Trouble with IV starts on Older Adults

Boomer MS, RN · Jun 4, 2017

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.

You are not alone. I assure you it will get better if you keep trying. Even the IV whisperer misses sometimes and would admit it. I would tell people I was healping, "You get confidence with the easier ones but get better with the hard sticks." Sounds as if yours all are hard though. I am not clear about your situation, but if there is any way you could spend a few hours in your facility's ED or an outpatient surgery department to get some extra exposure. Take your time; by that I mean go slowly into the vein and advance til you get a flash. Some tricks I found that helped were to use lots of alcohol which massaged the vein and made it shine and more visible, gently tapping the vein to help it pop up, dangling the limb over the gurney, wrapping the extremity with a warm wet towel and going directly in over top of the vein. Others have methods that are successful for them. Someday not too far off you'll be helping someone else to learn the IV skills. And I never ever had the option of using an ultrasound.

DowntheRiver · Jun 4, 2017

Thanks Boomer MS, RN!

I do use alcohol. I have been told I am "too gentle" - even by the patients! - when I am tapping veins so I'm working on tapping.

I do wrap with heat packs and towels.

I have no option of working in the ER but since we're a blood draw area they actually would send people to us to learn. That's a great suggestion though!

About half the the ones that I have trouble with I end up blowing. I get the flash and then start to pull back but I must move or something when I'm advancing the catheter. I have found that with difficult sticks that if I'm seated I have a better probability of getting the stick so I am troubleshooting what works for me.

Thank you so much for your response. It is greatly appreciated!

Boomer MS, RN · Jun 4, 2017

Thanks Boomer MS, RN!
I do use alcohol. I have been told I am "too gentle" - even by the patients! - when I am tapping veins so I'm working on tapping.
I do wrap with heat packs and towels.
I have no option of working in the ER but since we're a blood draw area they actually would send people to us to learn. That's a great suggestion though!
About half the the ones that I have trouble with I end up blowing. I get the flash and then start to pull back but I must move or something when I'm advancing the catheter. I have found that with difficult sticks that if I'm seated I have a better probability of getting the stick so I am troubleshooting what works for me.
Thank you so much for your response. It is greatly appreciated!

You are on your way. Sitting is another idea which you are already doing. The biggest mistake I would make when learning, and by that I mean blowing the vein, was because I went too deep. And when you get the flash, perhaps try anchoring the vein below the insertion to stabilize the vein as you advance the catheter ever so slowly. And stay level...don't go deeper. Keep picking all your colleagues' brains and have them watch you for some ideas. You will get better. Best wishes.

nursej22, MSN, RN · Jun 4, 2017

I had some luck using a BP cuff instead of a tourniquet because you can control the level of pressure you are putting on the veins.

iluvivt, BSN, RN · Jun 4, 2017

Are you advancing the catheter a bit more after you get your initial flashback and before you pull the needle back to thread the catheter? I need to know this so I can give you targeted advice. I have some tips that will help but need to know at what point you are having difficulty.

JKL33 · Jun 4, 2017

It sounds like you are doing well, actually.

I like skin fairly taut at (what will be) the puncture site if I anticipate "rolling" veins or an issue with the vein being mobile under the skin. As your dexterity with the procedure improves, you'll find ways to stabilize the vessel so it can't move away from you. I use the lateral edge of my left (non-dominant) hand to gently pull traction proximally, then left thumb and index finger on either side of my intended insertion site, and use my right pinky to pull traction distally (toward the hand) while right thumb and index finger hold my catheter. So, if I'm concerned that my only really viable vessel is too mobile, I basically make it so that it can't push or roll away from me in any direction. It requires lots of practice and the dexterity that comes with practice, though.

You mentioned being too gentle with your prep. Is there a chance you are also being "too gentle" (slow...) with the actual stick and sometimes pushing the vein away from you as you attempt to enter it? Even if it only moves a little, you increase the chances of nicking instead of puncturing...

The biggest area of 'failure' I observe with newer people is in advancing the catheter following positive blood return. I believe in a lot of the cases people actually go all the way through the vein by unintentionally advancing the needle instead of only advancing the catheter. This will come with time and focusing on NOT advancing the needle any further and only advancing the catheter once in the vein. I think a lot of times people just go too deep - they often report that "I got blood return but couldn't advance it" or "there must've been a valve"...often they are simply through the vein and although they saw a 'flash' when they went through, now the catheter won't advance because its tip is no longer in the vein.

Good luck!

PS - If you haven't sat down and examined both the types of catheters you are using, played around with how the catheters slide off the stylets, etc., I think it would be a useful exercise. I prefer the Insyte to the Diffusics just because of years of experience with Insyte. The mechanics of these two feel very different to me, and Diffusics really runs the risk of the operator inadvertently holding on to the portion that needs to slide forward, instead of having fingers only on the grip. Then it's rough/choppy to advance. But that's just me. My point is, it's a good idea to visualize the mechanics of both styles.

brownbook · Jun 4, 2017

I learned this from an IVDU patient. In difficult IV situations....when you finally get a little of the flash but it stops....stop everything, take a deep breath, hold the catheter where it is and gently tap with your "free" hand (left hand it you're right handed), anyway gently tap with your index finger on the skin over where the tip of the catheter is (I know you can't see it, but you have a pretty good idea). Gently tap tap tap and hopefully you will start to see a better flow than just the flash. Then as you get a better flow gently insert the catheter all the way.

Anyway you are doing great. As others have said even the IV Whispered misses sometimes.

angeloublue22, BSN, RN · Jun 5, 2017

Wow, you received a lot of great tips here. Thanks for asking this question because I have trouble with blood draws. This was very helpful for me as well.

prmenrs, RN · Jun 5, 2017

Try stabilizing the vein top and bottom--make a "c" w/the non-dominate hand, thumb below your planned insertion site, index finger above, so that vein doesn't wiggle away. Practice advancing the catheter while w/drawing the stylet more or less @ the same time. (If you've ever driven a stick shift car, it's kinda like the clutch-accelerator move.) Use your forefinger to push off the catheter, thumb and middle finger for the stylet.

Good luck!

maji2002 · Jun 5, 2017

I use a looser tourniquet or no Tourniquet at all. I put their head up and let their arm hang dependently and that usually is all it takes to distend a vein, without over distending and making it roll more. For even more challenging ones, warm towels can help too. Tapping the vein has never worked for me. Good luck!

allnurses Guide · Jun 5, 2017

A little trick I learned on fragile old veins is to set up your line with a small 100 cc bag of NaCl instead of a 10 cc syringe to flush the line. Once the line is in place open up the line ever so slightly and allow it to gently flow in rather than pushing the flush. You can't do this all the time and an a crusty old bat /IV whisperer taught it to me but it does work.

Hppy