zen and the art of cannulation.
By impactEDnurse • Apr 25th, 2006 • Category: the nurses desk:The ability to place a cannula is indeed an art. And like all art it should be elegant, unhurried and appreciated.
Step 1. Preparation:
Take a few moments to gather all the equipment that you might need. Bounding over to the bed like a Jedi Knight on heat with only a Jelco in one hand and a cap in the other is unprofessional, dangerous, unhygienic and produces bad karma. Set up properly using the provided trolleys. Open a cannulation pack and assemble jelco, blood tubes, culture bottles, tape etc….oh yes, it’s kinda embarrassing when you forget the cap. Think of this as a sort of Japanese tea ceremony. Slow down. Be the cannula.Next, prepare the person. Make sure you inform the patient of your intentions. And while you’re about it, how about explaining exactly why you need 20mls of his blood (not just “to run some tests”).
Apply gloves and eye protection. If I ever see you put a cannula in without personal protective equipment, a spanking will be iminent.
Select a good insertion site. A 20g in the back of the hand can be a pain in the anus for the patient, especially if it is in his dominant hand. It’s fiddly and frequently occludes with dorsiflexion. There are usually plenty of veins on the forearm…..well at least have a look. And don’t forget the basilic veins hiding under the forearm.
Make sure you shave the area with a surgical shaver if he/she is a hairy fellow. The tapes will adhere better and remove easier. Don’t use a disposable razor that might damage skin integrity. Confucius say; “pulling out arm hairs of big man sure way to hear sound of one hand slapping.”
If the patient is diaphoretic, a bit of Tinc Benz around the insertion site before taping and covering the cannula will ensure security.
Put some sort of protective surface down under the site to catch the spillage. A big blob of blood left on the patient’s sheets is poor form, and there is nothing as embarrassing as putting up the bed-side to find the railing covered in blood from a previous patient.
Select the largest cannula you can confidently insert into the selected vein. Remember: the larger the lumen the larger the flow rate that may be achieved. Size does matter.
Step 2. Insertion:
…… now Grasshopper, take a slow breath, focus, and think positive, beautiful thoughts.
You see, if you think you might prang the vein, you will probably be right. It sometimes helps to slowly chant the ancient Australian Zen mantra: gowin-yabugger gowin-yabugger (….its better to do this silently to yourself).
Use your non dominant hand to stabalize the patients arm. Try to enter the vein from the side rather than from above as it will tend to roll away from the needle. Aplying gentle traction to the skin will help steady a rolling vein. The more cannulations you do the more you will learn to feel whats going on through the cannula rather than by sight.
Look for a flashback of blood in the trocar hub. Remember the cannula tip sits a couple of millimeters behind the point of the trocar, so once you have a flash back, advance it just slightly to ensure the cannula is in the lumen of the vein.
Now holding the trocar stationary, smoothly slide the cannula into the vein.
Immediately dispose of the trocar into a sharps bin and cap the cannula.
Once you have it in….it’s time to take some blood. Use a vacuette or similar system to collect blood safely. And for goodness sake pay attention. This is a risky proceedure and believe me, you will not forget your first needle stick injury.
Once you have enough blood, inject a few mls of saline into the cannula to ‘lock’ it.
Apply the dressing as per your department’s policy. Make it elegant. For extra bonus points write the date of insertion in pen on a steri-strip and stick it over the dressing.
Step 3. Cleanup:
Dispose of your sharps, cleanup your mess (including blood spilt on the trolley, the bed, the nurse, the walls), thank the patient and disappear like a Ninja into the night.
impactEDnurse is also known as Ian Miller, a nurse with over 26 years experience working in a busy emergency department in, Australia. This site in no way reflects the opinions of that hospital.
All stories (although based on actual experiences) have been changed to protect patient confidentiality.
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I would add Must Sit Down for difficult cannulations, and I also have meditated over my veins before going in. I will now add your Austrailian Buddhist chanting to my repertoire, and will be able to start an IV to a dehydrated premie seizing.
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Nice and timely as I am currently doing my ALS (Paramedic) placement at the Alfred!
i’m a medical intern and I find this writing very informative and humorous at the same time. To all who laboured to produce this… keep it up!
It would be nice to add some address to vessel dilation such as dropping hand/arm below heart, making fists (the patient – not the health professional)encouraging warmth and vein tapping (no slapping) to get some histamine going.
Cheers.
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Also add that you can do everything right but still blow the vein sometimes.
do u need alot of flash to indicate that u have hit the vein properly? im currently learning to do iv’s and i enter the vein from about rather than the side.
Is there a better success rate at getting it from the side? In your opinion, at what degree should enter the vein. Note sure this is site to ask questions but then i won’t know unless I ask. Thank you
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what to do when you cant see any vein esp. in young women?
Great post, but the other important part: palpation. I choose which vein to use based on how it feels, not how it looks. Often the invisible ones which feel right are best, or sometimes when picking between some visible ones feeling them out is the best way to decide which one to use. There’s that feeling to a good vein you get with practice.
Definitely go for what you can feel, not just what you can see. Wrapping your patients arm in a warm blanket can help those tricky veins to show up a bit better. Also, good lighting, and make sure you are comfortable. No use trying when you are bent up in a funny yoga pose just to try to hit a vein you think is there.
I have just finished a block of nights as an intern, cannulations a plenty, and now understand that feeling “zen” is the most important part of the process! So important to take your time, relax, leave no area un-examined with both eyes and palpation. The basilic veins underneath are a great spot to find veins on an otherwise “veinless” little old lady. Likewise, underneath a watch-band, often there is a nice area devoid of oedema with a palpable vein. Another good spot is above the elbow with the tourniquet up further – often some nice fat veins there that haven’t been pre- mangled. You can depress an oedematous arm for a good 5-10 secs with your thumb to uncover a vein that otherwise would be impalpable. A couple of warm towels wrapped around an arm for 5 mins while you set up works well.