blowing veins during IV starts

[queenjulie, RN]

I've been a nurse for seven months, and I'm doing well, except that I suck at starting IVs. In school I was almost completely unable to do them, and I've improved to the point that now I virtually always can find and hit the vein with blood return, but I blow them constantly. I don't know what I'm doing wrong--I try to be gentle and advance the catheter very slowly, but they barely advance and when I try to flush, I just get a bubble under the skin and the patient gets a lovely bruis. I just suck at it, and my poor patients end up getting re-stuck by our charge nurse or someone who is actually capable of doing a decent job at it. It's incredibly embarrassing. Any advice? If it matters, I'm on a high-acuity step down unit with mostly cardiac patients.

[tyvin, BSN, RN]

Just keep plugging away ... ... if you avoid it, you'll never get good at it. With all the advice I know you already have, it comes down to confidence. When the flash hits don't get nervous and don't hesitate. You'll get it.

[Nurseadam]

In the ER, i blew so many veins, even with healthy people. veins blow because usually they're either fragile or your needle went through the vein... try your best to

-find where the vein track is, and adjust your catheter before you stick the pt

-try to go slow, and once you find blood flow, do not advance more, you're in, so why advance?

-when you see/feel a vein, lower your needle a little bit under the vein, then stick the pt and advance till you get a flashback.

I.V. placements is a skill, and you'll prefect it soon.

[danceyrun]

This may be a dumb question but how do you know if you've "blown" a vein?

[veggie530]

This may be a dumb question but how do you know if you've "blown" a vein?

The IV site gets swollen and it looks like they got a really, really big mosquito bite.

[Nurse SMS, MSN, RN]

A few things I have learned re: IV starts:

A deeper vein is usually less prone to "blowing" than a more surface (more visible) one, especially on the elderly.

If the catheter won't advance after getting flash, you are probably up against a valve. Try to stick in "straighter" places where the vein is less tortuous or not close to forking.

Forearms seem to be easier to hit and keep than hands and wrists and are easier on the patient's mobility after it is placed than an AC or wrist IV. I love a good forearm IV and I often am successful at getting an 18g in there for all but the very elderly.

I didn't tell the patient I was new at doing IVs. I would tell them they seemed to be a bit fragile right then and that I would give myself two tries and if I did not get it, I would find an expert to do it. Usually the patient has no problem with my two tries and often lets me do more if needed. But those two tries on every patient who needs an IV has given me a LOT of practice and guess what - I seldom need two tries anymore. The only exception is the little old ladies (and men) with paper thin skin and super fragile veins. Those I give myself one try, then call the IV team in.

[iluvivt, BSN, RN]

Ii is also an art and if you take a little extra time with assessment and filling up the selected vein or vein your success rare will slowly increase.You also need to figure out what you are doing incorrectly so you can fix it. I have been an infusion nurse for 25 years now and still enjoy the challenge immensely.

First. you need to figure out why you are unsuccessful and with your description I have 2 suggestions and if you could be more specific I can pinpoint your problem area down even more. I would like to know if you are hitting the vein and then it blows or if you are hitting it,getting a nice flashback and then you advance the cannula and then it blows? Those are two different issues! What product are you using if it is an introcan I have a nice step by step instruction sheet I wrote that I can E mail to you. There are slight differences in products so you should always read the manufacturers instructions or make sure that you know them.

1. Make sure you perform a good assessment. You need to know what you are going to infuse. What is the ph and osmolarity of the IVFs and medications and are they phlebogenic/irritating. Anything with a ph of less than 5 or greater than 9 and/or osmolarity of greater than 600 needs a vein that will provide good hemodilution and is best given through a central line. Keep that in mind so you can advocate for that if needed.

2 Apply the tourniquet. I like to apply above the ACF so I can assess the entire vasculature. A safety tip is to Always unsnap the gown all the way up or tape up the gown so you never forget to pop the tourniquet. Apply a warm pack if needed to the selected vein while you get your supplies ready. Select veins that are soft,are not in areas of flexion and ones that are proximal to previous recent venipunctures. Look at the length of the vein you have and select the appropriate catheter length. if you have a nice straight section but it is only an inch long select an inch catheter, You can select a longer length and tunnel it a bit but that is a more difficult technique. I will not go into the direct and indirect technique for accessing the vein b/c I think it will confuse you but I will describe the technique.

3. Reapply tourniquet,prep and all that stuff. Now here is an important point and a one of two of the most common mistakes I see. DO NOT make your angle of approach too deep . The angle will vary based upon the vein but usually you just need a slight angle of usually no more that 15-30 degrees and if the vein is on the surface and you can see it and feel it you should just go in almost flush to the skin.

So now perform your venipuncture and observe for blood in the flashback chamber . Once you see the flashback,stop advancing the catheter and drop the angle of your approach to flush with the skin. Some brands have an early flashback mechanism and you can see the blood come back through the cannula before you see it in the flashback chamber, You must now advance the catheter a bit more once your angle is dropped. I see this as a common mistake as well. In all IV catheters the needle is longer than the cannula so your needle may be in the vein BUT your cannula is not! The larger the gauge the greater the amount you need to advance into the vein. I suggest about 1/8 of an inch or so. You can see why it it important to get a straight section of the vein so when you advance a bit more you do not advance it into a side wall and then out of the vein. You know all is good if you keep seeing blood coming back.. Now pull the needle back just a bit. The needle will give the catheter stability during threading but b/c you have pulled it back you will not damage the vein and make an additional holes or in it. so advance the remainder of the catheter and flush and secure.

[iluvivt, BSN, RN]

Just an FYI and to share and not being confrontational..that is NEVER my desire. A deeper vein is NOT more prone to blowing! They are deeper of course, but that means they are usually larger so a deeper approach is needed. It is a matter of proper technique and feeling the vein and its quality and course PRIOR to prepping , They can be trickier to hit and that is why the previous poster thinks they blow more but this is not the case nor will you find any literature to support that claim.

[RNinCLE, ADN, BSN]

iluvivt has given some excellent advice here! I also was wondering if perhaps the angle you were going in was too high based on your description. But without seeing you, it's so hard to offer advice. The above is a great start.

And don't worry - it takes practice, and you WILL get it!

[healthstar, BSN, RN]

Practice practice practice is the only thing that will help improve your IV skills! My very first IV attempt was a success! My second was a success! One day I had 2 pts who needed IV access, 1 was a hard stick and 2 had great veins, but I could feel so many valves!!! I attempted and failed, I was upset and I asked a very experienced nurse 20+ years , she attempted twice! Got it with the second try. She could get an IV access with her eyes closed! Me on the other hand, I spend 10 minutes searching for veins, and I use sterile gloves to feel the vein after cleaning it with alcohol wipe, because I need to feel the vein 1000 times !

[hiddencatRN, BSN, RN]

Ask whoever is best at IVs to watch you do a couple if sticks. They can probably give you good pointers if they can see you in action. And practice practice practice!

[akulahawkRN, ADN, RN, EMT-P]

One reason why some people are able to get an IV with their eyes closed is because they let their fingers be their eyes. They feel for the veins and that's why they can get the veins that people can't see. It all just takes practice. Starting a line really is an art because you have to just learn how to adapt the technique to individual variations and situations. You just have to see the variations...

The only patient that I have never been able to successfully start an IV in was a young man who had absolutely GREAT looking veins... that ended up being so fragile that they just shredded upon contact with the needle. A couple Nurses in the ED that day couldn't do it either. He ended up getting a central line.

This really is just one of those things you just have to do. Me? I just visualize what the needle bevel sees as I enter the skin and advance toward the vein. It's kind of a zen thing... be the needle. Just practice and practice and practice some more. Also, you have to approach the whole process from a positive standpoint that you will get the line started instead of that you hope that you'll get that line started.