blowing veins during IV starts

[queenjulie]

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.

[Stcroix, ASN, PhD, RN]

my tip..in addition to the excellent advice above, is anchor the vein..and keep it anchored until you have finished advancing the cannula into the vein ... this was the tip that finally got me over the hump of 'every time i try i fail!'...

Can you please describe how you anchor the vein, I am not sure what you mean. Thanks!

[Tina, RN]

I just wanted to add something, I'm not sure if anyone else has noticed throughout the years...

When I had my first RN job back in 1998, I was pretty good at starting IVs. I actually enjoyed it! Then, I was out of the workforce, home with my kids for years. I came back to nursing in 2011. I noticed that the IV catheters were different than the ones I was used to back in the day. Anyway, I had absolutely NO LUCK with IV starts anymore! I was so upset. Obviously I was out of practice, but I used to be good at it! I dunno. Something about the newer design kept tripping me up. I'm a school nurse now, though, so it's no longer an issue for me.

Keep practicing, OP! You've gotten some fantastic advice, and you will be fine! :)

[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....

[rangerlil]

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:)

[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.

[sherbearccrn]

Thanks to all for sharing excellent tips. So....my 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)

[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

[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 veins...you could get at least an 18, maybe even a 16.

Note the angle. Practically nothing.

[thelema13]

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.

[queenjulie, RN]

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.

[queenjulie, RN]

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?

[queenjulie, RN]

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!