blowing veins during IV starts - page 3

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... Read More

  1. by   915Chief
    My two cents worth in addition to the great advice already given:

    1. Don't give up. Nursing school rarely gets you properly trained for IV starts, so you're definitely not alone.

    2. Don't forget that there isn't a nurse on this planet that hasn't missed a start only to have somebody come right behind them a get it on the first stick. Your day will come.

    3. Practice, practice, practice....and make sure you learn to palpate with the gloves on using alcohol swabs so your fingers glide. You'll watch others rip the finger off to do this. You'll wish you hadn't as soon as you hear words like MRSA, C. Diff, Scabies, etc. Also, make sure you palpate which direction the vein is going.

    4. Don't forget to check the backside of the forearm....amazing how many won't/don't do this. PT isn't a diabetic? Then the feet are also a candidate area. On larger PTs the axillary area where the breast and shoulder meet are potential candidates.

    5. Ask people who you think are IV experts for their tricks of the trade. Most nurses are happy to share their experiences. Have then watch you and give pointers.

    6. Did I mention not to give up?

    Best of luck to you....
  2. by   rangerlil
    Quote from queenjulie
    Yes, I'm getting the vein, getting flashback, but then when I go to advance the cannula, it just goes in a tiny bit and then sort of sticks, and the flashback stops, and that's it. Then, if I try to flush it in, I just make a big swelling under the skin. I think I forget to advance the needle that tiny bit more after I get flashback a lot of the time.
    It sounds like you are going interstitial. I find this happens from either going too deep(through the vein), or their vein blows. Maybe adjust your angle to go slightly more shallow upon entry. I used to have this problem and asked experienced nurses to watch me. Especially obvious surface veins (like on the hands), they don't need much of an angle to be accessed. Good luck
  3. by   Katieerin
    I saw a youtube video about this topic. I am not in NS as of yet but the lady advised that if you lay the catheter almost parallel with the vein and advance slowly your are almost likely to never blow the vein. I will see how it works for me when I get to that point.
  4. by   sherbearccrn
    Thanks to all for sharing excellent tips. 2 cents. When prepping the area with the alcohol pad I use some pressure (remember the friction not the alcohol is what cleans the area), thus increasing the circulation and hopefully plumping up the veins. I hold the skin and veins taut with my non-dominant hand (enough that I won't get movement of either) Once I get the flash of blood I immediately remove the tourniquet and IDO NOT MOVE the position of the needle because the flash tells me I'm IN the vein. I DO NOT REMOVE the needle before I've advanced catheter. Think of the needle as the stylus(guide wire) they use when they insert a central line (the needle is maintaining the introduction into the vein). Then while holding the needle in place with my thumb, middle and ring fingers, I use my pointer finger to gently push off the plastic catheter. Once the plastic catheter is in place I remove the needle (if I remove the needle too soon I have nothing to guide the catheter into the vein, therefore I may be unable to advance the catheter and/or it will bend). I'm hesitant to blame "valves" as the reason I can't advance a catheter (unless they are "sclerosed" shut) because they open towards the heart which is the same direction my catheter and IVF are headed. Also, just an FYI....if you see Two veins merge into One you have found the strongest insertion site for an IV (at the top of the triangle where all three come together)
  5. by   sherbearccrn
    The posterior forearm is my favorite site.

    1) Offers a large vein

    2) It's out of the way

    3) gives a lot of arm and hand mobility to the patient

    4) rarely infiltrates

    5) doesn't bend the IV catheter or the IV tubing
  6. by   hodgieRN
    If you are getting a flash, but can't advance the catheter, there's two main things probably happening. As mentioned before, once you get a flash of blood, you are not in the vein yet. The needle sticks out a tiny bit past the catheter. When you get that flash, the needle is in, but the cath is not. You have to advance the cath into the vein. I know it's unnerving b/c you are afraid of going through it, but you have to advance the cath about a cm after getting a flash (at minimum).

    See the metal sticking out at the end and see the white cath below it. You have to insert about a cm of the cath into the vein. If not, you are pushing the cath on the outside of vein and it won't thread.

    The other is that you are probably going at too steep an angle. I mentioned going as parallel as possible. Stay away from the 30 degrees.
    In this picture, the angle is zero! The vein is pulled taught with the thumb. If you went at a 20 degree angle on this hand, you'd go right through it.
    Notice the angle is practically flush with the skin. See the flash of blood? Where is the needle? It's still in, but slight pulled back. This is a 22 gauge.
    Notice the angle and notice that the needle is basically still in the cath. The tip is pulled back, so you can't puncture the vein, but the needle acts likes a guide wire. This is a 24 gauge. With those could get at least an 18, maybe even a 16.
    Note the angle. Practically nothing.
  7. by   thelema13
    Quote from not.done.yet
    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.
    Very true, I always go for the forearm. Also, on the obese, they always have a few good veins in their shoulder area that you can usually throw at least a 20g into.
  8. by   queenjulie
    Quote from 915Chief
    Then the feet are also a candidate area.
    Actually, at our hospital, we aren't allowed to start IVs in the legs or feet without a physician's order, because of the hazards of diabetic foot ulcers and circulation problems. I figured that was pretty standard, but maybe it's because I'm in a state with probably the highest rate of diabetes in the country.
  9. by   queenjulie
    Thank you all for all your advice! This is great. A phenomenal IV starter at work told me yesterday something interesting--she said she always goes in the side of the vein, not down on the top of it. She said running along the side keeps her needle at the lowest possible angle and seems to keep from going all the way through the vein and blowing it. Does anyone else do this?
  10. by   queenjulie
    Quote from sherbearccrn
    I hold the skin and veins taut with my non-dominant hand (enough that I won't get movement of either) Once I get the flash of blood I immediately remove the tourniquet and IDO NOT MOVE the position of the needle because the flash tells me I'm IN the vein. I DO NOT REMOVE the needle before I've advanced catheter.
    How do you hold the skin taut, hold the needle, and release the tourniquet at the same time? I'd need three hands! Seriously, though, I usually try to advance the cath with the tourniquet on or let the skin go to release the tourniquet. Maybe that's where I'm going wrong!
  11. by   VANurse2010
    Once you get a flash and advance the catheter a bit you can let go of the skin then pop the tourniquet. You don't need 3 hands to do that.
  12. by   Georgia peach RN
    "I hold the skin and veins taut with my non-dominant hand" -- This is called anchoring the vein

    after getting in the vein and advancing the needle just a bit then cannulating the cannula I take my non dominate hand and pop the tournequit, then I place a 2x2 just under my IV cath (incase I am not strong enough to prevent a mess, the 2x2 helps me) I move my non dominate hand to hold the colored end of the cath with my thumb and first finger and I use my pinkie to apply gentle preassure just above the end of the cannula, remove the needle completely and attach the little "pig tail" (that is MY name for the little tubing that actually attaches to the IV) then I flush.

    "if you see Two veins merge into One you have found the strongest insertion site for an IV (at the top of the triangle where all three come together" --This is my favorite find! but I like the fore arm too!

    Another thing when I was learning to start IV's I would tell everyone who I thought was good or excellent to please let me assist them when they started an IV and I watched them to see how they did it. then I would emulate them, I also would get them to observe me but I really had to feel comfortable with the person watching so that I did not become too nervous. Then when I come upon a patient who is a difficult stick and I know this I always say a little prayer while I am looking for that perfect vein.

    You have great advice wish you the best in this new skill you are learning.
    Last edit by Georgia peach RN on Feb 18, '13
  13. by   sherbearccrn
    @ queenjulie

    Yikes!... Sorry for the confusion...I usually have no problem with insertions but if I do I have no problem having someone else try. There are days it's just not going to happen and other days when I couldn't miss one if I tried. The procedure has become so automatic that after I read your question I had to re- evaluate my steps again.....

    So after I get rid of my 3rd arm...I actually pull the skin taut/anchor it /don't let it move... yada yada. I insert the needle. Once I see blood I advance the catheter without moving the needle..let go of the skin...hold the inserted IV with my non-dominent hand... remove the tourniquet with my dominant hand...then using both hands I attach a "pigtail" (AKA; PRN adapter, Lock). Place a small piece of tape on the pigtail tubing (frees up my hands) below the catheter hub and flush. If everything is okay I finish securing it and put a clear drsg over the site.

    And that's the truth!
    Last edit by sherbearccrn on Feb 19, '13 : Reason: mispell