IV tips and tricks

Dragonfair · Jun 3, 2005

If I have a curvey vein or one that is deep and down under I will bend my cannula in the direction I'm going. the slightist bend can get it in the right place.

Dragonfair · Jun 3, 2005

L&D patient have the nicest vein to first start on.

Thanks for all those very helpful tips. I am a third semester ADN Student and we will have IV Lab next week.After that we will be let loose to try our luck on poor unexpecting L&D patients.

Daytonite, BSN, RN · Jun 3, 2005

That vein is called the dummy vein. Any dummy can hit it. :chuckle

We used to called it the "cheater" for the same reason. Also, those frail veins on the inner lower forearm just above the wrist. Anyone can hit them.

massagecarepdx · Jun 3, 2005

Thank you thanatos for expressing your concerns about wasting space and time on allnurses.com. I wish I could have read your previous posts concerning IV's however I am a second semester BSN student who just joined all you wonderful nurses on allnurses.com. I appreciate the new thread and helpful hints.

Daytonite, BSN, RN · Jun 3, 2005

Hi all,
I am starting to compile a list of tips and tricks concerning starting venipuncture. The goal is to share experiences and tricks of the trade.

This is a long post--sorry. I took down notes as I was reading all the previous posts to this thread. Here's my 2 cents. :twocents:

I worked on an IV team in a V.A. hospital for 5 years. The first thing we were told was not to put any IV's in patient's hands. Panic! After a bit I got used to it. Now, I don't even bother looking at hand veins unless the patient insists. Too many problems with the IV flow.

Be careful how you loop and tape IV tubing. If your first loop coming off the IV hub is not large enough it eventually ends up becoming kinked off and occluding the line. Unfortunately, this is not known until 8 or 12 hours later when the nurse on the next shift has to deal with it.

I disagree with tying the tourniquet very tightly as it hurts the patient. A tighter tourniquet doesn't make a smaller vein dilate any larger and it hurts the patient.

The best advice I would give to anyone is to learn to find veins by feeling for them. This takes practice and isn't learned in a week. . .it takes months and years. This is a skill you will be perfecting for years to come. Engorged veins have a kind of bouncy feeling to them. Educate your fingers to that feeling. Carry a tourniquet around with you and check out the veins of everyone of your family and friends. You can make all kinds of comments to them that you wouldn't dream of saying to a patient! After awhile you'll begin to realize two things: (1) there are certain veins that are mostly in the same place on everyone, and (2) there are veins that show up in places you never would have thought. This is one of the times when nursing can get creative.

We also had a gizmo called the Venoscope that we used to help visualize veins when we were having trouble finding them. It has to be used in a darkened enviroment to be the most effective.

When you think you've looked everywhere and can't find anything have the patient bend their arm up. The basilic vein runs along the back of the arm, is usually quite large and will accommodate a large bore catheter. Because of its length it can give up at least 3 IV sites for you. If any of my old IV team buddies are out there reading this, remember that we used to call this vein "Oscar". This is a great vein for blood transfusions because it will usually accommodate an 18gauge needle quite easily. They require some dexterity to get into. Just make sure you insert the catheter so its open end is pointed toward the elbow and not the hand!

You can start IV's without a tourniquet if you can clearly see them. They tend to roll and the tissue is not as firm because the blood is not under pressure, but it can be done. The backflow of blood into the flash chamber will be slower because the vein is not under pressure, so be patient and wait for it.

Another technique you can use to visualize veins you might not be able to see is to get down at the arm level and look at it from different angles. Sometimes a telltale bulging will indicate a vein somewhere that you hadn't imagined.

Ditto on any drug addict who tells you that a vein you are eyeballing isn't any good. He/she knows what they're talking about.

If you've gotten into a vein, you're sure of it and are getting no blood return, you are probably in a sclerotic vein.

Start IV's in the lowest veins and work upward. When an IV is initially started at the most proximal point of, let's say the cephalic vein (the antecube), you are going to lose a couple of sites you could have had below it. In ER and OR this is where most of the IV's are placed, and for good reason. I have no beef with you guys on that. However, if there's any chance you can change the site to give you more potential sites later, try to do that.

Please don't let an IV go beyond a life of 72 hours. I know that there are patients who have bad veins and you are lucky to have gotten into the vein that is currently being used, but 72 hours is long enough. If a patient's veins are bad enough that you don't have any left to use it is time to address the idea of a central line or PICC line with the doctor. Don't subject these patients to countless unsuccessful sticks and terrible phlebitis in long dwelling IV sites.

Certain IV meds like Vancomycin and Dilantin are very irritating to the peripheral veins so look for those IV sites to get phlebitis a lot faster.

Regarding needle size. . .if there is any chance the patient might need a blood transfusion, is going to the OR, or may need emergency medications as in a code blue situation it is smartest to insert an 18 gauge cannula. You cannot bolus life saving medications rapidly through a 22g needle.

For very fat people I used 20g and 18g catheters that had 2-inch long cannulas. I had to finagle them from the anesthesiologists! On these patients you really have to know how to feel for their veins (i.e. the cephalic) and then you have to account for a lot of tissue you are going through just getting to the vein.

Whenever I could be kind and save the patient a stick, I would. If I was restarting an IV in the early morning I always checked to see if the patient was having blood work done. Before attaching IV fluids to the new IV I would draw off all the blood needed for his morning blood work, put it into tubes, gave it to the phlebotomists if they were on the unit, or send it down to the lab. Then make sure the phlebotomist knows so he doesn't stick the patient again for the blood. If you start doing this the phlebotomists will get to know you and check with you first before drawing blood on your unit. When drawing blood up into a syringe for this, do not force it. Put a very gentle pressure on the plunger and let the blood come at it's own pace, otherwise the blood will hemolyze and the patient will end up getting stuck again.

On patients who have generalized edema you can apply an ACE wrap to the forearm, elevate it and wait for about 15 minutes when a lot of the swelling will have gone down temporarily. When you insert the IV cannula leave a bit of it out and anchor it well. This will allow some room for the tissue to expand when the edema reoccurs (and it will) without causing the hub of the cannula to end up digging into the patients skin.

Dress and tape your IV sites in such a way that IV tubings can be removed or changed without having to also remove the dressing from the IV site. Less disturbance of the IV site results in a longer lasting IV.

I almost always used the excuse of starting an IV to pull up a chair and sit down. It relaxed my back for one thing, but it also let me concentrate solely on what I was doing with my hands.

I used the InSytes (butterfly cannulas) in hand and finger veins because there was less of a problem with the disruption in IV flow due to the patients movements.

I learned the technique to numb the IV site before inserting a large bore needle. It's very easy. You can use saline or 1% lidocaine. You may need to get a verbal or telephone order from a physician before using lidocaine if it isn't in your hospital policy and procedure. You insert the IV through the same puncture site as the saline or lidocaine.

You also need to learn the difference between phlebitis and infiltration.

Learn the signs of phlebitis: swelling (not the infiltrating kind!), redness, pain and warmth to touch. Most veins get some degree of phlebitis due to the presence of the foreign body in them and the body's inflammation response. The companies manufacturing IV cannulas are using materials that are less irritating to living tissue, but they are still foreign bodies. At the least mention of pain or the hint of redness I changed an IV site. Sometimes you have to convince the patient why you are doing this. In the long run, the old site heals up much faster.

If you accidentally stick an aberrant artery (it has happened to me twice in 30 years), remain calm, and hold pressure over that sucker for 5 to 10 minutes and apply a pressure dressing. As long as you used good aseptic technique and stopped the bleeding you will be OK.

The reason some IV's and PICC lines don't bleed when you remove them is because the physiological slime that collects along the cannulas is being squeegeed off and is collecting at the inner side of the puncture entrance as they are being removed. There is nothing you can do about this. The body will absorb it. Still apply a dressing to the site.

As LMPhilbric said in post #70 of 09-04-2004 "There is no substitute for practice. IV therapy is 10% talent and 90% practice." I always told people I was teaching IV insertion to that it's like going out onto the shooting range. Practice makes perfect. It took me about 6 months after I took an intensive IV course to even begin to feel like I was gaining some proficiency with this skill. Starting about 20 IV's a day as a full time IV therapist for 5 years also helped!

For standards of care check out the Infusion Nurses Society

z's playa · Jun 3, 2005

Daytonite:

I officially label you IV queen ! :)

Z

HealinghandsRN · Jun 3, 2005

Nurses eat their young is ad nauseam- seems like you have it down pat though?

I totally agree with u

Could u imagine the nerve someone has to talk at what u can just imagine the tone is. ...... Is this the attitude when anyone asks the same questions repeatedly? hmm food for thought!

mommatrauma, RN · Jun 3, 2005

As you may guess from my screenname, I am a pediatric RN in the ER, I work at a level 1 trauma center.
Anyway here is something I use to help start IV
I hope I don't get in trouble for recommending this
http:// http://www.copquest.com/10-2270.htm
This helps illuminate the veins in preemies, and many old and young alike. It works well in all skin colors. It doesn't work well in obese patients, but is great usually for chubby lttle 1 year old rolly poly.

We used a transilluminator in the last ER I worked with, awkward to first get used to, but lights up the veins very nice...Esp in those little dry ittie bitties...

mommatrauma, RN · Jun 3, 2005

We've actually used the ULS machine to visualize veins in overweight people, you keep the ULS probe on while you are sticking and you can see your needle and where in relation to the vein you are...It is a two person job, one to do the IV and one to hold the probe...If we were doing it, it was usually one of our Docs that held the probe for us...

rockstar79 · Jun 4, 2005

Check out the VeinViewer on Luminetx.com. I have been a nurse for a few years and I just started doing some research for this company. This device projects a real-time imagine of the patient's veins onto the surface of the patient's skin. The website is being re-constructed but you should be able to get some information and see articles pertaining to it. Hope this helps.

Hi all,
I am starting to compile a list of tips and tricks concerning starting venipuncture. The goal is to share experiences and tricks of the trade.
Tips e.g. on how to find that elusive "best vein", would be greatly appreciated. (and if you have a few that are not to be taken entirely serious those would be welcome as well).
Please answer me directly - no need to clutter up the board with this. I will post the text once it is finished.
Thanks in advance!
------------------
Katharina Loock, RN, BSN
Department of Education
Wadley Regional Medical Center
1000 Pine Street
Texarkana,TX 75501

nursesherry · Jun 4, 2005

A friend in nsg school had trouble remembering where her veins were once she had rubbed the site down with the alc pad, so our clinical instructor taught her to pick her vein, pick out where she is going to insert the IV and take the end of a skinny ball point pen (not the marking end) and make an indentation at the site (not enough to hurt the pt...), then clean. The indentation will stay long enough for you to stick. Good trick for beginners.
I go more for the feel of veins, rather than if I can see them or not. To me, a good vein has kind of a spongy feel to it. My best advice to anyone new at this is to do as many as you can, because that's really the only way to learn the tricks and perfect your technique. That's how I'm learning.

Great idea! I have also found that you can use your alcohol swab. After you have cleaned your site take the alcohol prep and place it just above where you want to stick with the corner of the swab pointing down to the vein like an arrow. Works Great!

Danianne · Jun 4, 2005

Just a few comments from the peanut gallery.

I am student.

1. when they say it hurts, it hurts.

2. some skinny people don't swell up right away (at least i don't)

3. If you are too chicken to re-start an IV on someone with cra**y veins say so, because telling the patient that you cannot find anything wrong with the site doesnt mean that they will suddnly be all better.

I have had some less than happy experiences with infiltrated IV lines. I really really really sucks.

* note*

am I weird or somthing I told the nurse that my Iv hurt, she said that "it doesn't look swollen" but my arms are really skinny, and one time the IV had been running for like 12 hours at 200ml/h then when the next nurse came on she said my hand looked a little puffy so she re-started and within 2 min the arm that had the first IV in swelled up to the size of a foot ball. can anyone explain this, so I can at least retaliate next time instead of believing that the nurse know everything and I dont because I am just a student. Thanks