Bad "sticker" needs help

Indy, LPN, LVN · Sep 25, 2005

Please don't kiss me, I'm not a good stick either. But I'll pass on what I've been told.

Release tourniquet when you have flashback and before you nudge the cannula off the needle a little. This is supposed to resore flow and help the valves to open up, decreasing your chance of blowing the vein due to a stubborn valve.

Size of catheter depends on why you have to have an IV/INT in, in the first place. If they're having surgery or some procedure, find out what that department wants you to put in, and try for that. I like 22's best of all, seems to fit better- I sometimes need 20's though.

How deep/what angle is hard to explain. I don't learn stuff like that by reading about it, unfortunately for my patients I'm learning to flatten the angle by trying, failing, and trying again. I used to do phlebotomy and absolutely hate the thought of "fishing" once I have punctured the skin, but sometimes it takes fishing to get IN the vein. Sometimes my flat angle of entry is nice until the Big Guy Vein decides to go away, and I have to dig in and go get it.

The blood pressure cuff is supposed to be more gentle on the skin of elderly people than the little hard-ish tourniquet, and cause less skin irritation. It's ok to use as long as you aren't pumping it up too high or leaving it too long, don't wanna trade less skin irritation for big nasty bruising on the upper arm.

But really, you need to practice a lot and you'll eventually have a run of good luck (along with improved technique) that will boost your confidence.

KatieBell · Sep 25, 2005

I'm a good sticker.

I think the best way to get good at it is to practice.

And, to take your time. really examine the areas you can stick on the patient.

As Indy points out, you really have to consider what is happening for the patient. 22g ivs are good for maintainence fluids, but they are not useful for surgery, ct scans, fluid resuscitation, etc. (for transplant preps we are "required" to put in a 16g), where you go also has a lot to do with the procedure involved. There isn't much point in sticking a patient with the wrong iv and having to do it all over because of that.

Ask if you can either go to the lab or to the pre-surgery area for a morning and work only on IV sticks and blood draws. You will probably improve quite a bit in just one morning. It sort of takes a while to get used to the feel of it.

Good Luck

Kristen_RN · Sep 26, 2005

I agree with Katie. I'm a good sticker. I've been working in the ER now for over a year (but as a nurse for 3 months). Practice, practice, practice. I got the hang of it pretty quickly, but then again, I stick 10-15 people a day. My favorite location is the AC, then the FA, then the hand. I know that the AC is tough on the patient b/c they have a hard time bending their arm, but I still like it. For older people, I double tournicate them: one above the elbow, then one above where I'm going to stick. We don't use butterfly's in the ER. I almost always stick with a 20, sometimes an 18, and very rarely a 22. Angle does have a lot to do with it. I like to go in at a flat angle as well. If you can feel the vein, but not see it, then you know it's deep, and you may want to go in at more of an angle. Now, about the releasing the tournicate. If I am drawing blood, I don't release the tournicate until I've collected all my blood. If I'm not collecting blood, then I release after I've advanced the catheter and retracted the needle. Hope this helps, and keep up the practice!

Daytonite, BSN, RN · Sep 27, 2005

I've been an IV therapist for 6 years. Here's the best advice I think I can give you to get you started with being a better sticker. Think of the vein you want to harpoon as a tube. You are entering the tube with a rigid needle and cannula at some kind of an angle. However, your goal is to get the tip of that needle into the tube of the vein and advance it a couple of millimeters more before removing the stylet. So, once you've harpooned the vein you need to lower the needle so it is more parallel with the tube of the vein so when you advance your needle it is not going to puncture through the other side of the vein.

You have to anchor the vein you are going to stick. Use your thumb to put some downward pull on the vein. That straightens it up a bit and also anchors and stabilizes it better. Try to stick the vein from the side rather than going straight down over and downward into it. Don't release your tourniquet until you know you are in the vein, for sure, and you have been able to advance the needle and cannula and are still getting a blood return in the flash chamber. For beginners use 22g needles (or 24g if you have 'em). They are easier to maneuver. When you get someone with a good garden hose (I mean you can see that sucker from across the room), try a 20g or larger. You might also try pulling up a chair and sitting down when you do you IV starting. It will help you relax and focus on what you are doing.

It takes many, many, many, many sticks to become competent at starting IVs. There are a lot of little nuances to it. Check out the thread "IV tips and tricks" in the Emergency Nursing Forum:

https://allnurses.com/forums/showthread.php?t=3793&highlight=Tips+Tricks started some time ago. Happy sticking! It took me 6 months of IV practice as a new grad before I began to feel like I knew what I was doing with IV insertion.

ZASHAGALKA, RN · Sep 27, 2005

I had no IV skills when I started out. My first employer asked me how good my skills were and I said "don't know, haven't tried".

Well.

I did all the sticks on my 40 bed unit for 4 months straight. No matter how difficult, nobody was allowed to try until I had tried twice or it was an emergency.

I missed 40 times straight at one point.

But now I'm a good stick, A resource starter for my hospital.

Practice, Practice, Practice. Don't pass up opportunities. Don't go get help until you've tried twice. No matter how difficult. Don't cringe at the opportunities. How else are you going to get good at it?

Learn to start both by feel and sight. I find the vein by feel BEFORE I put on gloves. If you can only start by sight, you are at a huge disadvantage.

Unless it's a child, avoid a 22g like the plague. It is simply not an adult catheter. They don't last as long, they aren't stable enough to site properly on an adult, and they are useless in an emergency. Using a 22g in an adult is cheating. (I know some will disagree with me on this, but I stand by it. You can't give blood through a 22g, and you can't give bolus fluids, if needed - they aren't large enough. And they don't last - they blow veins because the smaller the lumen, the more pressure you are using to flow fluids into the vein at that site.)

Because I was banned from using 22g in adults when I was learning the skill, I find it much easier to place a 20g than a 22g, no matter how small the vein. 20g and 18g are more stable. If you only practice on 22g, you will never learn how to start 'real' IVs.

Learn to use 18g PIVs. If it's a big vein, try an 18g first. It is my experience that 16g for OR/Trauma/Need to give fluids very fast, 18g are the preferred size, and 20g are for difficult veins. 22g are for children only.

~faith,

Timothy.

Daytonite, BSN, RN · Sep 27, 2005

You know what? The last poster (ZASHAGALKA) is right about the size of the needles you should use. Our IV Team also instructed med students and the radiology techs in CAT scan and in nuclear med. We told the nervous people to use 22g. People seem to feel more at ease with a smaller gauge needle. It might be due to a fear of sticking and hurting someone. The fact is that everything ZASHAGALKA said is correct. A 22g needle isn't worth squat when you have to give blood or the patient codes and you have to bolus life-saving medications. Most anesthesiologists won't use anything smaller than an 18g needle and the paramedics will use 14g and 16g. We actually reserved the 24g needles for the babies and small children. A person who is proficient in inserting IVs by feeling for veins is worth their weight in gold. I think, perhaps that ZASHAGALKA and I are in a small majority. I wanted to get good at doing IVs and so I took every opportunity to start them. I also read everything I could find on starting and maintaining IVs. That is really how you will learn. However, I do believe that the majority of floor nurses don't have the same passion for IVs that some do, so for them, a 22g needle is going to work. It is also a little more comfortable for the patient (the sticking part). It is a good idea to know a little about the patient before restarting an IV. If the patient is a potential candidate for the OR, coding or a blood transfusion, I'd go with an 18g needle without hesitation.

nurscee · Sep 28, 2005

Hey these are great tips!

Just one question. Today I stuck two people. I came in from the side and got in! Yea! Got a flash, a beauuuuuutiful flash,,,,then blow!!!

Do you turn the direction of the needle after you come in from the side? I don't know if I went all the way through. But I just couldn't tell once I was in where the vein was. Thanks. Nurscee

Daytonite, BSN, RN · Sep 28, 2005

You have to remember to think of the vein as a tube. You are inserting a rigid, straight needle into a flexible tube. Your goal is to slide that needle into the lumen of the vein before removing the stylet. You have to know where that vein lies and in what direction it is going before you stick. Use your fingers to trace the path of the vein above where you want to stick. Once you've accomplished the actual puncture of the vein you need to make two adjustments with the needle. First, you need to get the needle in the same exact parallel direction the vein is going away from you. Second, is to lower the needle and cannula so it is nearly flat to the patient's skin. Your goal is to slide that needle and cannula up into the lumen and seat it there before removing the stylet. These moves depend a bit on your intuition because, in essence, you are doing them blindly (you cannot directly see what is happening under the skin).

Veins "blow" for two reasons: (1) you've gotten into the vein and then gone out of it by puncturing through the opposite wall, or (2) you only had the tip of the needle in the vein, not the cannula, so when you removed the stylet, the cannula was still sitting outside the vein. It is the hole you created with the stylet that bleeds forming the "blow" (hematoma).

I learned after many sticks that this "enter the vein at a 45 degree angle" was not exactly correct and didn't work UNLESS you immediately decrease that angle as soon as you are under the skin. Picture, for a minute, a horizontal line on a piece of paper and draw another line coming in to intersect it at a 45 degree angle. You have to be pretty accurate to get the line that is coming in at an angle to stop at just the right depth in order to touch the horizontal line without going beyond it. Same thing is going on when you're trying to get into the lumen of the vein. Visualize a pipe and think about putting an IV into it. The purpose of the stylet is to puncture through the wall, but you still have to make sure the stylet is delivering the cannula part into the tube before you can withdraw that stylet. I often did my sticking with the needle and cannula almost flat to the skin in order to get into that lumen of the vein. Practice what I've suggested. Start thinking in terms of getting a few mm's of the IV device into the lumen of the vein, rather than just puncturing the vein and see if that doesn't improve your skill.

An old trick to verify that you are in the lumen of a vein is to gently wiggle the whole IV device to the left and right of the vein. If you are in the lumen you will see the section of the vein with the needle seated in it move nicely to the left and right. Don't be so quick to pull that stylet out the minute you see blood in the flash chamber. Take a few seconds to be sure you're in that lumen and gently push the IV device foward into the lumen.

Good luck!

tonet0908 · Oct 6, 2005

I was in a class today and I was told to release the tourniquet after you finish filling up the vials. I personally release it as soon as I attach my vial and the blood is still running but you have to be careful because sometimes you will remove the tourniquet and the blood will stop flowing :uhoh21: I go in a 30 degree angle and I have never tried using a blood pressure cuff but I guess that will work too. Also, you will get better with practice, it took me a while to figure out that not everyone has perfect veins, some have deep veins, some have sliding veins and sometimes you have to get a vein in an unusual place. The most important thing is there will always be some people out there that no matter what you do, no matter how good you are you will never get their veins and then you will have to call another nurse or an MD. Three times is my limit if the patient let me do it that many times, after that, I'm calling for help.

I'm a terrible sticker. It doesn't matter if I'm using a butterfly to draw blood, or putting in an IV.
Any tips?
Also, exactly when do I release the tourniquet?
Which size catheter? Best place to go?
How deep to stick? What angle?
I heard that using a blood pressure cuff is better on old and fragile veins. Any truth to that?
If you can help me I will kiss you! :kiss Nurscee

Darlene K. · Oct 6, 2005

All of the above poster have given some really good tips. I work in a surgical prep area and put in about 4 to 5 IV's an hour.

Another thing I like to do if I have someone that seems to be a difficult stick, is sit them up in the bed and hang both of their arms straight down (let them dangle). I let them do this while I arrange my supplies. Make sure you have good lighting and are comfortable (pull up a chair). Once I sit down and I am ready to go, I tie the tourniquet a couple of inches above their wrist. I like to have the patient place their thumb on the inside of their hand, it helps stabilize the vein. Have the patient tilt their wrist however you need to straighten the vein for you. I've never learned to enter the vein from the side, I have always went bevel up through the top. My angle depends on how deep the vein feels. Once I get my flash I straighten out my angio, advance slightly, then slide the angio off the needle. Then I release my tourniquet.

As the other poster said, the size of the needle and the location of the site will all depend on the reason for the IV.

Keep working at it and you will develop your own style that works for you.

Good luck!

TexasPediRN · Oct 10, 2005

Just a quick thought-

If you have nice nurses on the floor that you work with- see if you can practice on them! Thats how I learned :) The girls I worked with took me into our treatment room (it was a peds floor) and let me practice on one with another one standing right next to me guiding me. It really helped. I was able to do 7-8 IV's without hestitation on people who were guiding me before I went in to do them on real patients.

We were always told in my orientation that if you a having trouble with IV's to ask for it. Just remember it seems like each nurse has a different style, so you have to find one suited to you! (ie, arranging items, how you tape the IV, etc)

Also, if your hospital has one, you could ask to go with the IV nurse/team for a day and learn techniques. That would always help :)

Just try and jump in there and do all the IV's you can do- practice makes perfect technique , and just remember, everyone has bad IV days.

GOOD LUCK!!