blowing veins during IV starts - page 3

I've been a nurse for seven months, and I'm doing well, except that I suck at starting IVs. In school I was almost completely unable to do them, and I've improved to the point that now I virtually always can find and hit the vein... Read More

  1. 0
    There is some excellent advice here!! Veins are like two are alike on people which makes IV starts interesting. From your description of the immediate swelling around the site could mean that the cannula isn't fully inside the vein yet, so the blood is flowing out of the vein causing the swelling. Maybe try advancing the needle just slightly more ensuring that it is actually inside the vein and then advance your catheter. You can tell if your in the vein or not most of the time by how smooth the catheter advances.

    Also don't give up, this skill takes practice and lots of it!! So take every chance you get for IV starts and with time you will get them with no problem. Oh and heat packs do wonders too!

    Hang in there!

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  2. 2
    Some more tips...

    If you can't find anything in the hand or forearm, look at the bicep. Some people have nothing in their hands, but have massive pipes on the upper arm. It won't get in the way of starting a picc line either.

    On elderly pts, you can get away with not using a tourniquet. Some elderly have no muscle or tissue, so the vein is literally looking right at you. If you have a tourniquet on super tight, the backup in pressure can cause the vein to blow once you pierce the vein. That's why someone mentioned taking the tourniquet off once you got a flash. So, if you think there's poor vein integrity (and the vein is practically sticking out of the arm), just inserting the IV can greatly reduce your chances of blowing the vein.

    On elderly pts, if the skin is very frail, the the vein probably has poor integrity. Try and go higher. If you are looking at the vein and there are no clear borders (it looks more like a blue streak then a nice walled vein), then it will probably blow.

    Try to never fish. The more you poke back and forth, the more likely you are going to blow the vein b/c you can basically scrap along the outside of it or going through it. Now, that doesn't mean to never fish b/c you will have to on many pts, but if you are fishing over and over in the same spot, try a different site.

    If you look at the needle and cannula, you will notice that the needle sticks slightly out of the cannula. Once you get a flash of blood, only the needle is in. As nursehafty said, you have the slightly advance the cannula into the vein.

    Assess the need for a proper degree of angle. Nurses fall into comfort zone when puncturing the skin. I don't know the actual recommendation for angle (maybe 20-30 degrees ), but every vein is different. Deep veins need a higher degree, superficial veins need close to no angle. But some nurses still go with that 30 degree angle and then lower the IV to the skin with the flash. That can either cause the needle to pierce the top of the vein or cause it to kink. Think about it. If the vein is deeper, the cannula is thread through the skin at an angle and then bends to go straight in the can kink. Try and make sure you are inserting as parallel as possible (that's my opinion). If the angle is too steep, you will go right through it.

    Don't try to be a hero and insert a larger bore IV. If you are looking at a vein and you are wondering if you should go with a 20 or 22, maybe go with a 22. If you think a 20 will definitely work, but maybe you could get an 18, go with the 20. You're not a pushover if you insert a 22. There is no need to insert a 16 unless you are planning on giving lots of fluid in a short time. For students, the bigger the gauge, the more likely you will blow the vein. Threading is something that each nurse does differently. A larger bore IV means you're that much closer to the sides of the vein. Once you get experience, you will be able to thread larger gauges easily.

    If you hit a valve, there are two things you can do. You can advance the needle past the valve, but that is risky for now. You will learn how to advance the needle deep down the road. Or, you can remove the needle and then briskly flush the IV as you are advancing the cannula. When you give a powerful flush, the valve will open and you will be able to pass the cannula all the way in.

    When you find a vein, scrub the area over and over with the alcohol wipe. I usually wipe the area back and forth, scrub, scrub...almost until the skin starts looking a little red. Don't do it to the point of the scrubbing the skin off (obviously), but scrub it until it is slightly (and mean slightly) irritating the skin. By doing this, you are overstimulating the area. The brain is interpreting the irritation to the skin and it's distracting the nerves. When you poke the needle, they don't even feel a thing. It's diversion and it totally works. If you ever stub your toe, pinch the back of your arm really hard. Your toe won't hurt at all until you stop pinching. It's the same process.
    Akewataru and nrsang97 like this.
  3. 0
    Practice makes perfect. I love when patients tell me they are a difficult start, challange accepted. Take your time. Not too high of an angle. Don't always go with the veins you see, sometimes the deeper one you feel are the better ones.
  4. 0
    Quote from iluvivt
    I would like to know if you are hitting the vein and then it blows or if you are hitting it,getting a nice flashback and then you advance the cannula and then it blows? Those are two different issues! What product are you using if it is an introcan I have a nice step by step instruction sheet I wrote that I can E mail to you.
    Thank you, everyone, for your advice! Yes, I'm getting the vein, getting flashback, but then when I go to advance the cannula, it just goes in a tiny bit and then sort of sticks, and the flashback stops, and that's it. Then, if I try to flush it in, I just make a big swelling under the skin. I think I forget to advance the needle that tiny bit more after I get flashback a lot of the time. Maybe putting the tourniquet on higher up the arm (or not at all with the elderly, which I do sometimes, as recommended) would prevent some of the blowouts.

    I am generally just putting in IVs for regular fluid and antibiotics--we don't do chemo or anything like that. I'm not sure what an introcan is; my unit just uses normal IV needles, 20s and 22s. I don't think we even keep 18s in stock on our unit.
  5. 0
    Quote from JoyMatthews
    my addition to the excellent advice above, is anchor the vein..and keep it anchored until you have finished advancing the cannula into the vein ... this was the tip that finally got me over the hump of 'every time i try i fail!'...
    Can you please describe how you anchor the vein, I am not sure what you mean. Thanks!
  6. 0
    I just wanted to add something, I'm not sure if anyone else has noticed throughout the years...

    When I had my first RN job back in 1998, I was pretty good at starting IVs. I actually enjoyed it! Then, I was out of the workforce, home with my kids for years. I came back to nursing in 2011. I noticed that the IV catheters were different than the ones I was used to back in the day. Anyway, I had absolutely NO LUCK with IV starts anymore! I was so upset. Obviously I was out of practice, but I used to be good at it! I dunno. Something about the newer design kept tripping me up. I'm a school nurse now, though, so it's no longer an issue for me.

    Keep practicing, OP! You've gotten some fantastic advice, and you will be fine!
  7. 0
    My two cents worth in addition to the great advice already given:

    1. Don't give up. Nursing school rarely gets you properly trained for IV starts, so you're definitely not alone.

    2. Don't forget that there isn't a nurse on this planet that hasn't missed a start only to have somebody come right behind them a get it on the first stick. Your day will come.

    3. Practice, practice, practice....and make sure you learn to palpate with the gloves on using alcohol swabs so your fingers glide. You'll watch others rip the finger off to do this. You'll wish you hadn't as soon as you hear words like MRSA, C. Diff, Scabies, etc. Also, make sure you palpate which direction the vein is going.

    4. Don't forget to check the backside of the forearm....amazing how many won't/don't do this. PT isn't a diabetic? Then the feet are also a candidate area. On larger PTs the axillary area where the breast and shoulder meet are potential candidates.

    5. Ask people who you think are IV experts for their tricks of the trade. Most nurses are happy to share their experiences. Have then watch you and give pointers.

    6. Did I mention not to give up?

    Best of luck to you....
  8. 0
    Quote from queenjulie
    Yes, I'm getting the vein, getting flashback, but then when I go to advance the cannula, it just goes in a tiny bit and then sort of sticks, and the flashback stops, and that's it. Then, if I try to flush it in, I just make a big swelling under the skin. I think I forget to advance the needle that tiny bit more after I get flashback a lot of the time.
    It sounds like you are going interstitial. I find this happens from either going too deep(through the vein), or their vein blows. Maybe adjust your angle to go slightly more shallow upon entry. I used to have this problem and asked experienced nurses to watch me. Especially obvious surface veins (like on the hands), they don't need much of an angle to be accessed. Good luck
  9. 0
    I saw a youtube video about this topic. I am not in NS as of yet but the lady advised that if you lay the catheter almost parallel with the vein and advance slowly your are almost likely to never blow the vein. I will see how it works for me when I get to that point.
  10. 0
    Thanks to all for sharing excellent tips. 2 cents. When prepping the area with the alcohol pad I use some pressure (remember the friction not the alcohol is what cleans the area), thus increasing the circulation and hopefully plumping up the veins. I hold the skin and veins taut with my non-dominant hand (enough that I won't get movement of either) Once I get the flash of blood I immediately remove the tourniquet and IDO NOT MOVE the position of the needle because the flash tells me I'm IN the vein. I DO NOT REMOVE the needle before I've advanced catheter. Think of the needle as the stylus(guide wire) they use when they insert a central line (the needle is maintaining the introduction into the vein). Then while holding the needle in place with my thumb, middle and ring fingers, I use my pointer finger to gently push off the plastic catheter. Once the plastic catheter is in place I remove the needle (if I remove the needle too soon I have nothing to guide the catheter into the vein, therefore I may be unable to advance the catheter and/or it will bend). I'm hesitant to blame "valves" as the reason I can't advance a catheter (unless they are "sclerosed" shut) because they open towards the heart which is the same direction my catheter and IVF are headed. Also, just an FYI....if you see Two veins merge into One you have found the strongest insertion site for an IV (at the top of the triangle where all three come together)

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