Help! How do I stop blowing very good veins?

[bagbaje26]

I have been a RN for 1.5 years now. When I started nursing, I was pretty decent in placing IVs, probably not with placing difficult sticks. I knew the mechanics of it, but was probably not aware of my particular technique. All I know is that I often go in flush with the skin. However about 5 months ago, I noticed a decline in my IV insertion rate. I never have a problem getting in the vein. However, nowadays, I blow all my good veins. I often get a good flash of blood, filling the catheter chamber but by the time I thread it through I’ve blown the vein. Sometimes, I blow the vein immediately after getting into it. I understand that we can’t avoid blowing veins when they’re weak, but I also blow very good, 20, 18G type veins. I am concerned because I know where to find the good rarely used veins. However, I know something has changed in my technique that’s causing me to blow these very good veins. One experienced RN on my floor told me that once I enter the vein, I might be pulling back the needle too soon or too late. I will like more suggestions on what I might be doing wrong.

This has become my major stressor in nursing. I love the pace of nursing but I’ve definitely lost confidence in my IV skills, a very important nursing skill. Most of the time when I have a patient on continuous IVF, all I can think about is that I hope the IV last for the rest of my shift because it’s really difficult to find someone else to help place it. We often differ to the clinical specialist on my unit, who hasn’t been too forthcoming in helping me improve my skills.

I’ve talked to our clinical educator, the specialist about having a session in the ER, PACU, GI and other units where IV insertion is a constant task. They continue to give me the run around about not being able to arrange this (something about labor laws and overtime even though they are aware I will be doing it on my own time).

I will at least like to get the good veins and worry about difficult sticks later. I will definitely appreciate any tips from everyone. If anyone is in the Chicago area and have suggestions about where I can get good practice on my own time please I am very open to it.

Thank you in advance.

[GrumpyRN63, ADN, RN]

Good for you! oh yeh, best to learn on the sedated pts as well!!!, Keep your CONFIDENCE, everyone has a slump, don't let it get your confidence, that's really self-defeating and self-perpetuating, I Know I can, I know I can...

[NotReady4PrimeTime, RN]

Very few of these tips will work on kids... even if you have someone who can anticipate their reactions, they'll make it impossible for you to get that tourniquet off and still have the tip of the stylet under the skin!

[mscsrjhm]

Try not using a tourniquet. It really helps with the older folk. You don't really need a tourniquet to start an IV. You don't need the vein to stand up, you just need to know where the vein is.

I also rarely use a tourniquet. Good advice given to me while I was also going through a dry spell. By keeping an extremity below heart level while I get supplies set up, I found veins do not blow as often on the elderly.

Might use tourniquets on younger.

But I am terrible at those deep veins on the obese patient, and have stopped even attempting IVs on obese, dark skinned patients- I really need veins that jump up and down screaming "pick me- pick me!"

Have used a veinoscope a few times and love them.

[thedit]

I can't believe it! I'm having the EXACT same problem. I've been a nurse for a year and a half, was average at getting IVs, and then all of a sudden--I blow EVERY vein. And I get stressed about it too, just like you. Getting the flash of blood isn't the problem, and I can usually find veins in those who don't have many veins...but then I blow 'em, and then they're out of veins.

Sooo...thanks for posting this thread, and thank you for all of the responses. I will try some of these techniques tomorrow. Good luck to you!

[iluvivt, BSN, RN]

Usually when nurses say they have blown a vein they have done a through and through puncture or have nicked the veins side wall causing the vein to lose blood and a hematoma forms....So to prevent thatremember that every step in the process is important and never assume any attempt at venous cannulation will be easy. So do what needs to be done to increase your success

This is how I do it...its sounds long but after 29 yrs I am fast at it

1. I take a look a quick look at both arms (if applicable).then choose the best one for more assessment. I also always want to know what we will infusing and why That may make a difference about the size and location I may select.

2. I apply the tourniquet fairly high in the upper third of the upper arm. I always unsnap the gown so I do not forget to pop the touniquet. Keep the pts arm dependent when you apply it.

3 Then I look at what is filling....feel the veins for fullness and quality..look for soft bouncy veins that are not tortuous and avoid areas of flexion and the wrist. A huge number of IV therapy lawsuits are related to IV insertion in 2 areas...one is the distal cephalic above the thumb over the radial bone for approx 2 inches and the inner aspect of the wrist. There are large superficial nerves in these 2 areas....also even the deepest peripheral veins can be hit with no greater than a 15 degree angle. I will also apply heat if I see a good vein but it still needs to fill a bit more and it works fast

4. Select your vein and determine at what point you will access it...if you have an inch long catheter..detemine where the tip will end up if the entire catheter will be threaded..so you are able to thread the entire catheter...line it up and attempt to access the vein from the top wall...you can also do a side entry but need to be very fairly skilled not to advance through the vein wall

5 perform your venipunture at no greater than a 15 degree angle and once you get a blood return ...drop your angle flush to the skin....Always advance about 1/8th of an inch further to make certain you are well into the vein. The tip of the needle can be in the vein and you will be getting your flashback and if you pull your needle back before advancing it more....you will most likely pull the needle out of the vein and you will not be able to advance the cannula over it...so always advance a bit once you get your flashback.

6 now pull your needle back and advance the catheter into the vein..it should feel smooth and your blood return should still be present.

7 you never ever want to recannulate and with most safety catheters you can not do that anyway..but what you can do if you have advanced of out of the vein..is (its a bit messy so have some gauze ready and open) to try and save it....pull back the catheter very very slowly until you get a brisk blood return..then advance..watch to make sure blood return is still coming. This usually works on my first try and sometimes my second..after that your chance of saving the stick is not good..remember to only touch the hub to advance...and small catheters tend to buckle and you sometimes only get one chance at it

[cherrymaryRN]

Super helpful thread for new grads, thanks!!! At first I was terrified of trying, but now that I'm getting the hang of it I can't wait to stick somebody - although I try not to let them see the gleam of excitement in my eyes! :) None of the other nurses even want to try starting them, we always call the same one or two people out of another department for IV sticks which I think is a shame, so I'm determined to get good at it. We get a lot of super dehydrated folks in our urgent care center so it's always a challenge, and these tips are awesome. Thanks!

[diane227, LPN, RN]

You don't say what age patient you are dealing with here but from my experience, with people who are quite elderly and have fragile skin, I don't use a tourniquet. I use gravity. I have them hang the extremity off the side of the bed. I also use this with people that are young, and who have huge veins, who are out in the sun a lot (tough skin) or who weight lift. I just have them hang their arms off the side of the bed. I find that the back pressure of the tourniquet can cause the vein to blow. The only time I use a tourniquet is with a person who is overweight.

[BabyLady, BSN, RN]

What type of flushes are you using?

Our facility has prefilled saline flushes, but you have to make sure that you push some of the saline out, because the force behind it will cause you to blow a vein if you don't.

When I float to an adult unit, they usually have me stick difficult adults because I am used to sticking threads for veins...the biggest mistake I see made is that they push the flush too fast or they don't fill the barrel of the catheter with saline which causes an air pocket...which will also cause the vein to blow.