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IV Placement Hacks

Nurses Nursing Article  
Updated | Published

Specializes in Pediatric & Adult Oncology. Has 10 years experience.

Tips and tricks from an experienced IV RN, from tourniquet placement and vein stabilization to choice of dressing and site care. Let’s get your PIV game on point!

IV Placement Hacks

We all have our strong suits. What's yours? Maybe it's code management, mediport access, or another technical skill that requires just the right amount knowledge and finesse. There's always that "go-to" nurse on every unit. Staff turn to the expert on the floor for their experience with a specific issue. One who has perfected his/her technique over years of experience. Let's make you that nurse!

Get in There!

Obtaining and maintaining viable IV access is a learned skill. One that every nurse may not have mastered or even practice on a regular basis, depending on the area in which they work. Some hospitals have IV teams. A great resource, ensuring minimal attempts for the patient. However, it can prevent many nurses from ever even trying to place their own IVs for patients.

Unfortunately, trying (even when unsuccessful several times at first) is the only way to learn and hone your craft. As with many skills learned on the job, practice makes perfect. An important thing to remember is that no one expects you to have a perfect batting average when you first start. But your patients don't need to know that it's only your second time. Go into your patient's room with confidence. Decreasing their fears as much as possible can bring down the anxiety levels all around, making for a much more controlled and potentially successful attempt.

Tourniquet Use

The purpose of the tourniquet is to occlude blood flow and cause the vein to fill, making it easier to insert the catheter. I've seen many nurses generously place a tourniquet too loosely or use a folded paper towel to decrease patient discomfort. In truth, yes it is mildly uncomfortable - but temporary and necessary to ensure proper technique and possibly save your patient from another painful IV stick.

It's important to move the tourniquet depending on the site of choice. For example, if you're intending to use the antecubital (usually the most prominent vein in the middle of the arm on the opposite side of the elbow) you'll want to place the tourniquet on the bicep area, about 3-4 inches above the intended IV site. If you're attempting a vein in the hand or wrist, place the tourniquet instead on the forearm, 3-4 inches above the intended site of insertion. Time of tourniquet use should be restricted to under 2 minutes.

No Veins in Sight

Placing an IV correctly can be hard enough but especially so when there is perceivably little to work with. I like to go by feel, not just sight. When you are tapping around looking for IV sites, the vein should feel springy and kind of rubbery. I sometimes think of it like a rubber band injected with a bit of water. Working in Oncology, many of my patients have difficulty with IV access as time passes with their treatment regimen - hardening of veins from chemotherapy, dehydration can make veins incredibly small, and pediatric oncology patients (some only a few months old) can be incredibly challenging. Not to fear...there are ways to help coax those veins out of hiding!

Having a patient take some controlled deep breaths before insertion can increase blood flow, filling the veins (and decreasing their anxiety too!), leading to more IV site possibilities. Warming your patient can also help. Dry or moist heat can be used and both are effective. Examples of this include wrapping warm dry blankets or warm moist towels around the patient's arms. Of course, heat packs could also be considered for use. Some hospitals have a vein light available for use. It's not my favorite and I've only used it a handful of times in my career. Some nurses love it and the extra visual component it brings. Use what works for you.

When I'm really out of luck finding a vein for use, I like to go for the basilic vein. It's a nice big vein located on the opposite side of where you would normally look...on the backside of the forearm. It's not a frequently used site and therefore, usually in pretty good shape (lack of scar tissue & limited valves to avoid). Give it a try!

If you've used all of your resources above and still cannot locate a vein, do not blind stick. Digging an IV around under the skin unnecessarily can cause potential tissue and even nerve damage, not mention unsightly bruising. An important rule to keep in mind (even if it's not specifically stated in your hospital policy), don't attempt an IV more than twice on the same patient. Getting a fresh set of eyes and hands from another nurse is best at this point. Don't stress, you'll get it next time!

Vein Stabilization

Holding down the vein you intend to stick is crucial - those little things can be wiggly! This is the number one reason I see novice nurses missing IV's. Once your tourniquet is in place and your site is cleansed take your non-dominant hand and with one finger (I find the thumb works best, so you can wrap your hand around the patient's arm for more control) apply moderate pressure about two inches below your intended site and pull down just slightly. Now that your selected vein is anchored, fire away! A slow and steady insertion...see a bit of blood flashback and voilà , you're in! Continue to advance the catheter, promptly remove the tourniquet and use your dressing of choice.

I hope you find these tips helpful in increasing your success rate for IV placement. What are your favorite IV hacks, tips and tricks?

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20 Comment(s)

These are great tips!

I'm struggling with advancing the catheter into the vein. I was an LPN prior to being an RN and drew blood often so I'm confident about the initial stick. But having to advance the Cath once I get a flash is where I'm struggling. Ill get blood return then advance but then loose the vein and get nothing.

It's super frustrating, any ideas what I could be doing wrong?

Over the years, the single most frequent mistake I have observed is that of continuing to advance the needle along with the catheter once blood return is noticed. Then the problem is reported as, "I got in, but the catheter wouldn't advance".

S.S. Sally,

I hadn't seen your post before I answered; maybe a few more details will help your situation.

Take the opportunity to look at your preferred IV catheter closely (you probably have done this, but once more won't hurt as you process this information). You will see that the tip of the needle extends through and beyond the end of the catheter itself. When inserting, you will achieve the beginning of a blood return when the tip of the needle punctures the vein. The caveat is that the catheter itself may not yet be inside the vein, right?, since the end of the catheter is not "at" the tip of the needle. So, you have to advance "just" far enough, probably millimeter or fraction of millimeter in order to ensure that the catheter itself has entered the vein, but not so much that the tip of the needle punctures through the vein. (If you go all the way through with the needle, that is the path the catheter must also follow).

This ^ issue is why some nurses advise others to "flatten out" the angle once blood return is noticed - - it's an attempt to keep the tip of the needle in the vein as opposed to inadvertently pushing it through the vein while advancing the catheter.

So take a look at your cath/needle set. See that tiny distance between the tip of the needle and the end of the catheter? That is the distance you're working with as far as how far you need to go in order to get the end of the catheter itself into the vein. Not going that far, or going beyond that distance with the needle after blood return is where problems arise in my observations.

HTH.

SaltySarcasticSally said:
These are great tips!

I'm struggling with advancing the catheter into the vein. I was an LPN prior to being an RN and drew blood often so I'm confident about the initial stick. But having to advance the Cath once I get a flash is where I'm struggling. Ill get blood return then advance but then loose the vein and get nothing.

It's super frustrating, any ideas what I could be doing wrong?

It's a problem I had to overcome as well.

Remember that the point of the needle is down and the bevel is facing up - so before you advance (and after achieving a flash), it often helps to tilt the needle upward just a tiny little bit to make sure you're not trying to push the catheter through the wall of the vein.

Vein selection is another big factor here. Big veins are much easier to advance a catheter into than small ones; straight veins are much easier to advance than torturous ones. Recognizing valves also helps quit e a bit. Get as much blood flow to the vein as possible before you start as well - a tight tourniquet, lots of fist clenching, warm packs, etc - they all can help. In my experience, a lot of people who consistently have trouble starting IVs just don't spend enough time searching for, selecting, and prepping a site.

Ashley Hay, BSN, RN, BSN, RN

Specializes in Pediatric & Adult Oncology. Has 10 years experience.

Couldn't agree more with the answer below. It's a matter of advancing just a teeny tiny bit more, then advancing the catheter only (not the needle). Great in depth explanation!

"Take the opportunity to look at your preferred IV catheter closely (you probably have done this, but once more won't hurt as you process this information). You will see that the tip of the needle extends through and beyond the end of the catheter itself. When inserting, you will achieve the beginning of a blood return when the tip of the needle punctures the vein. The caveat is that the catheter itself may not yet be inside the vein, right?, since the end of the catheter is not "at" the tip of the needle. So, you have to advance "just" far enough, probably millimeter or fraction of millimeter in order to ensure that the catheter itself has entered the vein, but not so much that the tip of the needle punctures through the vein. (If you go all the way through with the needle, that is the path the catheter must also follow). "

HTH.

Pepper The Cat, BSN, RN

Specializes in Gerontology. Has 34 years experience.

One great tip I picked up from an anesthesiologist when he had to come to place an IV on a pt after multiple failed attempts. He had the pt dangle his arm over the end of the bed to fill the veins a bit more.

Also with these tips, I would like to add these.

1 have confidence, negativity brings doubt, and poor performance.

2 if you can see it, it is attainable. Also it probably isn't deep.

3 A turnakit isn't always necessary, especially with older veins or people on chronic steroids, the vasculature is more sensitive to blowing. Then don't use it and try a decent size IV and go SLOWER, cause it will take twice as long or longer to get a flash.

Happy Stabbing

RobbiRN, RN

Specializes in ER. Has 25 years experience.

If you cannot find a vein through any of your usual methods, lower the hand and as much of the forearm as you can get in a large basin of very warm water for about five minutes. This is much more effective than simple dangling or local warm packs. It is time consuming, but it works. Look at your own veins before and after your next warm bath or shower and see the possibilities.

MikeyT-c-IV

Specializes in Vascular Access. Has 13 years experience.

Great article and awesome tips!

vein_map.jpg.9dc5f3fe546077083fd1ea4227e5e188.jpg

DowntheRiver

Specializes in Urgent Care, Oncology. Has 6 years experience.

MikeyT-c-IV said:
Great article and awesome tips!

LOL, I wish! So I work in Oncology starting IVs all day, and I just trialed the AccuCath for my BD department and they used a portable ultrasound. It was wonderful and I wish we could have one all the time.

Patients in the Oncology setting just have the worst veins. Do you have any tips for little old ladies whose skin bunches up? Usually I'll get in but even holding traction with my thumb is just sometimes not enough!

KeepinitrealCCRN

Specializes in SICU,CTICU. Has 6 years experience.

@SaltySarcasticSally once you get the flash try lowering your angle to 5 degrees or so and going in a pinch more before advancing this should help.

I work in a community ER with a lot of either drug abusing patient's or elderly. A couple tips that work well for me:

1) look above the AC! A lot of nurses stop at the AC but if you look 2-4 inches above you can typically find something (even if it's only for a 22)

2) Unusual spots -- back of arm, thumb, top of arm towards chest, feet if not diabetic. In EMERGENCY situations I'll look in breast or belly tissue. I've seen nurses get 18 g. IV in ascites bellies--those veins can be gigantic.

3) set yourself up for success! get a team in there if the patient is a fighter, double tourniquet if you need to, ask a phlebotomist if they feel anything, etc.

4) A lot of times as soon as I get the flash I stop the needle and retrieve it, even if the catheter is 1/2 inch out. I then flush the catheter in or manually kind of slid it in from the hub. Especially on Wiggling patients! that way the needle doesn't poke through and blow the vein!

When, I start an IV on an elderly person, whose veins pop like a balloon:

1. I use a manual blood pressure cuff pumped up to 60 mmHg - 100 mmHg

Just enough pressure to see the weak veins start to bulge..

If, the vein becomes too full, a sharp needle will act the same way as on a balloon.

2. If, no manual cuff is available, then apply tourniquet look for what you want.

Remove the tourniquet, then when all items are ready apply again, and stick fast.

You don't want to wait for the vein to become over inflated again, the vein gets taught

like a balloon and pop. So, apply and stick.

3. Okay, so every know and then, you have nothing to work with to make this easy.

The elderly person's veins are just bulging, full already, they are thin and veins are

looking like sausages wrapped in tissue paper.

Apply hand pressure, like a tourniquet 3 to 4 inches above location, as noted in this

article. You will see, the vein bulge a bit more. With hand pressure, hold, stick, and

a second person can help out with attaching, taping.

Before I start, after someone has had failed attempts.

1. Ask, why could you not get the IV placement?

a) Did the vein blow/pop?

b) Is it edema in the way?

c) Could not locate the vein?

2. This way you can prepare equipment, and know what supplies you may need.

a) Manual bp cuff

b) Press many areas of the person's bony areas for edema, and under there, you may just see a very good vein.

c) Patient may need to heat up, turn up the temp in the room (if patient is free of fever), get a warm compress (not too hot:), dangle that arm. Make sure that Tourniquet is tight.

Long ago, I had no option, had to place an 18g in a thumb vein. Saw the flash, and floated it in with a little NS gently.

I'm not good at getting IV's, I know people who are amazing. However, with these little tricks it is often, I do get it in.

Thank you for reading:) It's so important that we share experiences, to improve the nursing we provide to our patients today.

Fleur deLirious

Specializes in Rehab, Ortho, Telemetry. Has 28 years experience.

@SaltySarcasticSally -- You may not be fully into the vein. When you see the blood flashback, continue advancing just a smidge to make sure that the plastic cannula, and not just the needle tip, has entered the vein lumen.You should be more successful.

Edited by Fleur deLirious
clarification

This is a huge help but my problem is management AFTER I get blood return; coordinating the bandage without spilling blood everywhere. It can make the patient, let's say... a little less than confident in me, the nurse! Help!!! Please & Thanks!!!

@MJW1962 -- have you started by 1) informing the patient it might be a bit bloody; 2) placing gauze under the site of the catheter; 3) Placing a finger above the catheter to occlude blood flow; 4) having everything set up ahead of time so you can grab the connector hub and place it and then 5) tegaderm it?

I'm sure you're doing all those steps, but it not only takes practice, but it can be bloody. I tell patient's that from the get go. Once the hub is on, I clean up the area with alcohol swabs before I tegaderm it.

Good luck!

This is a huge help but my problem is management AFTER I get blood return; coordinating the bandage without spilling blood everywhere. It can make the patient, let's say... a little less than confident in me, the nurse! Help!!! Please & Thanks!!!

I second what a previous poster said about placing a 2x2 under the hub before removing the needle. I also have the covers to all connections loosened so I can easily remove the cover and hook up the IV. All tape torn and ready to go. I also use another finger to put pressure at the tip of the catheter to stop the flow of blood coming out and going everywhere, but the 2x2 is there just in case. It takes a little practice but I rarely have a bloody mess when starting IVs.

CKPM2RN, ASN, EMT-P

Specializes in Emergency/Med-Tele. Has 3 years experience.

VaccineQueen said:
Do you have any tips for little old ladies whose skin bunches up? Usually I'll get in but even holding traction with my thumb is just sometimes not enough!

In cases like these, or people who've had extreme weight loss I will often used another person to hold the excess skin away from the IV site.