Bariatric: IV Insertion

All right guys. In this lesson we’re going to talk about inserting an IV in the bariatric patient. So one of the things that we want to look at our tips and tricks for these types of patients because these are going to be very, very challenging patient patients in theirs. It’s, it’s for very good reason. One of the things that we have to remember is that bariatric patients have a lot of excess tissue and we have to make sure we get the right location when we’re selecting that IV. Now, one of the things we want to consider, the hands are extremely difficult and it’s for several reasons. First off, you have the patient’s hand, right? And you have all of these, , the, the venous plexus, they’re everywhere. But the problem is these veins, they’re not straight, they’re branched, they have a lot of valves, and then accompany that with the excessive tissue that bariatric patients do have and sometimes peripheral edema that can make it really challenging.

So if we can’t go in the hands or if we elect not to go to the hands, and the next spot that we’re going to go is the forearms and the AC that Anna cubital fossa. And the reason we want to go here and very edgy patients is they have a greater area of success. While some patients will have that peripheral edema. One of the things we want to think about is that it’s typically going to be easier to get these forSs in AC. Just remember if you’re doing the AC, it’s going to, they’re going to have a greater likelihood of bending that elbow. And because of that, we want to make sure that the, that we educate our patient and make sure that they, that it’s like, Hey, just remember, don’t bend your elbow when it does cause it’s gonna include that IV and then your alarm is going to go off and they’re not getting the therapy as they need.

Now a couple of other tips that you want to think about with the bariatric patient. You want to start low, meaning that we wanna start as low as possible in the forearm. If this is the risk we want to start, some are not. And here we want to avoid the joint. What we don’t want is we don’t want the end of that IV catheter ending at that joint because like if it’s a wrist or if it’s an elbow, it’s going to occlude. And the other thing is this idea of going bigger if necessary. And what I mean by that is if you are gonna put in an IV and let’s say you think you can get a 20 you’re, you know, you can get a 20 but you think you can get it an 18 gauge. Well, think about this. If there’s a lot of excess tissue that 18 gauge because it’s bigger, is going to offer a lot more stability.

So you can use that 18 gauge if you have a good likelihood of hitting it and you know, you can get the 20 sometimes you just have to go big or go home. So it’s just something to keep in mind. So IV insertion, this is really important. You basically want to set up, you want to create the routine. Do you want to create a routine just like NBA players do when they come to the free throw line? You want to set up everything, you want to get it all, all ready to go and you want to walk in. So this is just an outline very briefly about the things you need to do. You need to make sure you prep your supplies, get everything you need, your IV, you need your IV kit. Just make sure you have everything you need to, you need that extension set and you’re also gonna need a flush.

Just make sure everything is good to go. Set everything up and then, and make sure, identify the vein. These things are gonna happen somewhat simultaneously. You need to kind of be looking at your patient when you’re doing your assessment. And I think about, Hey, I need you to IV, which size am I going to use? Am I going to use 18, 20, 22? What am I going to do for this patient? So let’s just think about that and then get everything set up. You get your tourniquet, apply it. Your tourniquet is going to be in this IV kit. And then once you’re all set, you prep it. Use that Clore prep, place that IV with confidence. And then once you’re done, get that thing secure. Now let’s talk about the hand insertion. We’re going to talk about several different ones. We’re going to talk today. 

We’re going to talk about the hand or and talk about, the forearm. We’re going to talk about the AC and we’re also going to talk about the bicep and inserting it in a couple of the nuances, a little tips and tricks that you’re going to see along the way. These are practical applications of doing this, this IV insertion and the bariatric patient. But if you absolutely have to go in the hand, one of the thing you remember is you want to start low. You want to try to give yourself as much of, um, an opportunity as possible. So if you start, if the wrist is down here and we’re starting really high up on the hand, we know that this is going to end here. They’re going to been there, Oh, oboe. And then you’re going to have a bunch of occlusion problems. So just remember trying to start, kinda near the knuckles.

That’s a good guideline. Um, just remember they could be difficult sticks and it’s going to be too that excessive tissue. So let’s take a look at a video. Now the reason we want to show you this video is because we want to show the difficulties that you could face. Not everything is cupcakes, roses and butterflies in nursing and just absolutely isn’t. You’re never going to get every IV every time. It’s just impractical. We’re going to show you what happens if you miss. We want to be practical. We want to give you that practical knowledge that , that sets you up for a realistic approach to nursing. We want you to be optimistic. We want you to be confident. We want you to walk in a but one of the things that we want to show you here is that important aspect. So you see that she starts to insert it and then when we talk about those valves, there’s lots of valves in the hand so you could see that right in here. 

She, she gets to the point where she’s going to insert it and there’s just something budding up against that IV Katherine, and it’s most likely a valve. And what happens is the vein essentially blows. This is a problem. And again, remember we’ve got, we’ve got a lot of branches, we’ve got a lot of non street veins, we’ve got a lot of these valves in here and it’s just going to happen we want, but this is what you’re going to see for these patients. You’re going to see that it just gets occluded and it’s not going to be successful. And this is just a challenge. It’s something that needs to be brought to your practical attention for these types of patients. Now let’s talk about the forearm IV insertion. This is a really, really good opportunity for you to be successful, especially in the bariatric patient. 

One of the things you wanna remember is start low. Remember where this is the hand, right by him. Poorly drawn hand. Hey, stay away from the wrist. We want to get away from here. So you could start just above this the distal end of the radius ulna. So remember, start there and then start to work your way up. If you start really high and you, let’s say you go for this a phallic vein, which typically runs alongside the thumb and this is the big vein. And if for whatever reason you blow that one, it may not be as successful up. If you blow it really high, anything that you’re infusing down here and we’ll be able to travel up. So always start low, you are going to have a greater likelihood of, but just remember to stay consistent.

You want that routine, you want that free throw routine. All right guys, so let’s kind of walk through this. She’s applying that that tourniquet 10 to 12 centimeters above the IV site. And she’s going to use those concentric circles to clean up, clean off the IV with areas where the IV is going to go. Once your, one tip I want to show you here is she, you could see that she’s actually rotating the stylette inside the catheter. What that’s going to do is help to break any sort of seal so that you don’t get caught with the stylette in the vein. That way it allows you to push it through. Now she’s got all her, all her stuff set. Now I do want to show you guys something. Now you can see this left hand. This is so really important cause it’s it, I’m going to point this out, is that she’s actually using her left index finger and her left thumb, which are both in her nondominant hand and she’s anchoring this vein down that keeps the, the vein from moving side to side and shifting. And then she’s got that 10 to 20 degree, uh, angle of insertion, which is really important. So let’s keep taking a look and see what she does. Um, and I’m going to point out one other thing as we keep going. 

So she gets it in. Now I want to show you guys something. Now she uses right here, this the end of the IV is actually right in here, but she’s using pressure above the IV site. This is called tamponada. What tamponada does is tapping out applies pressure and keeps blood from flowing down so that you can actually keep your patient from becoming messy with all that blood. And then so she’s applying the pressure. No blood is actually coming out. She got that extension set, she grabs the extension set, she removes the cap, and then what she’s going to do is she’s going to attach it and get it all set up.

Now don’t be afraid. Sometimes your patients are going to be a little bit messy. One thing she does here is she actually pulls back, get some blood return, and then flushes the IV and then she’s going to secure it. Here, we’re using a transparent dressing. And then the other thing you’ll notice that she does right after this, she’s going to get that transparent dressing applied. Make sure before you do that, make sure it’s clean and dry. But then the other thing that she’s going to do, she’s going to take, take this tape and this tape is used to keep that extension, uh, loop, uh, from getting snagged on anything. You just create this little loop. And then the last thing you need to do, which is so, so very important, is to time, date, and initial everything. You want to make sure that all of this stuff is documented in terms of a, Hey, we’ve got to make sure that this is clean and dry. 

And this was the last time the dressing was changed. So now let’s talk about inserting an IV and the AC. Remember this, AC is the antecubital fossa and what it is, it’s the elbow. It’s the one place that we know. This is really, really, uh, a favorite place for INI nurses is there’s a, this, a phallic vein runs. Let’s draw the hand again. This a cephalic vein runs just alongside the thumb and goes up and branches and it ends up bifurcating right in the elbow. But the cephalic vein is right there and then it continues up to the shoulder. That’s the actual, that’s this phallic vein is actually one that that continues up to the bicep. Now this Savallo vein is going to be one of your favorite friends in terms of, uh, it’s kind of your first go to. It was always my first go to, but that’s the area you’re going to want to look. 

But remember, you want to educate your patient on not bending that elbow. This is where you’re gonna get those occlusions. Now another thing to remember is typically we get that 10 to 20 degree insertion angle here. It may not work as well because it is a deeper vein at the location of the AC. So you may be looking at something like a 20 to 30 degree, uh, insertion. So here’s the AC and again, she’s going to anchor that vein down. She’s going to insert it. Everything’s being cleaned now. She gets the flush. And then I want to show you guys something real quick. Right here, you can see that typically this, uh, the hub of this IV is gonna lie just a little bit lower. But remember that’s a much deeper vein. So what’s going to happen is that that insertion angle is actually going to be a lot more steep. 

So it’s, this is almost a direction that she went when she placed that thing. It’s going to sit up just a little bit. So don’t be surprised. Remember, apply pressure if you need to apply that tampon OD to keep blood from flowing back and then you’ll get an idea of what that actually looks like. Now, one other trick I want to show you is you can see here this, you realize that there’s no blood coming back. That doesn’t mean that you should give out or pull out. What it means is that you need to be a little bit more persistent, adjusted just slightly. And you could see that what ended up happening was she was able to get it just flush. You’re confident, be confident. And where you place that IV and you’re good to go. Now let’s talk about bicep IV insertion. This is a last resort. 

It’s really great for bariatric patients. If you can’t get anything near the hands and forearms, another location that’s really good for our patients with peripheral edema because those peripheral owes patients with peripheral edema are going to almost feel like a bariatric patient. They’ll have swelling in the hand. You get all the swelling in the wrists, sometimes in the forearms, so you can actually shoot for that bicep. It’s not great. Sometimes you have to do it without a tourniquet, but this is one thing you want to consider in these patients that have this bad peripheral upper extremity extremity edema. Now one thing I want you to be mindful of is it can be painful and this is due to all the innovations and again, you want to start as low as possible. If you have to start right near the right above the AC, go for it. But if you have to start working your way up, that’s great. Another location is also the shoulders. So if you need to, you can go ahead and try those. All right, now I remember some patients are going to get a tourniquet here that’s sometimes effective. Sometimes it’s not. Uh, especially for the bicep. What she’s doing is palpating here. We’re going to try to find that vein, use those concentric circles just to make sure everything’s all good to go, 

and then she’s going to use that hand, anchor it down, insert. Now there’s something really important I want you to want you guys to see is that even if you tamping on, sometimes it doesn’t work. What this patient’s pressures just up a little bit and what happens is it’s going to be a little bit messy and that’s okay. You can’t go for perfection. What we’re wanting is we want this higher. We want our patients to be a safe. We want them to get a solid IVM. We want those IVs to be Peyton, but one thing that we can’t focus on is not getting blood. So prepare. You can also see that these chucks pads are here. These things are really, really helpful and especially in keeping your patients clean. All right, so let’s recap IV insertion in bariatric patients, it can be challenging, but remember, use evidence. 

So we’re going to use a right and aseptic. We’re going to use her rights setup. We’re going to use the right IV and also create those good or good habits. We want to create that routine just like we’re going for free-throws. Now avoid hands. We want to avoid hands because the, the veins have their branch. There’s a lot of valves, there’s a lot of excessive tissue. We also want to make sure that those catheters aren’t ending in those joints. That’s going to create a lot of problems that some occlusions, the patient’s not going to get all the medications they need. They’re not going to get the fluids they need. So try to avoid those as much as possible. Start distal, which also means to start low. We want to give ourselves the opportunity if we miss to go a little bit higher. And for patients that have that thicker skin, um, excessive tissue go bigger if necessary. Like I said, if you, if you’re solid, you can hit this 20 gauge and you think you might be able to hit an 18 gauge. If you, if that 18 gauge is gonna offer more stability, go with that 18 gauge and be confident. Remember, forearms and ACS are going to be a greater, in terms of having you be able to set those IVs successfully. 

All right, guys, I hope that this lesson has been extremely helpful in providing tips and tricks and even techniques in helping you guys become more successful in getting those IVs and those bariatric patients. We love you guys now go on and be your best selves today and as always, happy nursing.