IV Insertion Difficulty

[chanjyj]

I'm a new grad (Nov 2014), having a mid career change from business to nursing. I feel pretty competent in all aspects of my ICU nursing path so far except one - a horrific failure rate for IV starts.

At best, I probably get an IV in 10% of the time the past 8 months. I'm traumatized to the point where I avoid starting IVs like the plague, and get the phlebotomist to take blood. This is further compounded by the fact the most ICU patients have a central line of some sort and the opportunities to insert peripheral IVs are low. The facility in which I work in does not have senior nurses who are willing to watch you put in an IV - and I can't gain any feedback this way. Sadly, their mentality is to call a physician if you can't put one in; rather than try improve on your skills.

I've read multiple articles and "tips/tricks" on this topic. None seem like to have helped me.

I don't get a flashback most of the time and cannot figure out what I'm doing wrong. Been following textbook instructions to the letter. Any advice before I give up?

[dianah, ASN]

Practice is the key (I have allowed some ppl to practice on my veins, then I am able to offer advice and tips real-time, AND they get to practice on GOOD veins).

Seat yourself or bring the bed to a comfortable level. If you are hunched over with a difficult stick, it is distracting to be in a weird, twisted position.

Nondominant hand to steady the arm, and apply a little traction to the skin below where you stick.

After the "agitate, feel --- agitate, feel" (great description, BTW!), I mentally visualize where the vein is, and kinda how deep it is.

I enter at a 20-30 degree angle.

After the initial skin poke, I advance millimeter by millimeter till I get the flashback.

I advance just a smidge more after the flashback, so the plastic "needle" (not just the inner sharp core) is within the vein.

Then advance the plastic over the core, flush and secure.

It would be more helpful if someone could watch you and offer tips, rather than reading this (you indicated you had read a LOT of "how-to's").

And, agree with the suggestion to shadow in the ED (or in the short stay unit), for opportunities.

Keep trying. With successes, you will build confidence and skill.

[Creamsoda, ASN, RN]

Welp, hate to break it, but because you work in ICU, you will probably not make massive gains in IV starts quickly. You mostly have central lines etc. But that being said, I know theres a book I saw somewhere, I think it was at the NTI conference, and it was a book on tips and tricks for IV starts. It wasnt a big book but had a lot of usefull tips that your probably wouldnt have learned all about in school. Stuff that just comes from experience from a really good vascular access nurse.

Most ICU nurses in your shoes who go right into ICU probably dont have mad IV skills either. Probably only OK skills. At the very least id suggest that when you do get chances to start them, practicing getting the AC veins. Those are the easiest and biggest, especially in an emergency. Your gonna want to know how to get an emergent line, and thats where your best bet is. You almost cant miss them

But i was in your exact shoes. for 5 years i was terrible at IV's, never got them. I only worked ICU and all we had was central lines. Its nice to be able to practice on non responsive patients. You can go slow because their sedated, do your prep, warm blankets etc to give it the best chance. And the trend is to get central lines out sooner, so even in ICU you will have to get IV's before you can pull the line. I moved to a float pool, and got immensely better when I did ICU and all the other step down units and ER. I really improved after a while of floating to ER. You HAVE to get the IV!

Can you ask if you can spend a day with your IV team if you have one to get more practice and guidance? Same with the ER, you could ask to just work with someone there and start all the IV's for a day.

The crappy answer is you need practise. Its how we all get better.But your not the only one :)

[momathoner09, BSN, MSN, APRN]

I work in pre-op. Starting IVs is a big part of our job. We have to start them on everyone that comes from home and wind up re-starting new ones on inpatients because their IVs never seem to work. We also have to get 18s or 20s for most surgeries and only 22s if we absolutely can't get anything else. We have people come down from the floors to practice sometimes- maybe that is an option for you?

It took me awhile because I didn't have any experience either but I would say I am competent now (not great but a great deal better than I was 9 months ago!). I spend as much time as I can (for early heart surgeries we are rushed) in choosing the right vein. I think that is more than half the battle. We do have a vein finder but don't use it that often. I wouldn't recommend someone new in using one because I actually find that the light can be distracting. I like to look at both arms and palpate with gloves off. Once I make a decision, then I get all my supplies ready and commit to that vein. I raise the bed up so I'm not bending over too much and really hold the arm depending on where I am going in. Anesthesia likes us to start low so we do use the hand a lot or the wrist. We can't use the wrist all the time though bc they need to start an art line.

I would say that the best help I got from anyone involved them confirming that I had picked the best vein as opposed to having them doing it or watching. I can't tell you how many times I watched people start IVs and I really don't think it helped. Although I am the best IV starter helper around I would say ha!

Definitely don't give up! I think, and this is my opinion, that a lot of nurses have given up. Like I said we get so many patients who don't have working IVs. Meaning all the time they are in the hospital they do not have IV access. We always call the floor before and ask about their patient's IV access and we are always told they work and I would say 60% of the time, they don't. It's frustrating because sometimes we have time to start new ones and sometimes we don't and we wind up throwing them in with the OR team breathing down our necks ready to go. But perhaps that's why we are competent at them because we do have to do them under high pressure situations often. The only thing that helped me was practice over and over again.

[brownbook]

What Mago8688 said, there are a lot of you tube videos, I find watching them gives me a lot of confidence which is 90% of most IV problems.

Many of the videos are designated for Dr's and CRNA's.....of course doesn't matter, the technique is the same, just lets you know we are ALL beginners at some point in time.

[esrun2015, MSN, RN]

Do you have an education department? See if you can spend a day in outpatient surgery, they start a lot of IVs. This is what my previous place of employment did. It just takes practice and confidence. It took me a almost a year to become proficient and there are very few patients I have not been able to start an IV.

[Coldsvt]

i have days where i can't miss and then i have days where i can't buy a vein

just keep at it and relax

[LPNtoRNin2016OH, LPN]

Not sure if this is possible but can you request to follow a phlebotomist around (at your own expense I am sure) at your hospital for a shift? Not the same situation but I when I was a newer LPN, I started a family practice that would put one nurse each day on the blood draw room. I was kinda terrified of it. I didn't have much exposure. So those turds stuck me there every day for TWO weeks. No lie, I was getting them left and right at the end of it. The other nurses WOULD however come in and show me their tricks if I saw a vein that looked not so great.

I find inspecting the area before helps. Not sure if you have time to do this in the ICU with critical patients but I look at both arms, see which one is best, feel it for it, and decide which one I like best. We call it "speaking to the vein and becoming one with the vein" lol I swear it works for me mentally.

I also like You Tube videos, watching difficult sticks, etc.

[LPNtoRNin2016OH, LPN]

Forgot one more thing that was really holding me up. My anchor hand as they call it, would move so slightly when I was trying to switch tubes, enough that it would stop the blood flow. I really had to focus for a bit of time to not move my hand holding the needle in the patient as I took tubes in and out. This was difficult at times because I would have 10 tubes for some patients but once I got NOT moving the anchor hand down, I solved 75% of my can't get the vein issues. Again, not overly familiar with IVs so not sure if this will apply but wanted to share just in case.

[DowntheRiver]

Invest in Google. They currently have one (of many) patents out for a needleless blood drawing mechanism.

[martymoose, BSN, RN]

since this is on iv skills gaining, can I ask:

what do you do if you have a tendency to either go thru the vein ( blowing it) or subsequently, going too shallow and skating right across the top( and not getting the vein at all, and having one angry patient.

I believe the term " couldn't hit the broad side of a barn" pertains to me .

Any suggestions?

btw, i have spent time in preop, and have asked IV team for pointers. I still suck. I understand they are going to be doing away with our IV team, so in this customer service oriented climate, I'm going to have some angry patients

[dianah, ASN]

jrwest,

That nondominant thumb pulling the skin slightly taut will help anchor the vein so you can angle down just a bit more and puncture it.

Not too deeply, just enough for the flashback. a little finesse.

Also, sometimes a controlled, gentle descent of the needle towards the vein results in sliding over the top. Sometimes I have to (with the vein anchored with the thumb) give it a quick stab-- again, not too deep.

Some patients are very nervous getting an IV started. Sometimes too, the available vein is located in a tender area.

If your facililty policy allows, a small wheal of lidocaine 1% (using a small TB or insulin needle) may be injected right where you will enter the skin with the IV needle. This decreases the initial pain of the poke and patients tend to remain more relaxed ("I didn't feel it!") and not tighten up (which doesn't help when finding the vein). Be sure and warn them they WILL feel the small poke from the lidocaine needle.

[martymoose, BSN, RN]

Thanks Dianah- funny, have never seen the lidocaine wheal on the floors, yet when I get a surgery/procedure on myself ( same facility) they almost always use lidocaine- and im not even a bad stick! So must be a departmental thing or preop protocol. I know if I asked our docs for that they would laugh at me.

Maybe its a coordination thing with me. I also don't have a great sense of feel. Guess that doesnt help either.

But thanks for the pointer:)