blowing veins during IV starts

[queenjulie]

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 with blood return, but I blow them constantly. I don't know what I'm doing wrong--I try to be gentle and advance the catheter very slowly, but they barely advance and when I try to flush, I just get a bubble under the skin and the patient gets a lovely bruis. I just suck at it, and my poor patients end up getting re-stuck by our charge nurse or someone who is actually capable of doing a decent job at it. It's incredibly embarrassing. Any advice? If it matters, I'm on a high-acuity step down unit with mostly cardiac patients.

[VANurse2010]

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.

[Georgia peach RN]

"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.

[sherbearccrn]

@ queenjulie

Yikes!... Sorry for the confusion:confused:...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:o.....

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!

[sherbearccrn]

　

　

My Technique:

[COLOR=#9b00d3]Anchoring/keeping the skin taut;

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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);

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[COLOR=#9b00d3]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

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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.

Thick, rolling veins

...[COLOR=#9b00d3]**[COLOR=#9b00d3]Imagine cruising[COLOR=#9b00d3] next 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)

DO NOT PULL THE NEEDLE OUT OF THE CATHETER

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]**I have had the catheter tip wrinkle up as I'm trying to advance it over the needle.

　

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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=#9b00d3]never on the insertion site (remember, aseptic technique) to decrease the flow, and attach the "pigtail" (AKA; Lock, PRN adapter)

[eatmysoxRN, ASN, RN]

I'm not sure if it's been mentioned, but an inflated blood pressure cuff is a fantastic tool in IV starts to replace tourniquets. They provide more even pressure and are much more comfortable to the patient and I doubt you'd miss a big bp cuff while you may overlook a tourniquet.

The tightness of a tourniquet or cuff should depend on your veins. If they are already sticking up then you don't need to apply it tightly. I find veins blow more easily in those situations.

Don't spend 10 minutes searching. Usually I look for 20 seconds and give it a shot. The procedure isn't pleasant for the patient.

Make sure all of your supplies are ready. Tape pretorn (although our start kits have the little white cushioned adhesive holders). I also prefer to leave the loop tubing off and just use the lock cap. Have your saline lock primed and ready.

Clean per policy and do not touch that site again. Anchor the skin: hold firmly a few inches down and be sure to go in bevel up. I go as parallel as possible and once I feel the pop into the vein and see flashback, advance slightly more and push the cathelon in. Release the anchoring. Pop the tourniquet. Apply pressure above the site with my pinky to prevent a crime scene. Hold the cathelon with the same hand you're applying pressure with. Remove the needle and screw on your lock. I pull back gently to see if I get some blood. Either way after that I'll flush gently. If it's resistant I pull the cathelon back slightly while pulling back to get blood return. Once I do I flush gently while advancing the cathelon further. Securely dress your site and clean up.

It's okay if you don't get it. Be confident. Accept that you can't hit them all. Keep practicing.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

[caleeah80]

I worry about iVs as well. I always make a mess--once removing the tourniquet and the needle, there's so much bleeding! Is that normal? I get flashback and it flushes without a problem, no swelling at the site either....

[SquishyRN, BSN, RN]

I worry about iVs as well. I always make a mess--once removing the tourniquet and the needle there's so much bleeding! Is that normal? I get flashback and it flushes without a problem, no swelling at the site either....[/quote']

Apply pressure above the site as you withdraw the needle.

[rubato, ASN, RN]

This is all great advice guys. I'm a student still, but I LOVE starting IVs. We have started them on our fellow students a lot, but I've now had success 3 times in clinicals. I have had pretty easy veins though, so far. I'm happy to read all the advice for that day when I've got a puzzle in front of me.