Help! Struggling with IV placement in hand

[Guest1167668]

I've been a nurse for about two years and just started working as an IV infusion nurse. In the past, I've had experience with blood draws and have started IVs a handful of times.

I'm really excited about this position and I've been successful with most of my sticks in the AC/ bicep area and have been successful with placement in the hand a few times. I'm struggling with IV placement in the back of the hand. I usually get flashback and lower my angle but then the catheter won't thread or I go to stick them and the vein completely rolls. I anchor it, but find my hand placement gets in the way of my sticking hand if that makes sense.

What angle is recommended?

I've started to go more flush to the skin but have even been missing when adjusting my angle. Getting very frustrated with this and I have to admit it psyches me out everytime I know I have to place an IV in the hand.

How do you guys keep your cool when you've had a few bad sticks in a row? Also, is there anyway to tell where valves are besides for seeing them? I've hit valves on pretty good veins that made it difficult to thread it in.

Any help is appreciated!

[IVRUS, BSN, RN]

Well, Your process doesn't appear problematic, but how is your tourniquet placement?  If you are placing the line on a geriatric pt, you may very well have difficulty being successful if you tourniquet is too tight.  Elderly patients require loose tourniquet application, or you'll BLOW the vessel.  In addition, choosing a metacarpal vein isn't always the best choice for this populi as they have lost a lot of SQ in the back of the hand with age. That SQ used to support the blood vessel, and without it, the vessel appears to be a road map on the back of their hand, but actually is a very fragile vessel.  And, what gauge IV catheter's are you putting in. Remember INS standards say to choose the smallest gauge for the task at hand. 

[Guest1167668]

2 hours ago, IVRUS said:

Well, Your process doesn't appear problematic, but how is your tourniquet placement?  If you are placing the line on a geriatric pt, you may very well have difficulty being successful if you tourniquet is too tight.  Elderly patients require loose tourniquet application, or you'll BLOW the vessel.  In addition, choosing a metacarpal vein isn't always the best choice for this populi as they have lost a lot of SQ in the back of the hand with age. That SQ used to support the blood vessel, and without it, the vessel appears to be a road map on the back of their hand, but actually is a very fragile vessel.  And, what gauge IV catheter's are you putting in. Remember INS standards say to choose the smallest gauge for the task at hand. 

Thank you so much for responding. I’ve noticed I don’t struggle as much with the elderly, which is bizarre. It seems the common sticks I miss are with the obese population. 22 g is my standard. I’ve found whenever I use a 20 g I have difficulty threading in the catheter. 

[Asdf]

With the back of the hand I often will go at an extremely shallow angle from the side of the vein instead of trying to enter from the top, I also like to have the pt fold their fingers down over mine or make a loose fist and then pull traction down on their fingers so that my anchor hand is  not in the way.  The other “trick” I like for the back of the hand/shallow veins is, shallow angle, once I see flash advance a teeny tiny bit more and start to angle the catheter UP so that the vein is pulled into a arch, this helps me not to go all the way through those tiny shallow hand veins. Good luck! Also a hot pack on the hand for five minutes never hurt, doesn’t work all the time but sometimes it really helps. 

[Guest1167668]

1 hour ago, Asdf said:

With the back of the hand I often will go at an extremely shallow angle from the side of the vein instead of trying to enter from the top, I also like to have the pt fold their fingers down over mine or make a loose fist and then pull traction down on their fingers so that my anchor hand is  not in the way.  The other “trick” I like for the back of the hand/shallow veins is, shallow angle, once I see flash advance a teeny tiny bit more and start to angle the catheter UP so that the vein is pulled into a arch, this helps me not to go all the way through those tiny shallow hand veins. Good luck! Also a hot pack on the hand for five minutes never hurt, doesn’t work all the time but sometimes it really helps. 

I've been told that angling the catheter up can help but have not tried this yet. When angling from the side of the vein how far do you insert before you change direction to actually hit the vein?

[Asdf]

When going from the side it’s similar to  doing it the “normal” way insert until you get flash, insert another 2-3 millimeters and then attempt to thread. I would also recommend checking out some of the IV “tips and tricks” videos on Youtube, you can pick up some good tricks from there’re 

[JadedCPN, BSN, RN]

I agree that using a slight side approach on a rolling hand vein can help as well as angling up when you get flashback and are threading. I find that a lot of it comes down to proper anchoring though to really stabilize the vein. I will form a "C" shape with my non-dominate hand to stabilize the area of the vein that I need to, and use my other three fingers to have the patient grip onto. 

[LesYou]

I agree with going in from the side on rolling veins. But not totally on the side, more like on the side of the top. I go in from the opposite side of the closest bone. If the vein rolls, it rolls up to the bone which then holds it in place. For positioning the patient’s hand: I’m right handed. I hold the patient’s fingers in my left hand so that they are making a fist shape but I have control of how much their fingers are bent and the angle at the wrist. I anchor the vein with my left thumb and when I get flashback, I ease up a bit on the anchoring so that the vein can expand. I slowly release the anchoring as I slide the catheter in. 

[Epidural, BSN, RN]

Watch "ABCs of Anaesthesia" on You Tube. He has about 20 videos on how to start IVS. All of them are excellent. He will answer all of your questions on how to start IVs. He even has a few tips for the "I can get an IV in anyone" nurses. Enjoy!