I need HELP!! with IV starts

Canan · Feb 11, 2006

It's going to work out, don't worry!

Bets · Feb 18, 2006

Make sure you anchor the vein you are going to use. Use the thumb of the opposite hand to gently press & pull back slightly. I've had luck with this technique unless you get a 'roller'.

NephroBSN, BSN, RN · Feb 19, 2006

I find that IV starts are the most frustrating thing that I've ever had to do in nursing, perhaps the most frustrating thing I've ever had to do in my life. I could be, and very likely am, the worst of the worst, the baddest of the bad, at doing IV starts.
You could give me a juicy vein and I could miss it or blow it. You could give me the most cooperative patients, the best lighting, the narrowest needle and a bedside coach and I could still manage to screw it up.
I know basically what I'm supposed to do, and the procedure to do it and well, I could explain it to someone else so that they could give it a try, but hell could freeze over before I could get an IV start.
On the bright side, I'm really good at keeping IV sites. I watch that tubing like a hawk and snatch it up before it snags. I've contorted my patients into pretzels just to keep the lines flowing.
I know it's probably already been discussed ad nauseum, but could anyone help me out? What I need is a straight forward approach, that not only sounds good, but actually works. I mean I'm getting nada here.

Are you going for a vein you can see or feel?

I'll tell you the veins you can see aren't necessarily the best ones. I've stuck people where no one else "saw" a vein.

I'm gonna give you a hint and then run like he** and hide.

Go for the anticub.. I know I know other nurses will hate you. It's an armboard stick most times. But it's usually adequate, but not thick and tough or ropey as we sometimes say. Those big fat vein are usually tough walled with resistance and you go right through them and blow them. Get used to the "pop" feeling when you get into the vein. Don't go too steep.

What you need is sucess to bolster your confidence. I worked with a new nurse that would never try an IV . I made her. I told her go for the anticub. Ever notice that's the one the Paramedics and the ER nurses use the most.. They know something. They can't afford to miss.

So go for the anticub, be successful and then move onto other sites.

And for all the anchoring. I never do it. I think it makes the vein "roll" and the tauntness causes resistance and going "through and through"

As very snug tourniquet is necessary too. Don't cut off the circulation but pop that vein up so you can feel it.

Remember feel is usually better than sight.

thumperRN · Feb 19, 2006

Something that has made me successful is using a blood pressure cuff rather than a tourniquet. Just pump it up to 100, the veins come up and they don't blow as easily when the needle goes in. Has worked great for me - in fact, since a colleague shared this technique with me I can't remember the last time I used a tourniquet.

NephroBSN, BSN, RN · Feb 19, 2006

Something that has made me successful is using a blood pressure cuff rather than a tourniquet. Just pump it up to 100, the veins come up and they don't blow as easily when the needle goes in. Has worked great for me - in fact, since a colleague shared this technique with me I can't remember the last time I used a tourniquet.

Yep you are right I forgot about that little trick..

karnavati · Feb 19, 2006

hi all,

I am a new nurse too .but I think IV starting comes with the practice and more you do more you get comfirtable with.I never hurd of using BP cuff inatead of turniquette. ..but sounds like a good trick.

One more question as we are talking about IV's : I am doing my BSN and my topic of research is :

IS there a difference in the number of intravenous attempts in patients who are served by a dedicated IV team compared to patients who are not served by a dedicated iv team?

I have been trying to find an article or reserch paper about this but all I am finding is Iv sticks to the nurses or health care workers , if somebody in the Iv team or come across some related articles please send it to me I would appriciate it.

karnavati.

LPN2RNdude · Feb 20, 2006

dont feel bad, ive been starting IVs for some time now..... today i had a patient with wonderful veins (so i thought) and every time i would advance the IV after getting flashback, the vein would blow. even worse, i knew the family well, who happened to be at the bedside. after a co-worker tried several times, we finally called anesthesia. he got it on the first stick...... some days you can hit a thread, and other days you cant even hit a telephone pole.... itll come sooner or later:)

PICC ACE · Feb 26, 2006

Try the link www.nova.edu/~stmartin/IV/IVTherapyPrintout.html for a nice review and plenty of tips and suggestions.

IV starts,like all skills,take time to master. There seems to be an aura of mystique around IV skills,and too many nurses (new ones especially) equate being a good IV sticker with being a good nurse. It ain't so! I'm sure we all know plenty of excellent nurses that aren't so good with IV's. One aspect of being a good nurse is empathy,and imagining what it feels like on the other end of the needle,from the patient's perspective,is important. Imagine being miserable,sick,away from your family AND being stuck like a pin cushion. Not a pleasant experience.

My advice--know your abilities and know your limits,and consider your patient's situation. If you ever evaluate a patient and doubt that you'd be easily successful,there's no shame in passing and getting someone better than you. If you let the patient know that you want to find the best person to provide their care,that says much more about your nursing abilities than do IV skills.

A few PS's: Please leave the antecubital fossa veins for us (PICC'ers/phlebotomists).

For Karnavati--Do some Googling and you'll find a few studies. Dedicated PICC teams are correlated with a decreased incidence of central line complications and IV teams have higher success rates,lower costs and lower phlebitis rates in PIV's.

mstigerlily · Feb 27, 2006

Advancing the cath? If there's one step that's the problem, you can focus on that one.

I am pretty good at finding veins and getting the flash, but when I advance the flash either disappears or the vein blows or rolls. I think I've got the angle wrong. I see some people do it and they look like they are pulling the vein right up out of the skin when they are advancing and it looks painful but they get the IV start and I don't.

vamedic4, EMT-P · Mar 15, 2006

You can get better, but for some it takes more practice. If you need to spend a week in pre-op, then do so.............is there actually an IV nurse in your facility that you can spend some time with?

I agree with Suzanne here...practice practice practice is what it's going to take. When I first became a medic I couldn't hit water if I fell off a boat when it came to IVs. But I stuck with it (since it's an important skill after all).

Oh, and here are some tips for IV assessments ....(caffeine induced brainstorming at work here)...it's written for peds but I'm sure you'll get the point.

As I've started IVs here in Dallas for the better part of twelve years and probably over 1000 IVs, here's what I know.

1. If the baby's asleep and wakes when you flush the IV...it's probably bad.

2. If the left arm has an IV infusing and it's twice the size of the right arm (assuming no preexisting conditions)...it's probably bad. But check the TAPE JOB. Too tight on the tape will send an IV south very quickly.

3. If you're having trouble with an IV, break it down - take the tape off CAREFULLY and try to find out if the catheter is still in the vein - or in the skin for that matter. Sometimes over time the catheter can kink, especially with active children. Reflush, retape.

4. Flush your IVs frequently when establishing them. Both right when you hook up your tubing, and during the taping/securing process. You have no idea how strong little arms and hands can be and they can wiggle that catheter out of that vein like nobody's business.

5. During an attempt at an IV on a little one, the most important person in the room are the patients (*for obvious reasons) and the person HOLDING the baby still. An effective helper is the one who does ALL THE WORK and gets no credit. An ineffective helper is the one who doesn't hold on tight enough. You have to pretty well immobilize little ones - and that can be difficult. Swaddle the baby and leave out only the extremity you're working on, if possible.

6. CHECK YOUR IVs FREQUENTLY!! "It looked fine this morning but I didn't flush it..." Duh...and you graduated from nursing school??

7. Try your best not to "overtape" your site. It is a royal PITA to tear down all that tape 20 minutes / 2 days after you started it. Less is more...as long as it's secure.

8. Use a padded board to immobizilize the extremity. Tape securely but not tight enough to occlude circulation - it's easy to do (taping too tightly, that is).

9. Double side your tape for patients with sensitive skin (babies) / patients with tons of hair. In this instance, use your tape mostly on the skin directly around the insertion site, if you need it at all. We use a Tegaderm and silk tape for a chevron, if necessary.

10. Discretion is necessary when establishing an IV. Don't put a 24 gauge in a kid who's 10 years old, has great veins, and is gonna get gentamycin for a week. Use common sense. If he can tolerate a 22, or even a 20, give it to him.

11. Use whatever pre IV anesthetics your institution allows. We have cold spray and EMLA cream. Both work well, but be advised EMLA has a tendency to make veins disappear -and it gives the skin a "waxy" feel, which can make palpating a vein you found 1 hour earlier a very tricky ordeal.

12. IF THE SITE IS COLD, YOU'RE GONNA BE HARD PRESSED TO FIND AN IV. Warm the area up with a warm pack first if necessary. Cold extremities = no veins.

13. Start distally. Look for IVs in the patients hands before moving up the arm. Try to avoid the AC if at all possible, unless it's critical and you need fast access, or if the child just doesn't have anything else...it happens more often than you know.

14. Don't put an IV in a 16 year old girl's right hand IF SHE'S RIGHT HANDED unless you just can't find anything anywhere else. This goes for ALL children/ adults who are at the age where the dominant hand does most of the work. Also true of infants who suck "that thumb". Again, unless you have no other options.

15. DON'T EVER walk in and introduce yourself as the IV EXPERT. Kharma has a way of biting your ass. Let someone else build you up - that way your performance speaks for itself.

16. Be aware that some infusions, like Potassium, sting when infusing, especially to small veins. Antibiotics like gentamycin are caustic to veins as well. Keep this in mind when assessing your patient's response to therapy.

17. Look everywhere for the best access. A large vein in the saph is better than a small vein in the hand, at least for the purposes of the attempt. It's far easier to his a large target with a small needle than to push a catheter thru a tiny vein.

18. If your patient may require fast acting meds (Adenosine), establish an IV as close to the heart as possible. With infants and adults this can be a big deal, since there's maybe 12 inches the med has to travel, but with adults and older teens it becomes very important. When you've got a med with a half life of 12 seconds...it matters bigtime.

19. If you're going to be the one starting the IVs and you don't have much experience...practice on your coworkers before you come in and stick my child. Also, if you have the option - start small...work with the healthier kids before moving on to attempts on the truly sick ones. That way I don't have to worry about you blowing 2 veins I could have used for access.

20. Last but not least, know your limits!!! I can't stress this enough! If you stick twice and aren't successful - FIND SOMEONE ELSE. Preferably someone with more experience/ or someone you trust. Don't you dare get that whole attitude about " I'm going to get this IV, if I have to stick 5 times." You do that and I promise you some parent will kick your ***, and rightly so.

Don't let your pride get in the way. REMEMBER - YOU'RE THERE FOR THE PATIENT...not for your own personal "record".

This list is by no means exhaustive, but I'm tired and thinking isn't tops on my priority list right now. Have a great day.

vamedic4

Licensed Paramedic

Children's Medical Center Dallas

neneRN, BSN, RN · Mar 15, 2006

I know other nurses hate to see an IV in the AC, but I have to echo what NephroBSN advised; when you are STILL LEARNING, just go straight to the AC; its big and it doesn't move. When I started in the ER 5 years ago, this is the advice that a nurse gave me and it did me very well. Once you get a few successful lines in the AC, then move on to other veins; you'll have more confidence and a better feel about the whole process. We can give you all the tips/tricks in the world, but its all about PRACTICE.

TBLPN, LPN · May 20, 2006

When I first started in nursing, I was terrified of starting IVs. I didn't even want to attempt it. If one came up, I'd have another nurse do it, until the dreaded night I'm on shift by myself (I work LTC) and the IV running infiltrated and it was a necessity that it be restarted. I took a deep breath, remembered all the steps, and swore to myself I wasn't gonna freak out. I hit it, no problem. From then on, any chance I get to start an IV I do it. And in LTC you may go months without having an IV, then you may go months and that's all you have, IVs coming out your ears, which is the situation I'm in now. I've started/restarted so many IVs this month. I love it. It's one of my favorite things to do now. You will get better. You have to practice, it's a must.