IV tips and tricks

I'm sure this has been mentioned elsewhere but two other tips:

1. throw some alcohol on a general area where you suspect a vein and then hold the site at an oblique angle to your light source. Sometimes the light reflects off of the hand and shows the contours of the vien in very subtle shadows.

2. place a thumb on either side of the prey (insert vein for those of weak mind) and tug the skin left and right repeatedly. I find that viens that move as one with the skin are buried in the dermis and are usually very shallow, tiny veins. The ones that move a little incongruently with the skin are below the dermis and hold an IV rather nicely.

That dummy vein everyone is so hot for? My experiences have always been negagtive. I'll hit the vein and the pt will turn grey, grossly diaphoretic and be too busy trying to vagal out to complain. I read an article in Nursing 2003 or 04 about this, apparently the radial? nerve has (in the majority of people) 2-3 branches cross over the "dummy vein" just proximal to the wrist and nicking one of those creates this vagal like response or atleast a lot of discomfort. The article recommended going like a couple inches more proximal. I've tried it and had much better response from pt's.

I want to thank you all for your great ideas. Had never heard of the NTG paste. Many of the others I had simply forgotten.

Could someone explain the bifurcation one to me? Your inserting before or after the bifurcation? And it's a good anchor? It doesn't blow?

[quote=LMPhilbric]1. Be confident! Do not go in to the pt and say I'm going to "try" to start your IV. Would you like the nurse who's going to try or the one who's going to get it?

I was on the IV Team for 3 years and we each started about 3000 IVs a year. There is no substitute for practice. IV therapy is 10% talent and 90% practice. Good luck! ( GREAT ADVICE HERE )

PS I was also the only IV nurse on nights, so I had no backup. It's amazing how good you get when you don't have a choice.

Age, skin types, skin tones, diseases, etc., require different approaches when starting IV's. Putting the patient at ease through confidence and easy-going conversation goes a long way! Just about every time a frustrated patient tells me "You only get one shot", I almost always blow it. And I'm pretty good at starting IV's. Gotta put yourself at ease, too.

I've learned that veins other nurses dismissed as not being "deep" enough can actually last until a resite is due. Since I work almost exclusively with geriatric patients now, I don't always use a tourniquet because it's not necessary and causes veins to blow. If the vein is sticking up so high you can shoot it with a dart from the door, what's the sense in putting more pressure on it??? On fragile, transparent skin, forget the tourniquet, anchor the vein, stick and wait a few seconds and you'll see the blood return.

When I worked as an IV nurse, our nurse manager said if we used anything smaller than a 20 gauge there was no sense in starting an IV in the first place. I've learned that is not true. In the absence of a central line, a 22 gauge works for needed IV fluids, pain meds, etc. until that CVC is in place.

I work extended care now--VRE, MRSA, long term abx treatment-- and most of our patients have been stuck every place imaginable for labs and IV's. Yet most of them don't have central lines. Their veins are pretty well shot by the time we get them. So, 22's are actually the norm here unless they are getting blood.

If a patient has generalized or pitting BUE edema, palpating for a vein is next to impossible. But if you press down on an area where a good vein is located, you can actually see the vein running through the indentation left in the skin.

Reading through these posts, it's obvious that the situation of the patient merits what type of gauge they require. But since this post was about tips for starting IV's, I concur with the above post about practice. Bottom line is that the more you do, the better you get.

Do any of you use NS as a anesthetic? I learned this trick from an agency nurse. I only use it on adults who seem really anxious and definately on children. You take a TB syringe and make a small blip (just like a TB skin test) right where you plan to stick for the IV. You have to stick again immediately before the blip goes away. It amazing how it works. Pt's say "I didn't even feel that". They can deal with the 25G prick. I would definately agree with the 10% talent and 90% experience theory and with the feel not by sight theory. So true, so true.... I have never inserted anything larger than a 20G. We don't even stock anything larger on the med/surg floor. I'd hate to see a nurse come after me with such a large bore IV unless there was an anesthetic to accompany it. We don't get patients from the ER with anything larger either. Occasionally we'll get a patient who comes in with an IV started by an EMT and they are almost always a 18G and almost always in the antecubical and shortly thereafter need restarting because the pump won't stop beeping and driving both the pt and nurse crazy. Thanks for all the great info everybody!

Very informative thread. I think that is my major concern...I don't want to cause any more pain to a patient.

We run it wide open and it takes about 15 minutes.

Our policy is that we don't do any labs through IVs unless it's just been placed.

This erroneous statement--and thoughtless accusation (boldface added by me)--is really why I had to respond. We can run blood way faster than that through a 22. We don't usually have to run it very fast because most of our patients have issues with fluid volume overload, but I know it can be done in those who can tolerate it, because I've done it. Our transfusions usually take three hours, but I've done a few transfusions with a 22 in two hours.

22s are pretty standard for our unit. We have a lot of elderly people here and they simply can't tolerate anything larger. We try to leave the AC site for labs or for CT scans with contrast. Otherwise, we just use 22s.

P.S. Almost forgot the tips: I find that establishing a little rapport with your patient can help them relax and therefore, make the veins easier to access.

The poor girl who was in too much pain with the fractures should probably have gotten an IM to hold her over before the IV was placed, and I do sympathize, because I'm a very hard stick myself.

So I go in making a promise to my patients--I will not dig around in your hand/arm for that vein. I will either get it on two tries or I won't, but I refuse to cause unnecessary pain. It should come as no surprise that most patients visibly relax when I tell them that.

I have them dangle their arm over the side of the bed and wiggle their fingers and I ask them about their family or something else that's distracting and soothing, as I set up my tape, my flush, and my supplies. I line it all up in the order I'll need it. Then I place the tourniquet and put on the gloves and scrub the area with the alcohol swab.

I usually get them on the first try.

It is also part of my ritual to bring 3 IV needles just in case--a 20 and two 22s. For some reason, if I only bring one, and feel like I have only one chance to get it, I blow it.

This only backfired on me once. I failed the first attempt, and the patient then asked me why I brought 3 needles if I usually got it on the first try. I then realized why she'd remained so tense.

When I told her, she laughed and relaxed enough for me to get the IV in. Veins have a tendency to try to hide in tense muscles, which is why relaxing is so crucial to the process.

Hope that helps.

I'm totally loving this thread ... Please keep the tips coming.

Very informative.

I actually start my first RN job tomorrow night, and my duties (allegedly) are to draw blood for labs on research patients.

Of course I haven't done a stick in a year.

I really appreciate these tips--and I am more confident because I recognize that a lot of what is described here (helping the patient relax, using a BP cuff and gravity, feeling for the bouncy vessel as opposed to the tendon you can ID with ROM) I already do almost as second nature.

Thanks for all the tips, and especially for that IV website, gwenith....

Ive been both a nurse and a patient: These are two important factors to remember (coming from a pts point of view):
1. When you wipe the IV site with Alcohol, please give it a chance to dry a little. It hurts worse when you are being stuck with a needle coated in alcohol. Besides, it takes at least 30 sec for alochol to work, anyway.

2. When removing a needle from someones arm - dont put pressure on site until the needle is out. Some lab techs have put pressure on the site before they remove the needle - this will not only tear the vein its in - but it really hurst and leaves major bruising

To the previous poster about most painful sites to stick - in my experience its usually the top of the hands. But every one is different.