trouble finding a vein. I have never seen someone slap the vein who was trained and comfortable on ultrasound. Maybe the reason they can't find the vein is because the vein is too small for the IV catheter they have selected or any catheter for that matter.
Michael Mineau RN, VA-BC, CRNI
For pre-op patients, I would say the most likely cause of difficulty is fluid volume deficit and thus the veins will not distend. This is not the typical DIVA patient whose veins are used and abused. nIR could be beneficial if anesthesia would take the time to use it.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Tapping, vigorously scrubbing, or "slapping" the site causes a release of triggers, mainly histamine, that causes the vein to DILATE, not constrict. It serves the same basic purpose as applying a tourniquet, which is also often painful.
A FOUR FINGERED SLAP IS A NO-NO. That causes the vessel to spasm, and can be quite painful which leads to vessel constriction. Two fingers tapped lightly over the blood vessel, does release histamine and causes vessel dilation.
a famous IR surgeon said this was precisely the way you "puff" up veins
a famous IR surgeon said this was precisely the way you "puff" up veins. Slap slap slap...and quess what..it works!!