IV help: specific questions about insertion site and advancing

[vampireslayer]

I am a new nurse having terrible problems starting IVs! Please don't just direct me to search this site for info, I have spent hours reading all the IV Tips & Tricks pages (all 15!) here on Allnurses, as well as following all the links posted in that thread and any other sites that I can find. I have a handle on the theory, it's just in practice, I can't seem to get it.

I started out my first experience on the floor (ER in a big busy hospital!) missing most of my IVs for several weeks...finally I started getting about 90% of them, (I still don't know what I did differently) then all of a sudden, I'm back to missing 90%!

So I have specific questions:

1. Often I'll go into the skin, and at some point (sometimes before I get flash, sometimes after) I'll end up seeing a nice big bleb of blood under the skin start to appear...have I gone THROUGH the vein? Or is that what it means when "the vein blows"?

2. What exactly DOES it mean to "blow a vein"? I see that phrase all the time, but don't know what it means!

3. OFTEN, most of the time, I'll get a flash, but the catheter won't advance. Yes, I KNOW, most people have told me to get flash, go in a little bit MORE, then advance the catheter. I TRY, I really do...but there are so many times when I just can't get that catheter to advance...so I'll go in a little more, try to advance, then more, etc etc...then I end up with that big bubble of subq blood appearing. I HAD FLASH, I KNOW I was in...why won't' it advance?

4. What if I can see or feel a small a portion of nice spongy, elastic vein...do I insert the needle at that point, and assume that the catheter, when it is threaded off, will just follow the vein wherever it happens to go...(even if it turns?) or do I insert well below that visible part, hoping to enter the vein at that point that I can actually see/feel the vein? Is that clear? I mean, is that visible part of the vein the place where I want the catheter to END, once it's fully advanced? Or is that the place to start?

5. And finally, could speed of advancing the catheter have anything to do with my problem of not getting it to advance? My preceptor goes SO FAST, he gets flash, and BOOM he advances very quickly and it's done. I am so nervous, I know I advance very slowly (praying all the while that it'll go in!)...if I really am in the vein, but maybe my angle is off so I'm not perfectly pointing in the direction that the vein is running, would it help the catheter to follow the vein by advancing quickly? Or is that just totally unrelated?

Thanks for any advice...please believe me, I have read for HOURS on this site and others, about finding veins, techniques for all of this...I can find them, but I just can't seem to get them in successfully!

VS

[jadelpn, LPN, EMT-B]

Positioning is huge. I am not a huge fan of AC's only because it is a pain for the patient in an IV that needs to be left in. But in an emergency, you go for what you get. The forearm is a big juicy vein area. But you have to learn to feel for them, as opposed to seeing them. The hand is the land of the collapse-able veins. Not being able to advance has most to do with positioning, and/or thicker skin that the vein is rolling away or you are chasing it. Do not be afraid of holding the underside of the arm to anchor the vein. Do not be afraid to really have the arm out and down. If you feel like it is not advancing pull back a tad, get that skin slightly taut, and advance again. I like to have the forearm really hanging down. It makes it easier. And if you have to get an IV in the ac, the elbow needs to be out straight. If not, you will go through the vein. Hope this helps!!

[itsnowornever, BSN, RN]

In the ER I was just at AC was the norm...never know what you will use it for, so that's where they wanted it...and lemme tell you, the more "blind" the stick, the easier they are to get. If you know they are there, go for it. Don't go too slowly though, it HURTS. Having someone leaning over your shoulder to watch you is scary too, so just go into a zone. I get everything where I need it, have someone else distract the patient and zone out...it becomes just me, my needle and a vein. I say, "BIG STICK!" and go for it....I dont like hands since they tend to collapse often, and honestly, blind sticks are fatter veins and will be able to handle a newbie stabbing them better. It's a skill. Sometimes you have off days, other days you are a floors saving grace because you get them all.

[itsnowornever, BSN, RN]

Just wanted to add---it helps to know the equipment you are working with too. Find an IV start kit where you are working and open it and really inspect it. Is it hard to pop the catheter off the needle? Is it an easy one handed manipulation? I do my IVs two handed...one hand pokes, gets the flash, advances a little, the other hand glides the catheter in that way I can maneuver however I need it.

[sauconyrunner]

nurseliane said:

Looks like I'm reviving an old thread. I am a new nurse and could have written this original post. I can find a vein with no problem. I can get a flash with no problem. Then I blow it with no problem. Every single time! Or I almost blow it but stop because I just cannot advance the catheter. So frustrating. I work in L&D and feel more confident with neonatal resuscitations than I do with simple IV starts. Unfortunately, I only have an opportunity to try about once a week, sometimes way less than that.

Thank you to those who already responded. I will keep at it and envision myself as a resource person for other nurses who are having trouble with sticks!

Have you thought about asking your manager if you could spend about 4 hours in the Pre-op area for one day? I'd say the ED, but the ED is unpredictable. You may be doing something that is causing the veins to blow...but unless you get to try try and try again, it's going to be hard to see what it is. Plus, I imagine now each time that moment comes to start a line, you get the jitters. Once you get it, you'll have it forever!

[turnforthenurse, MSN, NP]

zambezi said:

I also have better luck with a 20g or bigger (usually I go with a 20 though)...it seems that whenever I go out the the floors to start and IV after multiple attempts by others, they have been using 22 or 24 g caths...

I can usually get the IV with a 20g first attempt...I find that when I use a 22 or smaller, I have a more difficult time too- they are just to bendy or something...I figure that 1 stick with a 20g is better than 2 or more with a smaller gage.

Funny, because I seem to have better luck with a 22g or 24g, unless the patient literally has garden hoses for veins. There is something about the 20g IV caths that are difficult for me...I think it's the way the catheters are. At my old job we had the IVs with the button that retracts the needle. The ones we have at m current job slide, and I find them to be very cheap. I had much better luck starting a 20g with the Spring-loaded caths than the ones I am currently using!

[wishiwereanurse, BSN, RN]

I used to have a lot of problems with 20g Nexiva caths, and had poor IV insertion skills for more than a year after I became an RN just because I was afraid of hurting people. But with all the advice given here and at work, what I did first was stop mimicking other nurses and realize that I must develop my own style. Trained myself to start IV while wearing gloves (all my mentors did not wear gloves when inserting IVs), closed my eyes when trying to feel veins on a dummy or on my own just to heighten my sense of palpation, start with 22g or 24 g needles as much as possible especially with elderly who get saline locked only. Conquered my fears on 20g caths by opening one and (with needle retracted and removed) feel how stiff/bendable the cannula is, how sharp the cannula tip feels, and placing it on top of my hand to see how far the cannula will thread. For some reason I had better luck inserting 18g, 22g, 24g caths than the 20g and had also thought maybe it was the catheter and not me. Nowadays I am a to-go person for IVs, another proof that the saying 'practice makes perfect' is so true.