Starting PIV = bane of my existance. Any advice?

  1. 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.
  2. Visit whykiki0103 profile page

    About whykiki0103

    Joined: Jan '09; Posts: 23; Likes: 14
    from US
    Specialty: 5 year(s) of experience in ER


  3. by   AirforceRN
    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?)
  4. by   humglum
    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!
  5. by   mama_d
    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.
  6. by   Sterren
    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.
  7. by   LittleWing21
    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. by   whykiki0103
    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. by   RedhairedNurse
    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. by   sbyramRN
    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. by   Morettia2
    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..
  12. by   flightnurse2b
    this is all really good advice! i don't have much to add except to reiterate on confidence and practice!

    when i first started starting IV's as a very young paramedic i could not hit the broad side of a barn... and i was frustrated, and the patient would get more anxious, and when pt's are anxious their veins hide.... ugh.

    my preceptor a long time ago told me when i missed once: "don't take that needle out, go get that vein and float it in".... and 99% of the time if i am nearby the vein i want, i can pull back and redirect at a little different angle, then get the flash and flush it in with saline... and get the vein i had wanted initially without sticking the pt again.

    good luck, you'll be a pro in no time
  13. by   Morettia2
    ok had a pt. last night who needed a new PIV. The day shift RN told me he pulled it out by accident around 5pm...I asked her why she didn't put in a new one..she said no one could get a vein, even the MD. I said wel there is a STAT dose of vanco that should have been given at 5:30pm according the ID MD's orders, and the 6pm dose of zosyn was also not given, it's now 7pm, we are changing shift and are all the MD's aware that the IV ATBX weren't given due to no PIV access..the RN said yes...little background on the pt, he's a renal transplant in rejection and ended up on my floor (which is interventional cardiology) due to a hypertensive crisis during a TMA operation. Now, the BP is undercontroll and the MD wrote for the pt. to d/c tele, but because he's been through so much medically his veins were all sclerosed...

    So I went into the room, introduced my self tld the pt. I was going to try and put a new IV in...he said ok like a good sport...

    I looked at both arms to see if he had an old A/V fistula or shunt due to the fact that he had a kidney A/V on either arm....

    So I brought in 2 22g and 2 24g angiocaths...

    I tried the left arm first, got a great vein to pop after tapping for a while, I made the skin taunght and went to stick a 22g, and nothing, I was in the vein b/c th guywas so pale this veins were bright blue but no flash but I looked at the vein and tried to figure out why I had no flash and began to palpate further up the vein and felt this hard lumps all up and down the I retracted and went for the right arm...the pt. said to me, "that vein you just stuck, everyone always thinks it's great untill nothing happens, everyone get's that vein and then they are upset b/c it dosen't work"

    I said no problems, no worries we still have the right arm to try...he said, "one this guy stuck me and I never felt it and he was the only one who actually was the only one who could find a vein" I said, "gimme a chance you will be suprised"

    So I put the tuniquite on the right arm, and NOTHING, I began tapping away, and nothing, tap tap tap, then finally I saw something, plapated the vien up and down, grabbed the 24g and stuck the pt, BOOM huge flash, I said don't move, he said to me, "you are in the vein?, I didn't even feel it, let me see I don't believe it." I said look...he said "back flush it I can't belive it, that you found a good vein and you didn't hurt me and you got it on the 2nd try, the MD couldn't get a vein to save his life and he was the best..and those 3 nurses that stuck me today just made me have a bunch of holes in my arms wth no success. And now they wanna put a PICC in b/c they can't get a line ever, but you did thanks, and you did it and I felt no pain"

    I hung the vanco watched the IV ATBX run for about 5 min to make sure it didn't infiltrate and it was all good no blown vein, called the ID MD told him I got a 24g in the right wrist hung the vanco and will hang the zosyn later, he said, "you DID get a vein? How? This guy has no venous access b/c of sclerotic veins, I can't believe you got one on the 2nd stick." I just said, "well I just sat there and waited for something to pop, and got a great vein but put a small gague b/c I didn't want to blow the vein with a large gague while the 250mls of Vanco runs in and have it blow, I also noticed that the vein looks big but when I stuck him it would shrink so that's why I also used a small gague. I know we can't do much with a 24g PIV but run fluids but he now has venous access."

    The doc said thanks...and this morning before I left the MD actually came in early to see, I had the 6am dose of zosyn running it was susposed to be given q6 hrs so the day shift didn't give him him 6pm dose the night before, but he got the 12am dose and 6am dose ...he just said " I can't believe you found a vein that works"...the pt said, "she stuck me and I didn't even feel it, I like her alot"

    It's just pratice and patience, and you find your own technique of inserting PIV's. I tend to talk to the pt. and distract them while I stick them, it seems to relax them and they are less likely to flinch when you are taking to them about something. I hate when a pt. pulls back or flinches b/c you end up with a mess and you are more likely to stick your what I found useful, I strike up conversation, get my stuff lined up as I am taking to the pt, and before they know it they have a working IV, and it also makes you the nurse more relaxed when you talk to the pt. insted of saying.."ok, I am going to insert the IV now..." I find that when I say that the pt. squirrms and moves and you blow the vein plus it makes you a little more on the spot b/c the pt is watching you every move...

    Some pt's like when you explain what you are doing, and are really into watching you which can be fun for you and the pt. b/c they are fasinicated and it's like Q&A time but is a learning exp. for the pt. and you as the nurse are teacching them.. but you also have to read the pt. before you stick them...I usually ask if they are going to flinch or squirm or pull away.

    Good luck, every nurse finds their PIV niche.
  14. by   nminodob
    Maybe my unit has fewer nurses with experience, but I found that I was pretty lucky with IVs, and now they come to me for help. As a new nurse there is nothing more gratifying than successfully starting an IV for another nurse in the last 10 minutes of the shift! I don't have any 'tricks" to add, except to say that the main reason not to rush is that most of the time the outcome is determined before you ever touch the needle to the skin - you either picked a good one, or you didn't - so take time and choose wisely. That said, there are somethings I can NOT do:
    I have heard about "floating" an IV into a vein, and had ZERO success trying it. If a vein has valves, even if you manage to get flashback it seems more than likely it will blow. As others have mentioned, the back of the forearm often has a good vein, and it is usually long and straight! Hand veins seemed the easiest when I first started, but quickly became most of my misses, perhaps because they usually aren't straight, or because the patient makes little moves with their hands. One other thing: We don't use 24 gauge on my unit - the smallest is 22. I only resort to these if the pt is dry or an IV abuser. We sometimes do draw labs when starting an IV, just by attaching a 10cc syringe with a Luer-lock connector and drawing back to fill it - but I don't like doing it because it can be messy and all that manipulation of the cannula increases the chance of blowing the vein..