Starting PIV = bane of my existance. Any advice?

  1. 0
    I started working @ ER as a new grad this February and I am doing pretty well with everything EXCEPT starting a line!!! I know I am supposed to take my time, but I also need to draw labs before attaching the saline lock, so I need to do it pretty fast before blood hemolyzes. So far my score is 50/50 before I have to call my preceptor for help. Everyone is really anxious which does not help my own anxiety. I need help!!

    So please~~ share some techniques/advices/experiences. I've asked around and the majority of the answers are: just do a lot of them and you'll get it.

    Question1: I was taught to enter the skin at 20~30degrees, but I've seen a lot of people go about 15 degrees or lower. What do you guys do?

    Question2: When you get a valvy vein, what do you do? Someone told me to just push through with the needle, but I ended up hurting the pt and had to try the other arm. What's your strategy?

    Question 3: what is your favorite site for PIV? (besides ac) I don't like doing it on the hands b/c 1) it's painful and 2) i feel like it's going to blow easily.

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  2. 14 Comments...

  3. 1
    I enter lower...probably around 20 degrees, especially if I'm scared of going too deep and going straight through (generally the older folks)

    I don't push past valves...I've tried a few times to "float" the IV in by infusing a bit of saline and advancing the cathlon at the same time but I have very limited success with this. Others seem to be able to do it much better.

    I like the radial-cephalic vein because I find them to be big and juicy most of the time. I also like the hands because they are easy to see but I agree with your pain issues.

    You may roll your eyes at me but it is all about practice. Its not like foleys where you insert one on a penis and you pretty much have it down pat. There is a definate learning curve...nobody goes from zero to hero with PIVs. I was fortunate to spend a few days in preop just starting IVs on the scheduled surgery patients...lots of practice, mostly hydrated patients. If possible give it a shot, it is a huge confidence booster!
    (As an aside, I don't draw blood from PIVs...never have...maybe its a Canadian thing?)
    whykiki0103 likes this.
  4. 3
    We don't generally draw labs from IV starts, either. And I would agree that the best thing for your skill and confidence level is practice. I work in a prison so I am usually starting IVs on healthy and muscular young(ish) men. Sometimes they have big, bulging veins that I can hit without a tourniquet. Sometimes they are IVDAs and their veins are crap. It's just practice and you learn far more from the difficult sticks than you do with the easy ones.
    I will start an IV in hand or wrist veins. If you are anticipating keeping an IV in for the length of a hospitalization it is best to start lower because if that one goes bad or if it's just time to change it, you'll need to go up from that site. So if you start at the AC you have far less veins to work with. I also like a couple of good unconventional sites, like the upper arm or the backside of the forearm.
    It's fine to start in the hand. Use an AC as a last resort. It's often uncomfortable and positional. The site that really hurts, in my experience, is the underside of the wrist.
    To answer your questions:
    I stick at about 30 degrees but once I get a flash I drop to a lower angle to thread the catheter.
    Like the previous poster I sometimes attempt to float the catheter past the valve. If you can't get past it by repositioning the needle or floating the catheter I'd try a different site. It's also helpful to learn the topography of the vasculature -- by tracing veins and watching how they bifurcate and how much actual vein you have in each direction you can make smarter choices and have more success. The more time I take planning the insertion and examining the veins the more successful I am.
    My advice: take time to relax and focus on what you are doing. Sit down if you can. Look at both arms before choosing a site. Do as many IVs as possible and then you won't be such a stressball when it comes to doing them.
    Good luck!
    RNKel, whykiki0103, and athena55 like this.
  5. 1
    The angle I enter at depends entirely on the patient and their veins. Skinny little old ladies = shallow angle in general. Swollen up people with deep hidden veins = slightly more extreme angle. People with no veins at all = guesswork and a prayer, especially since I usually get to them after other nurses have blown all their potentially decent veins.

    It's really all about the practice. The more you do it, the better you'll get. Trite but true.

    I hate starting in the inner wrist and will only do so as a last resort. Not only is it painful, but they just don't seem to last as long either. My favorite spot is in the forearm, usually there's a couple to choose from there.
    whykiki0103 likes this.
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    If you can see the vein in the hand, go for the hand. The radial-cephalic vein is also a favorite of mine, that one is so hard to miss. The biggest thing that helped me was remembering to advance just a tiny bit more AFTER you get the flashback, so the catheter is all the way in the vein. I also find it helpful to trace the vein up from where you're going to go, and mark it with a pen or even just pressing with your fingernail so you know exactly what direction you need to go. I tend to go for the ones I can feel more than see, so I don't go very deep, more like 15 degrees rather than 30.
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    Coming from a floor nurse, please don't start it in the AC unless you have to!!!!!!!!! AC IVs are the bane of my existence!!!!! The pumps go off every 10 min cuz the pt bends their arm "occluded pt side"...sooo aggravating. And for some people who bend their arms alot, the IV busts in less than 24 hrs. It stinks! They also seem to get leaky alot easier, probably for the same reason.

    I'm a new nurse too, and I do so-so with IVs. One of my fave in guys is the back of the forearm. Sometimes, it seems like they don't have any veins then turn their arm over and BAM! Oh and in little old ladies, I barely tie the tourniquet and that seems to help. I think the angle depends on the location too...on the wrist and hand much shallower, but usually the forearm req a larger angle since the veins are deeper.

    I think the number one key to starting IVs is confidence!! Which is hard for us newbies! Just try to use some positive self talk, and remember the time when you got that really tough stick!
  8. 0
    Thanks for all the helpful advices!

    I only use AC for people going for CT w/ contrast, people who need blood/ffp asap or just as a last resort.

    There definitely is a good day and a bad day for PIV.
  9. 0
    You'll get it in no time. I use to be scared of starting it's just second nature. It's so easy, and it just takes practice.
  10. 0
    I am a new grad nurse in a pediatric ER. I was nervous that the kids were going to be hard, but out of the 10 or so I have had to start, I only missed one. I actually got flashback on it, but it wouldn't flush. I think practice will make perfect. Also, I start them all in the hands. Once in trauma, I saw the nurse start in the AC, but other than that, they are started in the hands (or the feet in the liitle ones)
  11. 0
    My fav. place is the just put that tourniquite on and tap away at the veins in the hand untill you find something. The pinky and the thumb work well for pt's that have crappy veins....but patience is key...just wait, and you can always use warm compresses to make that puppy pop..I also come with an arsenal of gagues in pairs...18, 20, 22, when that vein does pop you can look at it and det. the gague you need...once you stick just make sure the vein dosen;t roll before you stick...some people LOOK like they have good veins till you mmake the skin taunt then magically it disappers...just keep praticing..

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