I am terrible at IV's!!

Simba&NalasMom, LPN · Jan 14, 2008

Sorry can't give you advice on starting IVs other than the usual techniques to get the vein to pop that you've probably already heard(warm washcloth, etc.). I CAN tell you that when I was brand-new I had the same problem with female Foley caths. What happened is that I finally just did enough of them, that one day I could just do them; everything clicked like a light bulb. I'm sure the same will happen with you; just give yourself time and honestly tell your co-workers that you have a hard time with IVs, and offer to do as many as you can with a more experienced co-worker looking on and offering pointers. Hang in there, it will come to you eventually. :mad:

hisblueskies · Jan 14, 2008

Some nurses are really good at starting IV's - others struggle - I'm one of the strugglers. My success rate is about 40%. Practice, practice, practice. Take your time - feel comfortable that you have a vein - if you are having a hard time seeing or feeling the vein then ask for help Don't be afraid to try. Some nurses like to insert the cathlon to the side of the vein - some insert it directly over the vein - do what is comfortable for you. If you don't get a flashback quickly don't spend alot of time repositioning the cathlon - that can be painful for the patient. There have been a few times I got my flashback and then I messed up by advancing the needle too far so I blow the vein. The more opportunity you get the more comfortable you will feel. Good luck.

paccookie · Jan 14, 2008

Starting IV's has never been an easy skill for me. I took off for 5 years to raise my family and am now working again. I am finding everything else fairly easy but starting IV's are such a challenge for me still. I have not started one successfully yet! Any suggestions or key points would really help me...thanks,....

It just takes lots and lots of practice. Start with the patients who have good, obvious veins. Get some good sticks on those patients and gain some confidence in yourself. Start off using 22s and 20s and move up to 18s when you find a patient with big veins. lol Don't do the 45 degree angle crap they teach you in school - it doesn't work and it makes you go right through the vein. Lay the needle next to the skin, almost parallel and slide it into the vein. This is the way my partner taught me to do it and it works nearly every time (I've never seen anyone who hits as many IVs as my partner). Be patient and realize that you're not going to get every one. Sometimes the only good vein is in the AC, even though most nurses hate using it. Don't be afraid to try a different vein though. And don't be afraid to straighten a squiggly vein if that's your only option. I got a good one in the left hand a few days ago that was very squiggly but straightened out easily with a little pulling on the skin.

Anyway, good luck to you. IVs are one of those skills that is really more about practice and luck than anything else. You have to develop your own way of doing them and you also have to have a bit of luck on your side. Some days you will hit every vein that comes near you, and other days you won't be able to hit the broad side of a barn. LOL Just don't take it personally.

Christina

Editorial Team / Admin · Jan 14, 2008

IV starting is a SKILL, and one that will be developed, as another has posted, with PRACTICE.

Most of my experience has been starting IVs on adults.

I'm sure peds IVs take a different kind of finesse (and bless the nurses who are good at these!!).

I can, however, give a few pointers (used to work in a Radiology Dept [X20yr], starting over 20 IVs a day, on all types of veins, for imaging studies):

**Take your time.**

Breathe.

*Try applying the tourniquet and mentally choosing one or two good veins, then let the tourniquet down while you get your supplies set up.

*Or, if you don't have a lot of supplies to set up, apply the tourniquet, ready your supplies, and eyeball the potential veins.

*Either SIT yourself down, with your supplies in easy reach (not tilted on a pillow, so they may fall), or raise the bed to a comfortable height, so you're not stooping or stretching. Put your supplies in easy reach.

*If I'm not sure if I want a particular vein, sometimes wiping it several times w/alcohol makes it stand up/out more (it's not the wiping, I think it's getting the skin wet that makes it look more defined. Just MHO)

*I prefer to use 20g, if the vein is large enough for it. 22g, being smaller and wimpier, requires sl. more handling finesse.

*VERY IMPORTANT to anchor the vein just DISTAL to where you'll stick. Hold the extremity with your nondominant hand, and with your thumb, pull on the skin just below where you intend to stick, to make the vein secure. Do not let up till after the initial stick, flashback and threading of the unit so you know it's well in the vein.

*When you see blood in the flash chamber, advance just a teeny bit more (to engage the cannula, not just the needle tip, in the vein). Then advance the cannula over the needle. This should not cause the pt extreme pain, and you should not meet with resistance. If pain or resistance occur, the IV is probably not in the vein. You may redirect or abort that site and begin again (been there, done that, got GOBS of T-shirts!!).

*Once the cannula is advanced into the vein, THEN let up your traction and use both hands to secure the cannula, flush it or attach the IV tubing.

One day a NICU nurse gave me a helpful hint. When the pt's veins don't pop up, even with the tourniquet properly applied: "I just aim for the blue streak, and I hit it nearly all the time," she said.

Also, I have found that the veins on the inner forearm are the most still and straightest (therefore the EASIEST to hit!), plus when the IV is in and secured, it tends to stay good longer, as it's not on the outer wrist or AC or someplace where it encounters a lot of movement.

That said, those are the veins that often require the "aim for the blue streak" technique.

Start shallow and go mm by mm (sometimes they're shallower than you realize, and you don't want to over-shoot).

With time and practice you'll be skilled enough to go through the skin quickly (for less pain) but then slowly enough to hit the vein without going through it.

Any chance you could shadow the IV nurse for a day or two?

Or shadow another nurse when they have to start IVs, to get their tips/techniques?

Or spend a day or two in Radiology (CT or Nuc Med), where a lot of IVs are started?

Good luck! You CAN do this. :)

Ahhphoey · Jan 14, 2008

Like others said, it takes practice. I actually volunteered to start my co-workers IVs or draw their blood so that I could practice venipuncture. I'm fairly good, but honestly it depends on the day. Some days I'll get every IV and blood draw I try. Other days I couldn't hit a garden hose...not sure why this happens though. Always remember though not to continuously try on the same patient if you can't get it after the second try. My limit, and hospital policy is two tries before getting someone else to try and developing another solution (i.e. PICC, central line, etc.). We once had a lady in our ICU who looked like she was wearing a purple glove with the fingers cut off...that how bad her bruising was after numrous nurses stuck her numerous times to try to start an IV. The bruise extended from her knuckles up to her elbow as one big continuous bruise. I believe she was on anticoagulants, so she bleed very easily and bruised even easier. Very sad, and actually embarrasing for her family to see that bruise and hear the reason it happened.

kmoonshine, RN · Jan 14, 2008

here are some iv tips (assuming that you are not drawing labs from the iv start):

for older people: tie the tourniquet lightly, or don't even use it at all
apply the tourniquet, let the arm hang down, and aggitate the vein using an alcohol wipe to help the vein stand upright.
don't smack the skin trying to get veins to stand up! i find that rubbing the vein with two fingers works well, or gently pat the veins with the tips of the fingers.
try to use sites other than the hand (i rarely use the hand). i usually go for the forearm; these veins are deeper, but if i get the tourniquet on tight, rub with alcohol, and push/feel, i can usually find something. and avoid the ac. however, if you get a patient who has no history of serious health problems (ie renal disease) and they have a great ac, try it - it will give you "the feel" of placing a successful iv.
go at a shallow angle and hold the skin tight; don't let go until you place the iv (if you get a flash and then stop holding the skin taut, the iv will most likely get moved out of the vein.
if you can't see any veins, feel for them; they should feel bouncy (practice feeling for them on yourself or a friend) .
practice, practice, practice
there is a really nice big vein on the underside of the forearm. it is a wonderful site because no one uses it! you pretty much have to squat on the floor to get underneath the arm to place the iv, but it is a great site!
be patient; spend time looking, feeling, and consider appropriate placement for the patient's condition (for example, don't go ac if the person needs fluids/abx 24/7).

it just takes time to get better with iv starts. i'm in the ed and when i first started working there, i sucked at iv's. but, you just keep on practicing and practicing. i now love putting in iv's; i love it when we get a patient that no one can get a line in (for me it is such a rush to get a line in). i now feel comfortable putting in iv's anywhere if needed (i've done fingers, feet, upper arms; 14g trauma lines; i'm getting such a rush thinking about it! but, know your hospital policies).

also, everyone is so against placing 18g iv's; some people think they hurt more. however, it's not the size of the needle, it's the technique used by the nurse that matters. hands, wrist, fingers - they hurt. they teach you in nursing school that an 18g iv is torture; it's not. a nice vein in the forearm can easily handle an 18g iv. i notice no patient difference in pain response when i place an 18g vs. a 22g iv (actually, i think 18g iv's seem to hurt less). i try to place 18g iv's in most of my patients and here's why:

1. 18g iv's don't bend like 22g iv's

2. 18g iv's can administer meds/fluids faster (something to consider depending on what department you work in; being in the ed, i will put 18g iv's in nearly everyone because blood draws are less likely to hemolyze and 18g iv's can handle lots of fluids/blood transfusion).

3. some people have very thick skin and only an 18g needle will work. you don't know how thick their skin is until you puncture it (and a 22g iv won't hold up...).

4. 18g iv's can handle iv contrast dye for ct. a 22g in the hand most likely won't.

for me, starting an iv is one continuous smooth motion. everyone has their own technique. is there anyone you can practice on? i used to practice on my husband at home! bless his heart...

here's some great info from bd's webside, with videos (i used to watch the angiocath video alot):

http://www.bd.com/safety/products/infusion/index.asp

here's some iv start tips: http://enw.org/ivstarts.htm

also, walk into the room with confidence; say "i'm here to start your iv". you gotta believe it to succeed. being good at iv starts won't come overnight.

*side note: please use chloraprep swabs to disinfect the skin! i use alcohol wipes to visualize the veins and to remove oil from the skin so the tape sticks better; i then sterilize the site with chloraprep swabs because chloraprep swabs clean the skin so much better when compared to alcohol alone. and don't use tape under tegaderm unless you want the patient to get an infection.

getoverit, BSN, RN, EMT-P · Jan 14, 2008

There are lots of great advice posted above. Sometimes you'll miss the easy ones and hit the ones that are just "anatomical sticks" (you can't see or feel it but you know it has to be around there somewhere). I"m one of the lucky ones and my success rate is probably close to 95%, every few months I run into someone I can't access with one needle. (having said that I"ll probably miss the next 10!!)

Anchoring the skin distally is important, advancing the needle just a mm or 2 after flashback to engage the catheter in the lumen of the vein, only using a tourniquet when you need it (I use it

My best advice for starting IV is to stick the one that you feel best about. That may sound too obvious, but what I mean is don't let someone talk you into sticking the one that they like best, look at all your options and keep in mind that you want to get in and out with only one stick. Sometimes the deeper veins are anchored better and the ones that look like ropes will blow more quickly. Develop your own technique of assessing your options and discovering which veins you have the best success with.

Hope this helps and remember that the best IV stickers miss 'em too!

allnurses Guide · Jan 14, 2008

Try to use sites other than the hand (I rarely use the hand). I usually go for the forearm; these veins are deeper, but if I get the tourniquet on tight, rub with alcohol, and push/feel, I can usually find something. And avoid the AC. However, if you get a patient who has no history of serious health problems (ie renal disease) and they have a great AC, try it - it will give you "the feel" of placing a successful IV.

Why is that? That you shouldn't use the AC on someone with serious health problems or renal disease? Is it just because the AC may need to be used for multiple lab draws, or in an emergency situation?

I dislike using the AC for that reason; that many times it is needed for morning lab draws. Also of course, patients bend their AC and then... BEEP BEEP BEEP!!!!! =)

pink2blue1 · Jan 14, 2008

Starting IV's was my biggest fear as a new nurse. So what I did was told every nurse who needed an IV started that I wanted to do it. This was an easy thing to do while I was precepting. I just kept doing them over and over and now I have gotten pretty good. I am an LVN and had to take an IV therapy/blood withdrawal class to get IV certified. That helped, but the people in class that I was sticking were all healthy and had nice veins. I've been a nurse for a year and now people come to me to start IV's. If you only knew how FEARFUL I was in the beginning! LOL! Now I love doing them.

But like someone else said, we all have our strengths and weaknesses. The nurse who precepted me, 30 years experience, is a genius with tubes of any kind (Foleys, NG's) but can't do IV's to save her life. So we trade off ;-)

kmoonshine, RN · Jan 15, 2008

Why is that? That you shouldn't use the AC on someone with serious health problems or renal disease? Is it just because the AC may need to be used for multiple lab draws, or in an emergency situation?

I will use the AC on a renal patient if that is all they have (and after trying a different site distal to the AC). You want to "save" the veins that these patients have left. Same goes for patients with other chronic illnesses, such as sickle cell, cystic fibrosis, or patients receiving chemo. (For example, I had a sickle cell patient in the ED who needed an IV. She was a very hard IV start - she said that at her last hospital stay they poked her 8 times! If that wasn't bad enough, she also said that the IV site blew 3 times during her admit stay. I took a long time assessing what sites I could use and I placed a 24g CIV in her wrist/forearm, saving her from multiple pokes. It delivered the pain meds she needed and worked fine for administering fluids).

However, using the AC totally varies by patient condition. If I have a septic dialysis patient who has a blood pressure in the toilet, I'd go AC if there wasn't an obvious site in the hand/forearm. But if I had a dialysis patient who had nausea and all they needed was zofran and fluids, I'd put a small gauge in the finger long before I'd go AC.

Basically, don't go AC if the patient has good veins in the forearm/hand. But if the patient is crashing, go for the AC (which is why we should save the AC - so it can be accessed when there is an emergency). Also, the AC is fine for a normally "healthy" patient (those patients who have had few, if any, IV's in the past).

MikeyBSN · Jan 15, 2008

Just make the ER nurse do it before the pt comes up, or call one if it infiltrates. That appears to be the unwritten practice in my hospital.