Pretty bad at starting IV's - page 3

I am a new RN, just out of school, and have been off orientation for a few weeks. I am having trouble with starting IV's and find that I need help with about half of them. It is very frustrating... Read More

  1. by   akulahawkRN
    My "go to" size is/was an 18. I rarely had to go larger than that. I consider that size more of a mid-size. Small-bore is 22-24 ga, mid-bore is 20 and 18, large bore is 16 and 14 ga. I generally do 20 ga in hands, 18's everywhere proximal to the hands. It's easy to control the flow with those, run-away lines don't dump fluid in that fast, and you can easily saline-lock them. As to "large bore" lines, I can count on one hand the number of times I've had to do a truly "large bore" peripheral line... and I have never missed one of those.

    If you're starting a line in a vein that will roll and there's no bifurcation that you can use, pull traction on one side of the vein to anchor it (can't go any further that way), enter the skin on the opposite side of that traction, then the only way the vein can roll is right into the cath. Once I've placed the cath inside the vein and I'm ready to remove the needle, that's when I release the tourniquet. Done smoothly (and remember, smooth is fast), it kind of goes: anchor the vein, enter the skin, flatten out the angle to the skin, point cath at the final spot inside the lumen, advance to that spot, see the flash, advance another 1/4 inch, advance the hub to the skin, release the tourniquet, place a 2x2 under the hub, tamponade the cath tip as I remove the needle, safe the needle, grab the IV tubing and attach it using aseptic technique to the hub, release cath tip tamponade pressure, open the roller clamp and verify flow... secure the site, regulate the flow to ordered rate. Total blood loss, 2 drops.

    All that is from the moment I'm ready to actually puncture the skin. From "flash" to secure takes about 20-30 seconds, if I've gotten everything prepped and ready for me to grab. It's all just smooth, deliberate movement that doesn't cease until the procedure is done. I do it the same way every time, rushed or not.
  2. by   AloeBlox
    practice makes perfect
  3. by   akulahawkRN
    Quote from coriaa1
    practice makes perfect
    As many have said, perfect practice makes perfect. What also helps could be a visualization technique were you visualize yourself doing the task perfectly. This way you prime yourself for doing perfect practice perfectly.

    I hope that was not too confusing.
  4. by   Racer15
    I'm doing my practicum in the ER, and after 7 days, I'm getting to the point where I can visualize the veins better in my head just through feel. It just takes practice! A trick my ER nurses have taught me is floating an IV in. Sometimes I get a flash but advancing the cath just does not work, it either won't go in any further, or the blood return stops. I pull it out slowly until I get blood return so I can draw a rainbow, and once I'm done, I attach my normal saline and just slowly push it into the line while slooowly advancing the cath forward. Works about 75% of the time for me. if I didn't learn that trick, I'd be missing a lot more IVs!
  5. by   IVRUS
    The problem with this approach is that at this "Y" you will have a VALVE. You are damaging that valve when you puncture it with a needle. This is NOT a good approach. Valves keep the blood flowing toward the heart. Valves are about every 3 inches and at bifurcations. Do not damage them.

    Angle is an issue, make it approx. 5-15 degrees for the elderly. 15-30 for the younger adult.

    And as already said, anchor that vein by holding the skin below with your non-dominant hand as you enter the vessel.
  6. by   dianah
    Worked in Radiology X21 years, starting 20+ IVs per day on outpts (some post-chemo, some dug addicts -- with no veins!) for CT scans and IVPs.

    Agree with most of the tips given!

    * Tourniquet on
    * Anchor the vein
    * Take your time (breathe) and talk with the pt (calms me and the pt down)
    * Angle about 10 degrees, not 45
    * When flash seen, advance "a teeny bit more", just a few mm, to get the plastic catheter as well as the metal needle into the vein
    * Advance the catheter and back out the metal needle at the same time (I don't like to advance a needle that may perforate the vein)
    * Undo tourniquet
    * Secure site enough to test-inject w/saline
    * Test
    * Finish securing and label

    Some questions/tips:
    * Some mentioned using nitro paste to numb the site first -- is an order needed?

    * I would often inject 1% lidocaine, in a wheal, right where the catheter was going to enter the skin. Used a TB syringe/needle.
    This (along with vocal anesthesia ) helps for those who are particularly frightened, nervous or scared of needles. I found ppl who are "scared of needles" tended to tense up, which seemed to me to make it more difficult to start an IV.
    I'd reassure the pt as I injected the lidocaine "this is a very small needle, hang in there, almost done, --- there, you should not feel the rest." Give the lido a few seconds to work, then start the IV. The surprise and relief on my patient's faces (that there was indeed no more pain and the IV was IN!) was worth the extra time taken.
    Note: I ALWAYS use Lidocaine if starting an IV in the thumb (if no other veins were available, thumb was last choice). It and the inner wrist are very painful areas to have an IV started. It's kind to numb the area first.

    * I'd often use veins of the inner forearm. Median and basilic. They are STRAIGHT (so the IV will flow, not be "positional") and easier, IMO, to "hit." No joints to worry about, no twistings and turnings of the vein.

    * A tip a NICU nurse told me, many years ago: sometimes you can't feel the vein but only see a streak of blue. Aim for the blue and advance the needle mm by mm until you hit the vein. This has worked for me. Aim for the blue.

    And to repeat a truth: Practice makes perfect!
  7. by   spongekarl
    as cliche as it may sound aside from perfect practice and confidence one thing that helped me a lot when i was doing iv insertion is that i always think that i'll just do it once because once is already painful for the patient so im not gonna do it always motivate me to do my best in my job. and also try to take your time to search or look for the vein.
  8. by   whichone'spink
    I'm also a new grad in the ER, and yes, I have the same problem as you do with IVs. Half of the time, I get them, half of the time I have to have my preceptor step in. It's very frustrating most days. I had a patient who I thought was in SVT, so I knew I had to sink an IV in quickly. Here I was, making sure I was staying ahead of the game, going to get that damn IV sunk in so I could possibly push some meds fast. I blew both my attempts. Fortunately, it turned out, this patient was not in SVT. He was more or less stable, but I was not very happy with myself. What if it was truly an emergent situation and I blew any access? And what if I didn't have any back up? I am very thankful I have my preceptor, but she and I know that in reality when I'm on my own, being bad at IVs can set me back.
  9. by   akulahawkRN
    Remember, slow is smooth, smooth is fast. Do it the same way every time. You can't miss the vein fast enough to make a difference other than causing your patient to feel like they're on the receiving end of a sewing machine. Yes, back when I put IV's in a lot, I rarely missed. I did have my "off days" but those were few and far between... But that simply meant that I had to utilize attempt #2 or (rarely) #3. Don't get me wrong, I'm no "God of IV" starts. I just approach the process the same way every time I do it, and that includes absolute confidence that I can get it done with one stick. The one stick is the one that I have in my hand.... even if I've had a previous attempt on this patient just a few moments ago. When I hear that someone got stuck a few times for an IV, I just think to msyelf, I could have gotten that one... Yes, I may be a little bit delusional about that, but it's a positive delusion.

    You know the procedure, the steps to getting it done the first time. It's all about having the confidence... and the experience to get it. Experience comes from having challenges... and I've had a few myself. But that's given me the absolute confidence that I can do it.

    Try that next time! Believe 100% that you can get it, no matter what. That attempt you're about to do is the only attempt that matters. And go smoothly, because smooth is fast.
  10. by   spongekarl
    a lot of practice and a big heart to provide the fast and immediate care the patients need would definitely boost your not treat each iv insertion as if it is a challenge you need to finish think about what the patient is going through and be that person who would help them alleviate their suferring
    by the way i was assigned in an er of a public hospital in the philippines
  11. by   NotReady4PrimeTime
    Quote from dianah
    Some questions/tips:
    * Some mentioned using nitro paste to numb the site first -- is an order needed?
    Nitropaste (nitroglycerin in ointment form) doesn't numb the site. It dilates the veins. Not to be trifled with because it's absorbed through the skin and can have significant systemic effects. It's an antianginal with similar effects to sublingual nitro, but because it's used topically it has a longer duration of action. We use it very occasionally on kids who have had septic emboli or extreme vasoconstriction from the alpha effects of inotropic meds used to treat shock states, whose perfusion to digits has been severely compromised. The local peripheral vasodilation it produces can often eliminate the risk of eventual amputation. I can't say that I've ever seen it used for IV starts... seems a bit radical and mildly dangerous! So I'd say an order would be imperative.
  12. by   eatmysoxRN
    A big tip that hasn't been mentioned or that I overlooked is asking the patient where they usually have IVs. It saves a search of good veins are limited. I tend to find a good vein in the wrist under the thumb often. Upper arms are decent. Remember to adjust your tourniquet so veins aren't popping too much or they'll blow. Putting pressure above your site before pulling out the needle does a good job of preventing the bloody mess that patients freak over. Stay close to the skin (angle wise). I float by pulling back on my flush until I get blood then slowly advancing back in. I always chevron with tape. I usually try to get a 20. I prefer a 22 over nothing though. Haven't used a 24 on anyone but a baby. Oh and taking the lock off the extension tubing and just using that instead of that plus the short tube can keep your site from blowing so easily as well. Scrubbing with chloroprep or whatever you use to clean can really pop veins out some too.
  13. by   whichone'spink
    I actually find I lose veins after I scrub with chloroprep.