Rolling Veins: A Quick Guide to Being a “Good Stick"
Venipuncture and IV insertion are skills that take practice and experience. It’s a good idea to practice on patients with good veins and save the “hard sticks” for after you’ve improved your skills.
Members are discussing techniques and tips for dealing with rolling veins during venipuncture and IV insertion. Some members share personal experiences with difficult veins, while others offer advice on selecting the best veins, anchoring techniques, and using the appropriate needle gauge. Overall, the conversation revolves around strategies to improve success rates and minimize patient discomfort during blood draws and IV starts.
"Rolling veins" can be a pain—literally—for the patient and the phlebotomist or the registered nurse trying to get a blood sample or start an IV. Medical professionals sometimes use the term "rolling veins" to describe those veins that seem to move or roll away every time a needle gets close to them. This article will discuss a few techniques to help you be successful with venipuncture and starting peripheral intravenous lines for IV therapy.
Sometimes veins roll because the surrounding tissue is not strong enough to hold it in place, and an inexperienced nurse or phlebotomist doesn't know how to anchor the vein properly. The elderly often have fragile, thin skin with minimal collagen to hold the veins in place. Collagen is a protein that provides strength and structure to your skin. It's what makes younger people have that plump, fresh, smooth-looking skin. For older adults, a lack of this strength and support under the skin will result in the vein slipping away from the phlebotomist every time the needle gets close to the vein wall.
How do Rolling Veins Happen?
Try to imagine a piece of cooked spaghetti lying under a sheet of plastic wrap. If you try to insert a needle through that plastic to puncture the side of the noodle, it will slip away from you. Now imagine gently pressing down on the noodle from above and below, where you stick it to hold it in place. If you can anchor the noodle, you'll have better luck puncturing the side. The same process will help keep a vein still. With a little bit of practice and a few tips, you can successfully access even the most slippery veins.
Risk Factors
Sometimes there is no known reason for patients who have these rolling veins. Often patients will say they have rolling veins because healthcare professionals have told them after multiple unsuccessful attempts that their veins roll. It's a good practice always to ask your patient if they have been a difficult stick in the past and if they have a vein you should avoid.
Sometimes patients have risk factors that make rolling veins more common:
Elderly or very young children
Poor hydration
Chronically ill patients
Very thin, fragile skin
Malnourished individuals
Tips for Dealing with Rolling Veins
With a few simple steps, you can be more successful with IV starts, and blood draws. Try these tips with your next attempt.
Selecting the best vein starts by choosing the straightest blood vessel you can find in a patient's arm that has at least ½ to 1 full inch of the visible vein. Make sure the patient is not cold and has had plenty of water.
Have the patient hold their arm straight, and if you're using a hand vein, it helps for them to bend it down at the wrist to anchor the vein from above.
Use a tourniquet tied in a slip knot to make the veins puff up, but don't tie it too tight. Put it about two to three inches above the insertion site.
It is best to release the tourniquet after one minute, but never for longer than two. If you need to, release it while the disinfectant is drying and reapply it just before you stick.
Clean the site you plan to stick with an alcohol swab for at least 15 seconds or Chlorhexidine solution for 30 seconds with a back-and-forth scrubbing motion and let it dry before puncturing the site.
Your patient can make a fist, but never "pump" their hand, as this can alter lab values. Sarah at RegisteredNurseRN provides some great tips for determining when a vein might roll and how to anchor them.
Using your non-dominant hand, wrap your fingers behind the patient's arm or hand and gently press in and pull down to "anchor the vein" with your thumb about two to three inches below where you want to stick.
To prevent infection, never palpate directly over the area you just cleaned.
Use the smallest gauge needle you need to get the job done. For blood work, a 21-gauge butterfly needle is a good option. For IV therapy, a 20 or 22-gauge IV catheter needle is sufficient unless you are giving blood products. You would only use a 22 to the 24-gauge needle on a young child.
In one smooth motion, puncture the skin directly above the vein, but only at about a 15 - 30 degree angle. You should feel a gentle pop and see blood return in the hub of your needle.
Gently drop the angle of your needle slightly and advance it just enough to ensure the tip of the catheter is entirely in the vein.
If you are starting an IV, do not push the needle itself in any further, but push the catheter off the end of the needle, then pull the needle out.
If you are getting labs, you can connect your transfer device, and lab tubes and blood should flow freely.
Once your blood is flowing freely, don't forget to release the tourniquet! This step will help reduce bruising.
Rolling Veins vs. Blown Veins vs. Collapsed Veins
Blown veins occur when the needle punctures through the vein wall, and blood leaks out from the hole made in the vein. Sometimes, the walls of the veins are so fragile that as soon as the vein is punctured, blood leaks around the needle and appears to blow up. This occurrence makes the vein useless for a blood draw or IV insertions. A collapsed vein will sometimes occur when you put too much pressure on it, blood flow stops in that area, and the vein walls collapse. Nurses can resolve it by releasing the pressure on the vein or releasing the tourniquet.
Summary
Venipuncture and IV insertion are skills that take practice and experience. It's a good idea to practice on patients with good veins and save the "hard sticks" for after you've improved your skills. Be sure not to stick with your patients more than once or twice. If you miss the first one, getting someone you know is a good stick to try the next time. There will always be another patient you can practice on. Your confidence has a lot to do with your success; the more you miss, the less confidence you will have. Learning how venipuncture works and how veins react to it can be a significant first step in accessing even the most difficult veins.
STAFF NOTE: Original Community Post
This article was created in response to a community post. The comments and responses have been left intact, as they may be helpful. Here's the original post:
Quote
I start a lot of IVs. On all kinds of people.
Patients frequently tell me "I have rolling veins". Meaning some nurse(s) missed, and blamed the patient.
There are many conditions that can make an IV difficult. Obesity, IV drug abuse for example. But what the heck is a rolling vein? Of course they can move a bit, that's why you anchor them. And, even if they did roll, unless it rolls out of the patients arm, follow it. How far can it roll?
So knock it off. If you miss, you miss. We all miss. Better luck next time. 90% of the time somebody else gets it using the same tools as you.
RegisteredNurseRN. [Username]. (2012, September 15). Prevent a rolling vein when starting an IV or drawing blood [Video].YouTube. https://www.YouTube.com/watch?v=MbG_1-_mnoo
Specializes in Nurse Leader specializing in Labor & Delivery.
At my last job, I sometimes filled in in the lab. When I was in there, it might mean as many as 25 blood draws in 3 or 4 hours. And yes, I've experienced veins rolling to the side. I have gotten better at chasing them and fishing around successfully, but not always. I consider myself an excellent IV starter/phlebotomist. But sometimes veins roll and I can't get them. And sometimes I just can't get them for whatever reason.
Hey nursegirl525 i'm a phlebotomist i been a phlebotomist since 2008 any way when you see veins like the ones you describe get your thumb and pull back the skin just below the vein this way you hold it down and it does not roll
We've all had experience with that huge rope that ran away when we tried to stick it with the 18g IV even though it looked so easy. Especially when the the patient has thick skin. Thick skin + rolling vein = bad combination.
hherrn, I am good but not great at IV sticks and blood draws. Since I work LTAC, our patients have been getting stuck daily, some several times per day, for months at a time. Many of them are elderly and/or obese, and A/V fistula in one arm, so we can't use that arm (per our policy). The more of them I do, the better I get. But I have definitely come across problematic rolling veins. Even when anchored, they still roll somehow out of reach. This is pretty common in elderly people who lack the sq tissue and muscle tone to hold everything in place. To top it off, they are usually "ropey" as well.
My technique is pretty simple, and I would say I have about 85% success rate. I spend a lot of time looking for the right vein. I massage, change position, use heat, and sans tourniquet if necessary. I am not afraid to go grab another RN who I know to be good and ask for assistance-either a confirmation of where I want to go, or just to have someone there to hold the arm if it will be an awkward position. Lastly, if I can tell that the veins roll more than usual, or if the patient know this, I try to go in from the side of the vein. It sounds counter-intuitive, like it would just roll further, but I have better luck with this method than I do approaching from the top. (and, of course, always anchor)
Specializes in Mental Health, Gerontology, Palliative.
Sour Lemon said:
I guess it's better than saying, "Sorry, but you're really fat."?
Speaking as a really fat nurse, the only time someone ever had trouble sticking me for an IV was when I was septic, dehydrated and has a temperature of 40 degees C (104F). It took this person (who apparently never had to stick more than once) seven attempts to get a line in.
So perhaps instead of sitting in judgement of patients you could get on and figure out how to improve your IV skills.
And also, master "floating" technique. It does miracles on LOLs with spiredy and rollery veins.
What is this 'floating' technique ? Curious. I'm always looking for ways to better my iv-fu (like Kung fu but with needles).
One of my favorite techniques, on patients with sclerotic rigid veins, which impede the progress of the IV catheter : I stick em, when I have blood in the chamber and if I have trouble moving the catheter up the vein, I take out the needle, connect my bag of saline and open the drip. The flow of liquid in the vein helps the me make the catheter progress up without friction (less chance of spasms)!
What is this 'floating' technique ? Curious. I'm always looking for ways to better my iv-fu (like Kung fu but with needles).
One of my favorite techniques, on patients with sclerotic rigid veins, which impede the progress of the IV catheter : I stick em, when I have blood in the chamber and if I have trouble moving the catheter up the vein, I take out the needle, connect my bag of saline and open the drip. The flow of liquid in the vein helps the me make the catheter progress up without friction (less chance of spasms)!
Floating is precisely what you so nicely described
Seriously?! ALL VEINS "ROLL" (aka travel) people!!! What the original posts author is trying to say is...stop telling patients things that aren't true. If you can't cannulate the vein, it's your skill that is lacking, it's not the patients fault and it is very unlikely due to their physiology...and unless they have had some medical issues or are/were an iv drug user, there is always a vein you can hit if you know what to look for. I've never not been able to find a vein; it's just a natural skill I guess, but when I hear a medical professional tell a patient that their veins roll, I cringe...it's embarrassing. If your patient is fat, use a tourniquet above the wrist, palmate, and go in the hand. The vein will roll, or "move" as ALL veins do. You have to take that traveling distance into consideration when you are deciding where to anchor and where to insert the bevel. If you don't go in with the right amount of force, at the right angle, and at the right velocity, the bevel will sometimes fail to pierce the vein wall and will subsequently "roll" OR push the vein to the side instead of cannulating it. Learn better technique and stop making stuff up. Rolling veins is not a condition, nor is it recognized medical terminology. I sincerely hope that phlebotomist or LPNs are the ones propagating this nonsense and not Registered Nurses.
Didn't realize this thread was old! I am thin, I am sitting here "rolling" the vein on the back of my hand from one side of the metacarpal to the other. And the cephalic vein from one side of my radius to the other. Yes veins roll, yes you can see ahead of time they may roll and there are techniques to anchor them. But nothing works every time.
I have seen "experts" from the best RN's I work with to anesthesiologists unable to access a vein. This is out patient surgery, not ER with a patient bleeding out or severely dehydrated. Sometimes we have to use the foot or an internal jugular vein. Some people just have really lousy veins!
I seldom tell patients it is their fault if I blow their IV. Occasionally, if we have developed a rapport, I say jokingly as I go get another nurse to start the IV, that is was their fault, they have bad veins.
What I think is more wrong (bad English?) is nurses saying, "I hit a valve", instead of just saying, "Sorry, I blew it". I have hit valves and a nurse can tell the difference between blowing it and hitting a valve. 99% of the time if you hit a valve you can pull the catheter back a little and or "thread" the IV through the valve.
Specializes in Nurse Leader specializing in Labor & Delivery.
volfanrn said:
Seriously?! ALL VEINS "ROLL" (aka travel) people! What the original posts author is trying to say is...stop telling patients things that aren't true. If you can't cannulate the vein, it's your skill that is lacking, it's not the patients fault and it is very unlikely due to their physiology...and unless they have had some medical issues or are/were an iv drug user, there is always a vein you can hit if you know what to look for. I've never not been able to find a vein; it's just a natural skill I guess, but when I hear a medical professional tell a patient that their veins roll, I cringe...it's embarrassing. If your patient is fat, use a tourniquet above the wrist, palmate, and go in the hand. The vein will roll, or "move" as ALL veins do. You have to take that traveling distance into consideration when you are deciding where to anchor and where to insert the bevel. If you don't go in with the right amount of force, at the right angle, and at the right velocity, the bevel will sometimes fail to pierce the vein wall and will subsequently "roll" OR push the vein to the side instead of cannulating it. Learn better technique and stop making stuff up. Rolling veins is not a condition, nor is it recognized medical terminology. I sincerely hope that phlebotomist or LPNs are the ones propagating this nonsense and not Registered Nurses.
As you just explained - all veins have the capacity to roll. Acknowledging that isn't implying that there's anything wrong with the person's anatomy.
Saying "Sorry, I missed that because it rolled" is not untrue, nor is it blaming the patient or their anatomy. Yes, it's due to poor technique or an off day on the part of the IV starter. But saying that the vein rolled is not "making stuff up"
Yes, some veins are rather mobile. The cause of a miss truly isn't always carelessness or a terrible skill level. But, a number of times I have seen interesting technique (primarily going very slowly and pushing the vein instead of puncturing it, going through or snagging the vein, etc.) and heard nurses say there was some sort of vein-related problem.
Complete miss = "rolled"
Snagged vein = "blew"
Punctured and went through = "valve"
Just my observations of technique and what nurses say.
These statements most often don't feel true to me (if I'm the one who had the unsuccesful attempt). So...on those (luckily occasional/rare) occasions, I simply say something like, "I'm not able to get this site to work this time; I'm really sorry. I hate to poke twice and I know it's not pleasant for you, either."
I'm not great at starting IVs. My success rate is around 50%. There's not many IV opportunities in psych so I don't get to practice as much as I'd like to.
I don't blame the patient or their veins, other than saying that they might be a difficult stick. Actually, most of them will tell me upfront if they're hard to stick or not, and several even point out what veins I should try.
Well, a year and a half on (almost) from my post...I have had the opportunity (still do) to start tons more IVs. I'm at about 60%. I can't do really hand IVs to save my life, but I'm getting damn good at the antecubital.
In fact, my LVN asked me to start one for her patient today (she wasn't IV certified). I got it...took two tries (hand: fail; AC: score). So maybe up to 61%?
What has helped:
* Watching lots of YouTube videos on tips and tricks.
* Reading a few IV start books...not textbooks, but the "101 hacks to starting a successful IV every time" type that you can get for $2-4 on Amazon.
* Trying to pass up as few opportunities to start them as possible.
and most importantly:
* Knowing a per-diem coworker who does IVs all the time at her main job and who loves to help me develop my skills ?
I still try to avoid blaming the patient and their veins in any way, though truth be told, sometimes it IS the vein's fault: some of them do seem to go into hiding as soon as they see me ? If I miss, I just say, "sorry about the stick, let me try another site/get you the pro to start it"
Just my observations of technique and what nurses say.
klone, MSN, RN
14,857 Posts
At my last job, I sometimes filled in in the lab. When I was in there, it might mean as many as 25 blood draws in 3 or 4 hours. And yes, I've experienced veins rolling to the side. I have gotten better at chasing them and fishing around successfully, but not always. I consider myself an excellent IV starter/phlebotomist. But sometimes veins roll and I can't get them. And sometimes I just can't get them for whatever reason.