Trouble with IV starts on Older Adults

[DowntheRiver]

Hello all -

I am seeking your advice on how to start IVs on difficult sticks, preferably older Adults with rolling veins. I work in a setting where I start IVs, access ports, and draw blood. Our patient population is cancer patients and those in the process of being diagnosed, as well as genetic testing for families of cancer patients. I've only been with the company several weeks but have been a nurse 3 years. I did the occasional IV start prior to working for this company but not all day every day! I'm doing pretty well, usually 5/7 or 6/8, so missing approximately two a day. Every single time these patients have been older adults over 80 with fragile, rolling veins. My preceptor and crew is awesome and very helpful but I'd like to get some tips and tricks from those nurses outside of work.

We start IVs for scans and chemotherapy infusions. For scans, we can use 22's and 24's that are power injectable. Occasionally we have to use a 20 in the AC if they are getting an angio. The equipment I mostly use is the BD Diffusics 22 and 24, and then the BD Insyte in 20, 22, and 24.

Using ultrasound to insert is not an option - I'll just grab someone, usually my preceptor, who gets them every time. She's the vein whisperer, and I listen to what she has to say, but she says it will just come with time. I already see myself getting better, but I was just wondering if any experienced nurses out there have any thoughts.

[DowntheRiver]

Update:

Sorry for not responding sooner. I worked 4 in a row and then had to come home to do homework every night. Gotta get that BSN!

You all have given wonderful advice. Monday I only had to ask for help with two, and then Tuesday, Wednesday, and Thursday I didn't need assistance with any. I did have to stick some people twice but got them on my second stick.

What is working well for me:

Taking an extra minute to find a better vein that I am happy with

Hot packs

Making sure I really feel it

Not using a tourniquet

Using a smaller catheter on fragile veins

Holding/anchoring the vein with the "C" method or wrapping my hand around their arm

What I'm having an issue with:

People requesting to use a vein that I don't see or have a good feeling about. Some of these patients are pretty insistent about using that vein. I'd say in this situation I miss about half of those. What do you say when a patient insists upon using a vein that you don't think is a good choice? Usually these veins are very superficial or zig-zag.

Time management

My confidence has increased as well. It definitely makes a difference when you have a positive attitude going into the procedure. Management is very happy with my progress so that was a confidence booster as well.

For any of you new grads out there, YOU CAN DO THIS! Practice really does make perfect. I've been a nurse three years and still learn new things every day.

[JKL33]

Update:

What I'm having an issue with:

People requesting to use a vein that I don't see or have a good feeling about. Some of these patients are pretty insistent about using that vein. I'd say in this situation I miss about half of those. What do you say when a patient insists upon using a vein that you don't think is a good choice? Usually these veins are very superficial or zig-zag.

Thanks for the awesome update. Good work on your part.

Regarding the above, when I approach the patient to start an IV, before I do anything else I let them know the plan and tell them that I'm going to take some time to carefully look around for the best site before I poke anything. That is usually reassuring and gives me freedom to select the best site.

There are patients who have experienced this many times and do know if they have a 'go-to' site. I listen to their experiences. The caveat is that they (and thus you) don't always know WHY other sites were not successful. Many times when I look at the vein and they say they've had problems with it in the past, I can only conclude it was the skill level of the previous person, or something went wrong, or maybe they were dehydrated that day. In these cases I reassure them that I am confident of the chances of success.

Patients also don't usually make a distinction between the procedure of having blood drawn vs. an IV start. In these cases I explain to them how what I'll be doing is different than having blood drawn, and that's why I won't use certain sites that may work just fine for blood draws. ("It does look like a great spot for a blood draw, but today I need to slide in a small catheter...it needs somewhere to go, and this area of your vein is not going to work well for that")

Then you have the occasional person who, for whatever reason, just wants to control the process. Sometimes these are manipulative people and sometimes just have various fears or negative past experiences. Either way, I try to be therapeutic about it. I ask them about their past experiences, etc. If they are insistent, I usually say something like, "If you insist that we try that site, I'll do my very best - with the understanding that I'm telling you I don't think it is the best option and we may end up having to try again." If I am unsuccessful with their preferred site, I insist on choosing the next site. I don't have to deal with it much any more...there is a skill in talking to and reasoning with people and these situations become far fewer with good communication skills and reassurance.

[jeshelby]

I find it helpful to try and puncture through the skin and in to the vein at a steeper angle, usually between 20 and 45 degrees. Once in the vein dropping the angle and slowly advancing the catheter. I am sure in a few weeks you will no longer have any trouble. Good luck

[NuGuyNurse2b]

I find it helpful to try and puncture through the skin and in to the vein at a steeper angle, usually between 20 and 45 degrees. Once in the vein dropping the angle and slowly advancing the catheter. I am sure in a few weeks you will no longer have any trouble. Good luck

We were taught 30-45 degrees, but the experienced nurses on my unit go at an even lower angle, like 10-20. But I find that difficult because of the skin and I just end up nicking the patients.

[Lulubeans]

Lots of great advice here, not sure how much more I can add but here are a few other pointers:

1. I agree with the other posters on taking the time to find a good vein. Sometimes when veins blow it is because the vein was not able to tolerate the catheter long enough to hold the gauge of the catheter you are trying to advance. Take the time to pick the best vein you can find, and measure and ensure that you will start inserting the catheter at a point where the entire catheter will fit. The best veins are long and straight. Good veins also have a particular "bounciness" to them that you can palpate with your fingertips, but getting a good "feel" for veins takes time.

2. I also usually stabilize the vein with my other hand while inserting, and avoid pushing the needle too far in or else it will puncture the vein and it will blow.

3. Sometimes using a little alcohol to wet the vein a little can help you visualize it better.

4. I always try to insert IVs with the limb pointed downwards whenever possible, gravity can help fluids flow downwards, fill the vein, and make it easier to see (try comparing your own veins when your arm is pointed upwards versus downwards).

5. If you cannot see the vein very well (especially if the patient has a lot of edema), you try holding the arm downwards and pressing gently to get the vein to come forward and displace any surrounding edema temporarily.

[DowntheRiver]

So another problem I'm now running into -

I keep having an issue with veins on older adults (again, usually age 80+) who are on blood thinners. My preceptor told me those veins are more fragile and just to go slowly. I do watch her when she's doing it - and of course she gets it! Usually in these patients I get in and get a flash but then in blows.

Definitely getting better at feeling them versus seeing them. Last week had a guy with sleeves (tattoos) with thicker arms and couldn't see a thing so it was all feel. Had to stick him twice but the second stick was beautiful! Had a rough Monday - only 6/7 IVs and missed on Veni - but I bounced back the rest of the week. I've tried a lot of these tricks and overall I'd say these approaches work well but definitely are not one size fits all.

I think I'm harder on myself than other people are at this point. But, I still love it and keep learning something new every day so it is staying interesting!

[Flatline, BSN, RN]

When assessing for vasculature sites feel should be 70% of your assessment and visual 30%. How fast or slow you insert is important. The polyurethane blends that are often used are relatively soft and will quickly soften more when they warm causing crimping and the edges to catch. You generally have about 15 seconds or so before the material really starts softening. This is what causes a lot of "it wouldn't thread" failures. This is why materials like Chronoflex are becoming all the rage in some vascular catheters.

They best way to practice the actual insertion technique I have found is to take a pen cap and lay it on the table and then approaching from above insert the pen into the pen cap in a scooping motion without touching the edges of the cap. Picture that in your head and scoop into the vessel.

[akulahawkRN, ADN, RN, EMT-P]

Sounds like you're actually doing quite well. I first learned to start IVs about 17 years ago when I was in Paramedic school and I got pretty good at starting lines in some less-than-ideal circumstances. I ended up taking a little over a decade off from patient care and I'm now pretty darned close to where I was when I stopped working as a Paramedic. Many of the posters here have given awesome advice. Here's my little addition.

Find 2 sites that you feel pretty good about. Remember, two is one and one is none... Next, feel the vein for where it runs, how straight it is and I sometimes stroke the vein backwards to gauge how readily it refills. You'll know if that looks decent enough. Feel for how wide the vein is. Anchor the vein using whatever technique seems to work best for you. If the vein is well anchored, go at it from directly above, shallow angle, pierce the skin, pick up the skin just a little, and "see" in your mind what the tip of the needle would see and just enter the vein + 2mm. Nothing more. You should get a flash and you'll be able to advance the catheter.

Yes, sometimes I misjudge the vein and think it's more inflated that it appears to be and accidentally go all the way through. It happens to all of us. That's why you always pick a 2nd site.

Here's where I differ from most of my colleagues: I always have an attitude of "I'm going to get this in 1 stick." My attitude is that I'm really just that good. Not arrogant about it, just extremely confident. It makes a difference. This is true even if it's my 2nd stick... or my 5th (because there have been times in my EMS career where I've had to do that many and the line was absolutely necessary and IO wasn't an option back then) and don't just give up. If you really can't get the line, don't be afraid to ask for help. I've gotten lines that my colleagues couldn't and they've gotten lines that I couldn't. Why project that confidence? Well, by using such positive thinking, you don't let yourself even consider that you can't do it. A little sports psychology goes a long way!

[bgxyrnf, MSN, RN]

Why project that confidence? Well, by using such positive thinking, you don't let yourself even consider that you can't do it. A little sports psychology goes a long way!

When I was brand new and learning to start lines, I missed several. One day I consciously decided to ACT like I was an expert, despite the fact that I had missed most of my previous attempts. I thought about what the expert would do... and decided to play the role as I perceived it... exuding confidence that I didn't have. It was the turning point for me in developing basic proficiency.