blowing veins during IV starts - page 4

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. 1
    The posterior forearm is my favorite site.

    1) Offers a large vein

    2) It's out of the way

    3) gives a lot of arm and hand mobility to the patient

    4) rarely infiltrates

    5) doesn't bend the IV catheter or the IV tubing
    Ir15hd4nc3r_RN likes this.

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  2. 0
    If you are getting a flash, but can't advance the catheter, there's two main things probably happening. As mentioned before, once you get a flash of blood, you are not in the vein yet. The needle sticks out a tiny bit past the catheter. When you get that flash, the needle is in, but the cath is not. You have to advance the cath into the vein. I know it's unnerving b/c you are afraid of going through it, but you have to advance the cath about a cm after getting a flash (at minimum).

    See the metal sticking out at the end and see the white cath below it. You have to insert about a cm of the cath into the vein. If not, you are pushing the cath on the outside of vein and it won't thread.

    The other is that you are probably going at too steep an angle. I mentioned going as parallel as possible. Stay away from the 30 degrees.
    In this picture, the angle is zero! The vein is pulled taught with the thumb. If you went at a 20 degree angle on this hand, you'd go right through it.
    Notice the angle is practically flush with the skin. See the flash of blood? Where is the needle? It's still in, but slight pulled back. This is a 22 gauge.
    Notice the angle and notice that the needle is basically still in the cath. The tip is pulled back, so you can't puncture the vein, but the needle acts likes a guide wire. This is a 24 gauge. With those could get at least an 18, maybe even a 16.
    Note the angle. Practically nothing.
  3. 0
    Quote from not.done.yet
    Forearms seem to be easier to hit and keep than hands and wrists and are easier on the patient's mobility after it is placed than an AC or wrist IV. I love a good forearm IV and I often am successful at getting an 18g in there for all but the very elderly.
    Very true, I always go for the forearm. Also, on the obese, they always have a few good veins in their shoulder area that you can usually throw at least a 20g into.
  4. 0
    Quote from 915Chief
    Then the feet are also a candidate area.
    Actually, at our hospital, we aren't allowed to start IVs in the legs or feet without a physician's order, because of the hazards of diabetic foot ulcers and circulation problems. I figured that was pretty standard, but maybe it's because I'm in a state with probably the highest rate of diabetes in the country.
  5. 1
    Thank you all for all your advice! This is great. A phenomenal IV starter at work told me yesterday something interesting--she said she always goes in the side of the vein, not down on the top of it. She said running along the side keeps her needle at the lowest possible angle and seems to keep from going all the way through the vein and blowing it. Does anyone else do this?
    rockstar11 likes this.
  6. 0
    Quote from sherbearccrn
    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.
    How do you hold the skin taut, hold the needle, and release the tourniquet at the same time? I'd need three hands! Seriously, though, I usually try to advance the cath with the tourniquet on or let the skin go to release the tourniquet. Maybe that's where I'm going wrong!
  7. 0
    Once you get a flash and advance the catheter a bit you can let go of the skin then pop the tourniquet. You don't need 3 hands to do that.
  8. 0
    "I hold the skin and veins taut with my non-dominant hand" -- This is called anchoring the vein

    after getting in the vein and advancing the needle just a bit then cannulating the cannula I take my non dominate hand and pop the tournequit, then I place a 2x2 just under my IV cath (incase I am not strong enough to prevent a mess, the 2x2 helps me) I move my non dominate hand to hold the colored end of the cath with my thumb and first finger and I use my pinkie to apply gentle preassure just above the end of the cannula, remove the needle completely and attach the little "pig tail" (that is MY name for the little tubing that actually attaches to the IV) then I flush.

    "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" --This is my favorite find! but I like the fore arm too!

    Another thing when I was learning to start IV's I would tell everyone who I thought was good or excellent to please let me assist them when they started an IV and I watched them to see how they did it. then I would emulate them, I also would get them to observe me but I really had to feel comfortable with the person watching so that I did not become too nervous. Then when I come upon a patient who is a difficult stick and I know this I always say a little prayer while I am looking for that perfect vein.

    You have great advice wish you the best in this new skill you are learning.
    Last edit by Georgia peach RN on Feb 18, '13
  9. 0
    @ queenjulie

    Yikes!... Sorry for the confusion...I usually have no problem with insertions but if I do I have no problem having someone else try. There are days it's just not going to happen and other days when I couldn't miss one if I tried. The procedure has become so automatic that after I read your question I had to re- evaluate my steps again.....

    So after I get rid of my 3rd arm...I actually pull the skin taut/anchor it /don't let it move... yada yada. I insert the needle. Once I see blood I advance the catheter without moving the needle..let go of the skin...hold the inserted IV with my non-dominent hand... remove the tourniquet with my dominant hand...then using both hands I attach a "pigtail" (AKA; PRN adapter, Lock). Place a small piece of tape on the pigtail tubing (frees up my hands) below the catheter hub and flush. If everything is okay I finish securing it and put a clear drsg over the site.

    And that's the truth!
    Last edit by sherbearccrn on Feb 19, '13 : Reason: mispell
  10. 0
    My Technique:
    [COLOR=#9b00d3]Anchoring/keeping the skin taut;
    Insertion to the forearm
    Say, I have a client with very loose, tissue-like skin. I choose the anterior forearm(where I might do a TB test) Although, this would probably NOT be my first choice, as it is extremely sensitive. I place my tourniquet ABOVE theelbow, prep the site (betadine, alcohol) per your hosp. policy. I always slightly twist the needle/cath to make sure the catheter will advance smoothly. Then I grasp the client's arm(on the opposite side I intend to insert the IV) posteriorly, and gently pull the skin toward the palm of my hand (this is the only way I can think to describe it, for you to get a visual). Obviously, I don't fill my hand with skin...but enough to smooth out the skin on the anterior side. As I smooth out the skin gently/firmly, I'm hopefully immobilizing and straightening out the vein underneath.
    Insertion to hand (posterior);
    [COLOR=#9b00d3] [/COLOR]
    [COLOR=#9b00d3][/COLOR]I hold the hand (as though I am going to kiss it ) and using my thumb gently/firmly pull downward to smooth the skin and straighten the vein.
    Other methods
    Depending on the site I choose. I will firmly "push" the skin up, above the area I'm intending to insert the IV so I can straighten/anchor the vein and smooth out the skin. Or, using your forefinger and thumb (as though your zooming in on an iphone) above and below the insertion site will help to smooth skin and straighten/immobilize the vein).
    [COLOR=#9b00d3]**If veins are really torturous you WILL have to keep it anchored until the catheter is completely advanced.
    [/COLOR]Thick, rolling veins
    ...[COLOR=#9b00d3]**[/COLOR][COLOR=#9b00d3][/COLOR]Imagine cruising[COLOR=#9b00d3] next [/COLOR]to another car and suddenly turning the wheel 45 degrees to hit it. (it's kind of a quick jab) you see a flash of blood then advance the needle a mm to insure your catheter is also in the vein before you move the shringe to a more parallel position, then continue to advance the catheter (otherwise, the catheter may bend)
    or push the mechanism that causes it to retract) before advancing catheter ....if you do, you may have alot of difficulty advancing the catheter esp.on clients with weathered, tough skin [COLOR=#9b00d3]**[/COLOR]I have had the catheter tip wrinkle up as I'm trying to advance it over the needle.
    [/COLOR]REMEMBER, YOU CAN NEVER RE-INSERT A NEEDLE THROUGH THE INSIDE OF AN IV CATHETER ONCE IT HAS BEEN REMOVED. (shearing of the tip may occur and cause an emboli to the patient)
    If a lot of blood is escaping I will place my ring finger from my non-dominant hand above the insertion site and over the underlying IV catheter [COLOR=#9b00d3]...**[/COLOR][COLOR=#9b00d3][/COLOR]never on the insertion site (remember, aseptic technique) to decrease the flow, and attach the "pigtail" (AKA; Lock, PRN adapter)

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