I just became a rn. we didnt have iv insertion class at school but i had successfully extracted blood under the supervision of my c.i before but that was it-- my only experience relevant to iv insertion. currently i am in the middle of my iv therapy training, ive passed the lecture with good marks and (quite surprisingly) passed my practicum, and i think that is just because there was an iv therapy expert assisting me with the procedure. my problem now is i STILL HAVE NOT inserted an iv catheter properly and im starting to feel really bad about the harm that i have brought to the patients with my inexperience and incapability in inserting ivs. i come prepared at the bedside and my hands dont even shake but after locating the vein, and inserting at a 20-30 degree angle (with i believe the right pressure, not too superficially) then laying the cath almost parallel to the skin, and pushing about 1 mm, i dont get blood visualization and in 2 of that 4 failed insertions, have produced infiltration. in all that 4 insertions, i had a supervising nurse at my side, and ive asked feedback from them ranging from wrong choice of vein (on 2 occasions) or too much pressure. i really am listening and opening my mind to their suggestions but i still cant do the insertions right. im currently looking at videos and rereading the procedure but i dont really know what to do anymore. i dont want another patient sporting a swollen hand. has anyone experienced this like i have? what did you do to improve?
although some of my patients were dehydrated, the supervising nurse was still able to immediately insert the ivs easily so it ist the question of the condition of the patients rather my skill. :C
Specializes in Orthopedic, LTC, STR, Med-Surg, Tele.
Not super technical advice... but I used to get soooo nervous about starting IVs, and almost always missed even when I thought the pt's veins were huge prominent ropes.
Don't forget to breathe! I find being calm and collected relaxes the patient, as well as yourself. Like one of my personal heroes, Cesar Millan says, calm assertive energy!
The other thing I do is talk to my patient, and take time setting up. Obviously in an emergent situation you can't do this, but since I work nights, I can take a little time, fuss with everything, get everything all set up the way I like it, and the whole time I am talking to my patient, like "how was your day today, did you get a good night's sleep, whereabouts are you from, looks like it's gonna be another warm one out there, wish I could go skiing, who do you think is gonna win the Super Bowl," etc etc. It relaxes me, and my patient isn't all tensed up.
But when I used to be in outpatient chemotherapy, the nurses used to soak my hand in warm water prior to doing an IV canulation because I had terrible veins and refused to have another PICC placed.
It bought up the veins and softened the skin (I thought so, it was less painfull that usual).
I have had better success over the years starting IVs on children than adults. Their veins tend to be straighter and less mobile. Also, I do tap on the vein and it does work, despite what others say.
There is alot of good advice from others and here is some other tricks I use along with what they have written.
When I start an IV I only use a high enough angle to get the needle into the vein. As others have stated advance about a mm before inserting the cath. One other thing I do when inserting the cath is to push it up far enough so it goes past the tip of the needle then push the cath & needle in together. This allows you to use the needle as a stilite. Also, if it is a elderly person I do not use a tournquiet unless I have too. The added pressure of it can cause the vein to blow as so as enter it.
One thing you might do, is vow to only poke the patient twice, and then have someone else do it if you are unsuccessful. That way, it alleviates some the guilt and stress and allows you to relax and concentrate. You can also stand by and watch what they do differently.
Last suggestion. Before you poke the patient, ask them if they have had IV's in the past, and if there have been any problems people have encountered in placing them. A patient that knows they have rolling veins, or difficult veins in a certain area can save you a lot of trouble.
Yes my limit is 2, unless the patient is a VERY hard stick and I need to bring in reinforcements lol, I'll usually limit it to just 1.
I also agree with asking the patient regarding IV site placement. They can tell you which spots may be easier or have better luck with. Try to place one in their non-dominant hand if possible, especially if the patient is going to have continuous fluids running.
It is true that the more you practice "the art" of placing an IV catheter, the easier this skill will come for you.
For the elderly populi, make sure that the tourniquet is NOT as snug, or tight as you would normally place it for a young adult.
The vessels are more fragile and will easily blow with tight tourniquet application. In addition, place the catheter utilizing the right angle. For the elderly, that should be a ta 5-15 degree angle as they have lost much SQ tissue. A younger person will need a 20-30 degree, and the really obese, even sharper angle. Remember that the veins we use for VP are in the superficial fascia, or SQ. So if that is plentiful.....
Be sure to ALWAYS pull back on the skin distal to the VP site with your non-dominant hand to keep that vein from rolling. Once this skill is accomplished, you'll see much greater success.
Also, use the SMALLEST gauge and length for the prescribed therapy. That means, if you are administering a unit of blood to an elderly person who is going to get the transfusion over 3-4 hours, put in a 22 gauge. THIS WILL NOT LYSE THE CELLS.
Using the smallest gauge will allow for better blood flow around that IV catheter and decrease complications.
A larger catheter that a 22 is ONLY needed, if I'm trying to get that blood in quick, fast and in a hurry, like they may in an ER setting. In that case, with both Crystaloids and Colloids being given quickly, the flow warrents it.
Ah OP I feel your pain. I have 14 months of IV experience. YAYYY man I cant tell you have nervous I was about IV starts. I'd literally start sweating when I started an IV. Literally. I was so embarrassed I just thought patients could tell I was nervous. After about 4 weeks of starting multiple Iv's everyday I got better. I still have moments where I miss a vein, blow a vein, and have to stick easy sticks multiple times. D'oh! it happens. I used to use a 23 gauge on everyone! Even those needing blood! D'oh then I realized I 20-18 gauges were my friend lol. You will definitely get better over time. I'm still no expert, I still run to the senior nurses for really hard sticks, and hey even they can't get it sometimes. (that secretly makes me feel better lol)
Ah OP I feel your pain. I have 14 months of IV experience. YAYYY man I cant tell you have nervous I was about IV starts. I'd literally start sweating when I started an IV. Literally. I was so embarrassed I just thought patients could tell I was nervous. After about 4 weeks of starting multiple Iv's everyday I got better. I still have moments where I miss a vein, blow a vein, and have to stick easy sticks multiple times. D'oh! it happens. I used to use a 23 gauge on everyone! Even those needing blood! D'oh then I realized I 20-18 gauges were my friend lol. You will definitely get better over time. I'm still no expert, I still run to the senior nurses for really hard sticks, and hey even they can't get it sometimes. (that secretly makes me feel better lol)
I use a two-step approach to starting an IV. The first step is to simply penetrate the skin. After the skin is pierced, I'll flatten-out the cath and point the bevel right at the opposite wall of the vein I want the cath to end up in. I just get kind of zen with it and visualize the bevel going right in and coming to a stop right before the opposite wall of the vein. This gets me the "flash" and then I can just advance the cath and I'm usually in the vein w/o much difficulty. I do use my fingers to feel the path of the vein, depth, size, etc but I do use my eyes to focus on the very precise spot that I'm going to penetrate the skin. After that, it's all feel...
Yes, I do occasionally slap, tap, or otherwise stimulate the area that I'm going to puncture, but I'm not going for raising up a vein, it's to desensitize the skin to the next insult... the puncture. Basically, I'm trying to stimulate the A-afferent neurons so that the C-afferent neurons don't get a chance to send strong pain signals to the CNS. Yes, the gate-control theory... A quad-polar TENS unit would work spectacularly well if the setup is correct.
Getting good at IV sticks just takes time doing a lot of them. That's the secret. There are many tricks to doing it, but learning them just takes time doing the sticks.
excellent advice!! I second the advice about not slapping the skin. I was a phlebotomist for years before going into nursing and I NEVER slapped anyone's arms/hands and nearly always got blood on the first stick. And, a warm compress for 5 - 10 minutes will get the blood circulating to those cold extremities.
OP, you will "get it". As everyone has said, it just takes practice. If you have friends, relatives, spouse or total strangers that you know that are willing, practice on them. Pay them, bribe them, ply them with good food and wine.
Believe me, once you "get it" it will become second nature.
Morainey, BSN, RN
831 Posts
Not super technical advice... but I used to get soooo nervous about starting IVs, and almost always missed even when I thought the pt's veins were huge prominent ropes.
Don't forget to breathe! I find being calm and collected relaxes the patient, as well as yourself. Like one of my personal heroes, Cesar Millan says, calm assertive energy!
The other thing I do is talk to my patient, and take time setting up. Obviously in an emergent situation you can't do this, but since I work nights, I can take a little time, fuss with everything, get everything all set up the way I like it, and the whole time I am talking to my patient, like "how was your day today, did you get a good night's sleep, whereabouts are you from, looks like it's gonna be another warm one out there, wish I could go skiing, who do you think is gonna win the Super Bowl," etc etc. It relaxes me, and my patient isn't all tensed up.
Just my two cents