Nursing Skills: Starting a killer IV!

So students seem to think of IVs as the holy grail of nursing school, veteran nurses are still bummed out when they can’t get a stick, and there is always that one IV go-to person on the unit that can somehow find a vein that you never saw during the 30 minutes you spent combing those upper extremities! Ahhh the IV!

So some tips on getting that first stick golden IV! Firstly, get to know your IV catheter. My hospital just changed from the small catheters which have the needle safety cap on withdraw, but doesn’t have the valve so you have to hold pressure on the vein below the catheter while connecting the tail and flush – to now we have the huge long catheters with the button for needle retraction. Honestly they both have their pro’s and con’s, and I have found that both need a modification in getting the vein just right. So like I said, get to know the catheter; if you’re a student, roll up some gauze and practice getting the needle in at the right angle and gliding in the catheter with your index finger.

Before starting your IV, get prepared! Have extra IV catheters in case you don’t get the first stick or the vein blows. Set up your stuff, your IV lock and flush etc. I like to set up my tape too, because I still do chevron when I have time to secure the hub.

Check out the extremities before applying the the tourniquet, there is no point just throwing on the tourniquet above the elbow, look to see if you can see a clean vein before applying, this will make the process quicker.

Once you have your spot and tourniquet applied, tap the vein to get it to stand up. It will make it much clearer and easier to puncture.

Use your non-dominant hand to keep the area taught, this will reduce rolly veins from running or sinking away from you.

If you don’t get a good stick, don’t beat yourself up. Sometimes it happens and who knows the pt might end up with a PICC due to poor venous access anyhow!

Practice makes you better! If you are a student take every opportunity to watch or attempt an IV start. If you are a new nurse and still intimidated by IVs, tell your colleagues to let you know if they have a pt who needs an IV, let the charge nurse know you want to practice or assist them in starting IVs – they will be impressed by your eagerness to learn and guaranteed you will get better! Good luck and get sticking!

This is a decent video for students who want a start to finish visual on venipuncture!

Related articles

• Turning IV failures into successes (timesofisrael.com)
• IV tips: (emscapstone.com)

Cardiac Tamponade

This has nothing to do with tampons in the heart ok! Just an FYI.

When blood or fluid accumulate in the sac which surrounds the heart it exerts pressure against the heart, making it harder for the heart to pump. As you can imagine, if the ventricles cannot fill fully or contract effectively then cardiac output decreases. Decrease cardiac output is not good news!

So how do you know if someone has this?

Well the symptoms are nothing unusual: chest pain, restlessness, quick shallow breathing, palpitations, pallor, tachycardia, weak peripheral pulses, pulsus paradoxical, distended neck veins, low BP… (do these all sound a little familiar? MI anyone?) Well causes of cardiac tamponade can be MI, Dissecting aortic aneurysm (thoracic), end-stage lung cancer, heart surgery, Pericarditis caused by bacterial or viral infections, or direct wounds to the heart.

How do we diagnose? Echocardiogram is the usual diagnostic tool, but MRI, CT, CXR or EKG can also highlight or confirm this.

Can you see the halo of fluid around the heart?

This is an emergency! The fluid must be drained to reduce damage to the myocardium and reestablish cardiac output.

Pericardiocentesis is a procedure that uses a needle to remove fluid from the pericardial sac, the tissue that surrounds the heart. The patient will be hyperoxygenated, given fluids to maintain blood pressure. It is important to note that a pericardiocentesis may have to be repeated because cardiac tamponade can return. With fast treatment the outcome is usual good, without treatment death is immanent.

A pericardial draining tube may be placed during surgery to keep in place postop. The drainage will be measured every shift and documentation on the color, amount and consistency is very important! The tube will usually be removed slowly over the postop recovery weeks at the discretion of the cardiologist.

NCLEX Success: Remember your A-B-Cs!

Say it with me: AIRWAY, BREATHING, CIRCULATION!

If you have renewed CPR with AHA recently you’ll know that they have changed that to CAB from ABC, but for NCLEX you need to stick with the ABC.

So here comes that irritating priority question. You try to apply Maslow but all options are physiological, so there is nothing to eliminate. What do you do? You apply the ABCs.

Airway will always be the most important factor to take priority: anaphylaxis? Choking? So look for it, if it isn’t there, look for breathing, it could be simple like raising HOB to decrease dyspnea in a CHF pt – keep focused on the “B” until you can rule it out. If no luck at that point, move to circulation. Hemmorhage? Potential for bleed? Change in vitals (↑HR, ↓BP)?

Look at the big picture and apply all the ABCs and use them to lead you to the right answer! Priorities will always contain ABC/Maslow or combination! Use your question answering skills! 🙂

NCLEX Success: Maslow’s Hierarchy of Needs

Maslow is a great tool to narrowing down or answering NCLEX questions. Those pesky priority questions are the ones in which Maslow can lend a helping hand. Here is how you use the Maslow Strategy:

1. Look at the answer choices. Determine if the answer choices are both physiological and psychosocial, if they are – apply the Maslow strategy.
2. Now, eliminate all psychosocial answer choices.
3.  If the answer choice is physiological, don’t eliminate it. Maslow states that physiological needs must be met first. Although pain certainly has a physiological component, it is considered a psychosocial need on Nclex.

The Nursing School Letdown

While in clinicals I met a lot of other students from other schools. I was always amazed at the camaraderie and closeness of their clinical groups, unfortunately mine was just not like that. There were times when I thought that it was me, maybe I wasn’t embracing my classmates or I was distancing myself; then over time I realized that I just so happened to be put in a group of people which just didn’t work well together. Very much like some of the units I worked on – sometimes the characters just don’t mesh and it alters the whole atmosphere of the unit.

I know friends from other nursing schools who have made life long friends through the bonding that nursing school fosters, but for me, I’ll probably never see or speak to my clinical group classmates again.

One thing I believe is that nursing school is what you make of it. I chose to buckle down, fight through it and stay focused. I have never been a slacker, and so I couldn’t connect with those in my clinical group who would slink off the unit for a long trip to the cafeteria or for a quick cigarette outside. I was there to learn, and would totally kick myself if I missed a learning opportunity. This mentality automatically separated me from the group, and ultimately caused a cold and nonchalant ending at graduation.

So why am I writing about this? Well because there may be someone reading this who feels the same way about their clinical group or nursing class. They have no-one in there that has their back, and in nursing school that really can make all the difference.

Luckily for me I had a very good and loyal friend in a different clinical group who I had all my other classes with, and together we helped each other through. I am so happy that my friend and I are such good friends and have shared our nursing journey together. She now works as a Med-Surg nurse in a huge healthcare system in South Florida and I’m a Telemetry nurse – we still call each other to celebrate our nursing triumphs!

Although my clinical group was a letdown, the fact is that sometimes you just have to make the most of a situation knowing that your apart of a dysfunctional team. Nothings to say that you won’t walk out of nursing school and find the same situation on your unit – the mix of people make the culture of a unit, so hopefully the former experience will lend some guidance. I feel that I learned a lot from my letdown, and even so I still wish all my old classmates much success in their nursing careers.

My Biggest Shock As A Nursing Student

I’m gonna give you a little insight into my first experiences in nursing as a student. Some of it is funny, some of it is sad and some of it it plain ole’ X rated haha! I’m mainly writing this because when I first switched my major to nursing I tried to do a lot of research into what it really is like to be a nursing student: what’s difficult? What’s the best bit? Worst bit? Etc. I worked with a girl who was currently in an AS nursing program, but she wasn’t much help to be honest (I realized when I became a nursing student, that no-one really understands what a nursing student is going through except a nursing student, so she flat out didn’t even try to scare me with the deets).

So let me begin by hoping that my insight through this blog can help everyone, but particularly those nursing students or pre-nursing students who have NO medical background at all – I was one of you. (Yes you smarty-pants CNA‘s you already know all about it, this isn’t for you guys lol!). My pharmacology prior to nursing school consisted of Tylenol and Motrin. I had been to the ER three times as a child, but never for anything major, the usual kid stuff: sprained ankle, needing eye wash and I trapped my fingers in a car door – yes that sounds stupid now, I know. I honestly knew zero about nursing. No family members had even finished college, let a lone entered a medical profession. I really had no idea what I was getting myself into.

The biggest shock hit me on the first day of clinicals, those of you already in clinicals can probably guess what I’m going to say.

The biggest shock was – NAKEDNESS!

Seriously, I was bombarded with saggy boobs and more abdominal rolls than I even thought anatomically possible. As someone who enjoys my personal space and certainly maintains other peoples, I found myself really uncomfortable touching all these body parts and all that skin. The best part was that most of the old people didn’t care at all! Old men would ask me to put their penis in the urinal and I had to be OK with it, they couldn’t do it for themselves. Many of my first patients were stroke patients, and by being thrown into mostly total-care situations, I learned very quickly to be comfortable in other people’s personal bubbles, but still being sensitive that I was touching someone. I tried to use empathy in every situation, and somehow the nakedness began to blur into the busy day and eventually I didn’t notice it at all.

When patients come into the hospital, many of them are not prepared for the amount of “touching” that is necessary to fulfill nursing care. It is so important to ask permission to touch someone and ensure they are comfortable with you assisting them in personal tasks. For the majority of my patients it was not their first rodeo and they quite enjoyed the help, but for those who are admitted for the first time or have cultural differences, this can be a big shock therefore, as nurses we need to show sensitivity and cultural competence in these situations.

For those of you which are pre-nursing – Congratulations, if nursing really is for you, it will be the most patience testing, trying, exhausting and fulfilling thing you ever do in life. For those of you that are in it for the money? I’ll be generous and give you a year at it. If it’s not for you then don’t waste your time, you have to have a genuine desire to qualify. Period. Just wait until your first anal suppository! *High five!

So embrace the nakedness! Let’s face it, we’re all naked under our clothes anyway! 🙂