I need HELP!! with IV starts

[Jasano]

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.

[Jasano]

You're absolutely right of course and I'm getting better at starting IVs now. HOWEVER, (and notice that 'however' is capitalized), I feel the CNO and other nursing bodies, which do not INSIST on the inclusion of this skill teaching at colleges and universities, are GROSSLY negligent in their duties as nursing bodies. Medicine teaches IV starts and so does paramedicine - why nursing is so afraid of things medical when it is right in the thick of it all is beyond me. Well, that off my chest, I believe I promised to give some tips if and when I got a clue, so here goes.

First, and this is absolutely important, you must be firmly planted and comfortable before you start. You may not think this is such an important step, but I cannot emphasize enough the importance - how do you think you'll hit a vein through stacks of tissue with a tiny needle, when you're jumping around as much as the patient is?

The standard tips are good of course - dangle the arm and apply heat - this will help you to visualize. I recommend the kind of lighting that hospitals don't provide - open a window curtain, turn on the overbed lights, hell even bring your own light. (Rocket Science has nothing on the subtleties of IV starts).

Relax yourself and your patient as much as possible with some banter; I always like to point out that three strikes and I'm out and I'll get someone better - this often calms patients who have heard horror stories of 6 or more pricks. I also point out the similarity to needles and most patients are able to cope with the thought of those at least.

First get all your supplies ready - tear off tape and apply it to the overbed table, open up your tegaderm or opsite or other brand name item, and leave it face up on the bed. Place the IV line as close to the patient's arm as possible. To keep it from moving, place a piece of tape over the line. Uncap the end of the line and stick it in something sterile - like the dressing package you just opened - now it's ready to go when you get the IV.

Always free the needle of the canula to be sure that it will advance into the vein when you need it to - rotate the canula back and forth a few times and use this moment to calm your nerves as well. If you rotate the cannula rythmically, you may be able to employ self hypnosis to some effect. :)

Apply the tourniquet - apply it less tightly if the veins were popping out at you to start with, more tightly if you think you may need ultrasound to find them - check circulation though, you don't want to make it too tight!

Approach as you would an airplane to a runway - keep your bevel up and come down at a low pitch - not a giant arc. (15 to 30 degrees is recommended, but I recommend you start at an even lower angle of approach - you can always dive as you work your way up the vein, but if you dive first, pulling up won't be an option). Anchor that vein! I mean hold the vein with one hand and try to flick it with the finger of the oposite hand. If the vein rolls back and forth, either anchor it more or keep looking.

In fact, intentionally feeling veins and attempting to roll them before you get started, will give you a much better idea of where to start. Tapping the veins helps, but you could just rub them vigorously with an alcohol pad.

Now, make your approach. If you don't get blood return, try angling slightly upward as you move your way up the vein. If you're at a high angle and aren't getting any blood, consider you may have missed or the vein rolled. Not a problem - often times you can leave the needle sit there under the skin and try to see whether or not you're in line. If you're off, readjust - if it's still under the skin, and there's no blood, and you haven't pulled it out, you're still on your first attempt! When you see blood flash back, advance the needle almost flush with the skin, just a touch and then move the cannula in as you move the needle back - remove tourniquet. Connect your IV tubing to the site and release the clamp that you ingeniously placed at the connecting end of the tubing close by. Dripping confirms insertion, so when you see it, take the clear dressing and place it over the insertion site to secure it.

Phew! I hate doing IVs and probably always will. The thing is though, I'm getting much better at it and so will you. If our nursing education had not become so anti-medical, then perhaps we would feel less stress about these procedures now, but what can you do? I wrote letters to the CNO and was completely ignored.. ditto for the educational institutions. Anyway, I recommend people take a course if that is still an option for them, in IV starts. You'll just feel a lot better about it than I did starting out. Don't be afraid to try - if you fail a couple of times, call it quits, but don't be afraid to try.

I hope if you're a newbie reading this, that you might gain some insight into the subtle art of starting IVs from this long diatribe. I certainly know how frustrating it can be for both nurse and patient.

Remember - you are an airplane coming in for a landing (just don't get carried away with the propeller noises like I sometimes do.)

[Natkat, BSN, MSN, RN]

If you don't get blood return, try angling slightly upward as you move your way up the vein. If you're at a high angle and aren't getting any blood, consider you may have missed or the vein rolled. Not a problem - often times you can leave the needle sit there under the skin and try to see whether or not you're in line. If you're off, readjust - if it's still under the skin, and there's no blood, and you haven't pulled it out, you're still on your first attempt!

I don't do IV's but I cannulate patients for dialysis regularly - bigger targets yet much larger needles - so I can relate to the issue of needing practice.

I want to reinforce what Jasano said about readjusting the needle once it's under the skin. I do this once in a while. Once the stick is over, I find I can move the needle around and the patient usually can't feel it. It's the initial stick that is painful. Once it's under the skin it's easier for the patient to deal with.

Now, I don't spend much time digging around looking for access if I can't find it. I give myself a few seconds to try and then call in refenforcements. Too much looking around will create a clot the blocks the needle.

I have found that over time I can feel the needle under the skin. Granted, I'm talking about .15-gauge needles and grafts the size of garden hoses. Still, I was surprised to find that over time my senses become more "aware" of what was happening and I could tell if the needle had made it through the graft or was sliding over the top. I never would have believed I could do that until one day I noticed it.

I remember learning to cannulate - hands trembling, knees knocking, sweat dripping from my forehead. It was very nerve-wracking to think I was going to actually stick a needle in someone. Now that I've done it a couple of hundred times, it feels routine. It just takes time and patience. In dialysis the patients are always in a hurry to get started and tend to rush the techs. I've learned to tune them out and focus on the business at hand. I don't let them rush me. I ignore them and take my time so I don't miss or risk doing a really bad stick that ends up infiltrating them later on.

Just give yourself time to get it. And at the risk of sounding like everyone else. there is no substitute for practice. You'll get there.

[sunny.shine]

become one with the vien , relax ask for help from a higher power..I go for God..pull skin up so its not too lose..but dont make it too taunt go shalloowneedle is very close to angle with skin..go in slowly ..its not a race ( if its pediatrics have a good holder)..once you get flashback ..pause then pull skin above Iv slightly more taunt..advance needle just a little bit more slowly..this is not a race then with fingernail start to thread off needle, once threaded pull needle out then put lslight prressure on site so youre not getting blood all over, hold catherther so it does not move hook up extention dry iv site with gauze put piece of tape to secure slowly start iv ..then come back an complete tape job ..always keep hold of the iv cathether so at this critical point it does not twist and pull out..stay out of your left brain..its really a right brain thing..let it flow! good luck! :Melody: :Melody:

[Jasano]

become one with the vien , relax ask for help from a higher power..I go for God..pull skin up so its not too lose..but dont make it too taunt go shalloowneedle is very close to angle with skin..go in slowly ..its not a race ( if its pediatrics have a good holder)..once you get flashback ..pause then pull skin above Iv slightly more taunt..advance needle just a little bit more slowly..this is not a race then with fingernail start to thread off needle, once threaded pull needle out then put lslight prressure on site so youre not getting blood all over, hold catherther so it does not move hook up extention dry iv site with gauze put piece of tape to secure slowly start iv ..then come back an complete tape job ..always keep hold of the iv cathether so at this critical point it does not twist and pull out..stay out of your left brain..its really a right brain thing..let it flow! good luck! :Melody: :Melody:

I agree with the posters who say: practice, practice, practice, BUT, that is not to say that the classroom has nothing to offer. Putting in IV's is a complicated process, where plenty can go wrong. It is best to get the basic mechanics and idea down in a classroom, before you go hunting for veins.

Here's another tip that might help in starting ivs. Have you ever noticed that when you apply pressure to that juicy vein, that you lose all sight of it? Try marking the vein with the needle tip, by just knicking the surface of the skin before you pull it taut. (Do not draw blood here - i'm talking about a surface knick only - this should drag up a little bit of skin marking your position). Then, when you do apply pressure, you'll see the tiny mark you made and know where the vein is.

I like what you said about it not being a race - this is where a number of beginners go wrong - they see the flash back, get all excited, and forget to advance, advance at too sharp an angle, or too far. Since i've only fairly recently caught on to the whole iv thing, I can tell you newbies out there that this tip is gold. A higher power might help too, though you'd have to have established lines of communication. :)

[MUSKOKA MEDICS]

hey, sounds like you need a confidence boost. i would recommend you spending a few days in day surgery where you are going to see many patients in a short time period, and be around nurses who start IVs all the time. everyone has their own tricks.

when i am teaching, i always urge nurses/paramedics to take the extra time when selecting a vein, if you rush it, and you are not confident, you will blow it. tap the vein, warm it up, drop the hand, make sure tourniquet is tight.

when you approach the vein make sure you have secured it so it does not roll. if you are starting iv with your right hand, use your left to anchor the vein. when starting the iv, how you hold the catheter is extremely important. i use ProtectIV and BD catheters. i hold the catheter with my thumb and third finger. i use my first two fingers to anchor or lean my hand on the patients hand to steady my catheter, i keep my fourth finger on the push off tab and use it to "direct" or steer the catheter in the right direction.

i always teach that going into the skin is the hardest because skin is either thin, frail, stretchy, or firm, rough and sometimes really tough. guaging the pressure you use to go through the skin comes with experience.

here is what i teach our medics: skin/vein entry is one step, then you see flashback, so advance a little, then push off the catheter and retract the stylette.

it works like minute rice every time!

the other thing you can do is shadow someone who is really good and watch their technique first.

and lastly, be confident, when you approach the patient, say "I am here to start your IV".

i cringe when i hear the medics say "I am going to try your IV" there is no guarantee of success in trying. anyone can try, you want to DO.

hope this helps

[MUSKOKA MEDICS]

in addition, manikin work is really valuable especially if you have the ones with fake blood

you can see flashback and you can see when you are in

i start my paramedics on skin pads, then they move to hands, then to the IV arm simulator

once they get all that, they start them on each other in class so that they get their hands on real people before they get to clinical

if you can get a great instructor to help you, the hands and arms are really valuable.