IV help: specific questions about insertion site and advancing

  1. 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 wont' 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!

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    Joined: Sep '05; Posts: 74; Likes: 32


  3. by   neneRN
    1. Yes, you've gone through the vein and its blown. Occasionally, when this happens, you can still save the line by pulling back a little before you try to thread. If this works, the hematoma will stop growing larger and you'll be able to aspirate blood/flush easily. More often than not though, once you've blown the vein, IV's no good.

    2. When you blow the vein, this means you've created a hole, which allows the blood to leak out of the vein and into surrounding tissue, causing the bubble of blood you're seeing. Hold some pressure over the site to minimize further bleeding.

    3. Before you advance, drop the angle at which you're holding the catheter just a little. Otherwise, you're going to keep going through to the other side of the vein, blowing it. Once you're in the vein, you shouldn't feel any resistance when threading. If you do feel a resistance, pull back just a tad and change your angle. Sometimes when threading, you may get stuck against a valve. In that case, try floating the catheter in by removing the needle and gently flushing with your saline, which will push the valve out of your way.

    4. When you're palpating the vein, don't just stop once you've found a vein; continue feeling to see if the vein continues in a straight path. This way you can tell if the vein continues in a straight path long enough to accomodate your catheter. It also allows you to feel if the vein bifurcates. Start your catheter where you feel that nice bouncy vein, just make sure the vein continues along the path you're inserting for at least as long as the length of your catheter. Look at your own arm, i.e., your AC, to see what I'm talking about- you may SEE only a small portion of the vein, but you can generally feel a greater length of it than you can see.

    5. Your preceptor can probably do everything about inserting an IV fast, that comes with experience. Threading the catheter slowly is not going to hurt anything, in fact it may help as your main concern seems to be threading/blowing the vein. Doing it too quickly when you're just starting out may cause you to rush and push it through the vein.

    It all comes with experience. IV starts are more about getting the feel for it rather than book learning about it. You'll get it- especially in the ER, where you get to do it over and over.
  4. by   meownsmile
    All good tips,, and some i can use. But also remember, IV insertion is kind of like several other things, you can go a long time and hit all of them, even the hard ones noone else seems to be able to get, then as quick as the wind changes,, you have a cold spell and you cant get a successful stick for anything. But rest assured, the wind does change again.
  5. by   jeepgirl
    good tips. I have had problems getting my IV's started... it has gotten better. Big things include making sure that you decrease the angle after you get that flash and then advance in just a little bit and then thread. LOTS of times I have gotten resistance when threading... I HATE that! Sometimes I think you're just up against a valve because you have a perfect stick otherwise... you just can't advance. There have been times when this happens when I have been able to release the tourniquet for a second and then put it back on after a little bit and then get it threaded.
  6. by   Pete495
    I agree. You will have days where you might get all the IV's you can, then there will be days where you can't hit the broad side of a barn.

    Also, sometimes twisting the catheter into the patient helps it to go in, esp. if it is a thin vein and likely to roll. I've tried this technique a couple of times with good success, and although it takes extreme patience as it takes a while to twist it all the way in, it usually works.

    It's also important to remember that the toughest patients will require a couple of sticks probably even if they don't like it. I usually spend more time looking for a vein than I do actually putting it in, because like someone already said you want the straightest one possible, and the thickest possible in most cases.

    Don't worry about missing. we all have off and on days.

    GOOD LUCK!!!
  7. by   Aneroo
    Great points. You have days where you get the IV's, then the next day you're missing all of them. You were doing something right if you were getting them for a while! maybe your folks have crappy veins!
    I always try and go in there with the mentality "I am going to get this IV". When I go in the room, I tell them "I'm going to start your IV", not "I'm going to try". The patients can tell you are nervous (trust me- a patient told me "calm down" one time! )
    Sometimes lately I've had problems with hitting valves. I can't get the cath to advance. I get my flush, pop the needle, and try and flush it in. Almost always works! I can get blood later, the IV is more important to me.
    When all else fails, I say a quick word of prayer! I had to stick my first baby the other night (14mo girl), and was scared to death. I went in there with my "I'm going to do this first try" attitude, and got it! -Andrea
  8. by   Heather A.
    I'm a new nurse as well who has had major issues starting my IV's. Something my preceptor pointed out to me that has helped me IMMENSELY: insert my needle a little slower and watch for my flash. My preceptor noticed that I was inserting so quickly that by the time I noticed my flash, I was all the way through the vein and had blown it! I go in right on top of the vein at about a 30-45 degree angle just a little bit and wait/watch for my flash. If I don't get one, I advance a bit farther and watch for my flash. After I get a flash, I immediately stop advancing, drop my angle, and advance the needle just a bit farther. Then i thread my catheter. So far, this has been working well for me.
  9. by   hospicemom
    very good IV tips here!!!!!!

    Im a floater. I have my J loop connected to the cath...and once I get the flash, float the baby right in!!
  10. by   Cubby
    For about two years after I got out of school I was petrified about IVs-I looked for jobs where there would be the least amount of starting and maintaing IVs. Finally my dear husband said to me one day-"Junkies can start IVs" I got over my apprehension and started really trying-practice makes perfect (almost). If a junkie can do it-By God so can I. You will get there, I promise. Just don't quit.
  11. by   skipaway
    Quote from Heather A.
    After I get a flash, I immediately stop advancing, drop my angle, and advance the needle just a bit farther. Then i thread my catheter. So far, this has been working well for me.

    This is very important to do. If you look closely at the needle/catheter, you'll notice the needle is about 1-2mm farther out from the catheter; therefore, you'll get your flash before the catheter is even in the vein. If you start to try to thread your catheter before it's even in the vein, you'll have a tendancy to fail. Therefore, see the flash, lower the angle of the needle and advance that extra 1-2mm, then thread your catheter. Good luck.
  12. by   zambezi
    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.

    Also, I hate hand veins. I think they are uncomfortable for the patient, they get in the way, etc. I prefer a nice forearm vein- I try to go lower forearm first...but usually I go where I know that I can get the stick on the first try (don't forget to look on the inner aspect of the arm if there is nothing on the outer portion). Look at your own forearm or a picture to know where the different veins are located. If there is nothing to be found and I need an IV, i go AC (but try to start it a little lower than the bend of the arm so it dosen't occlude everytime the patient moves). I also use the upper arm on occassion-the vein is deeper but can hold a large gage.

    As for insertion, I usually don the tourniquet or bp cuff (which sometimes works better for those with delicate veins), search around and find my point of entry. Prep the site, anchor the vein (everything else is set up already)...I usually go with a fairly low angle of insertion otherwise I find that I blow the vein- especially if the vein is very prominent. If it is deeper, I will of course adjust the angle of insertion as I need to (something else that just comes with practice). Once I get into the vein (I usually do a fairly quick stab in), I advance just a little bit more after I have leveled out the angle. I undo my tourniquet and then advance the rest of the way (before I started undoing the tournquet prior to advancing, I found that I blew more veins).

    Last but not least- practice is what makes you better. Go in to the patients room with confidence. Don't be afraid to look at both arms, take your time looking for the right vein if need be. If the patient does use IV drugs or is a frequent patient- ask them where to (or where not to) start the IV. Some patients will just be more difficult than others. And some days you won't be able to hit the broadside of a barn...but after practice, all of that will even out. Everyone is going to have a system that works for them. I watch other RNs who start IVs totally different than I do but have good results too. When I first started with IVs, I was so scared that I would shake...but I made sure that I tried every IV I could. I also watched when others started...if there was another RN that I knew was a good start, I would watch them start a few and then try their technique to see if I liked it better. It took some time to find something that worked for me.
    Last edit by zambezi on Sep 4, '05
  13. by   nurseliane
    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!
  14. by   jadelpn
    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!!