Tips for inserting an I.V. in an older patient

Nursing, Jul 2004 by Moureau, Nancy L

ESTABLISHING AND maintaining venous access in an older adult is challenging. In this article, I'll review some common problems and describe techniques that increase the chance for success.

Multiple challenges

With aging, the skin loses tone and elasticity and becomes more fragile and prone to bruising. Loss of subcutaneous tissue makes veins less stable, so they're more apt to wiggle and roll under the skin as you try to insert an I.V. device. All these changes make vein tears, "blown" veins, and bruising more likely.

An older patient is also likely to have multiple medical problems and a weakened immune system, putting her at greater risk for infection. Maintain meticulous aseptic technique during I.V. insertion and throughout therapy to avoid introducing bacteria into the bloodstream.

In an older patient, signs and symptoms of infection may be subtle and atypical. Be alert for such warning signs as subnormal temperature, bradycardia or tachycardia, fatigue, lethargy, and decreased appetite.

Prepare for success

Here are some suggestions for how to reduce the risks of venipuncture in older adults.

* Be gentle to avoid bruising or skin tears. If possible, use a tourniquet made of softer material and apply it lightly. Never use a very tight tourniquet on an elderly patient; it can cause petechiae, hematoma formation, or vein pressure resulting in vein "blows."

* Use a sharp needle for easy penetration through the skin with a clean cut. A smaller-gauge needle (such as a 24-gauge) works well with older patients.

* Note the depth of the vein to determine the right angle of insertion. Most veins are very shallow in relation to the skin surface and require an almost flat (10- to 20degree) insertion angle.

* Before penetrating the skin, stabilize the vein to reduce wiggle by applying traction to the vein below the insertion site. Don't obstruct the vein below-you won't be able to see where to penetrate the vein.

* Allow plenty of time. This reduces the tendency for jerky long strokes instead of short smooth ones. Go very slowly but steadily-one short stroke through the skin with advancement into the vein. Once the needle has penetrated the vein, advance it and the cannula slowly. Feel the needle penetrate the vein.

* Because elderly patients' veins are small and often hard to find, consider using a butterfly needle for blood draws. You may be more successful using a small (23-gauge) butterfly needle carefully in a hand vein than trying to access an antecubital vein. Use the same slow advancement technique.

* Many older adults have prolonged bleeding times, so after you remove the needle, apply pressure to the site for a longer time than you would with a younger patient. If bruising occurs, apply cool compresses for the first 24 hours to promote hemostasis, then apply warm compresses.

Monitor your patient closely for signs and symptoms of infection, infiltration, and fluid overload. Infiltration may not cause immediate swelling, but it may cause color changes as the fluid seeps under the skin. When appropriate, use I.V. pumps to regulate fluid infusions, making sure the preset pressure limits are low. Monitor the patient's lungs for crackles in the lower lobes, which indicate fluid overload.

These tips can not only increase your success rate but also reduce risk to the patient. Teach the patient to report pain or swelling at the site, and teach her and her family signs and symptoms of complications and when to report them. When discontinuing the I.V. device, remove it gently to avoid skin tears or bruising. Mastering a gentle, smooth technique for administering I.V. therapy will benefit your patient and reduce complications.

SELECTED REFERENCES

Hadaway, L.: "Vascular Access Devices: Meeting Patients' Needs," Medsmg Nursing. 8(5):296-303, October 1999.

Millam, D., and Hadaway, L.: "On the Road to Successful I.V. Starts," Nursing2003. 33(5, Supp1.1):S1-16, May 2003.

BY NANCY L. MOUREAU, RN, CRNI, BSN

Nancy L Moureau is an educator, consultant, and president of PICC Excellence, Inc. (http://www.piccexcellence. com) in Hartwell, Ga.