Need some advice about IV starts

[CS#3]

i'm a new nurse doing an internship in the er were i'll be working upon completion. i'm having a real problem with iv starts, and i am curious if anyone else has this same problem (and if so, how do they cope). i can not see the deeper veins in the forearm. apparently everyone else can see the forearm veins as blue lines in the arm (as it shows in the textbooks). i can't see those blue lines. i've had a test for color blindness, and i'm not, so i'm not sure what the heck is going on. my contacts have a very slight blue tint to them, so i'm going to try just wearing my glasses next shift and see if that helps. am i the only one who has this issue, or are there other people that struggle with this? i mean, if they have good acs or hand veins i'm golden, but we all know that isn't always the case.

any advice??

p.s. while i'm still new, i don't feel this is a matter of i haven't had enough opportunities to stick. i've had other nurses, aides, students, and lay people point out vessels to me and all i ever seem to see is just plain skin.

[zahryia, LPN]

I'm not an expert in this. I pretty much suck at IV inserts myself. But I was taught not to rely on the visual and focus more on feeling for the veins.

Can someone explain why I shouldn't stick someone solely based on seeing the vein?

Thanks.

[iluvivt, BSN, RN]

Once you have mastered accessing veins that you can see and then feel you need to challenge yourself and go for the veins that you can only feel. Prior to accessing ANY vein you need to "feel" it and make certain it is bouncy and soft..that way you will train yourself on how they feel and behave. Try to train one finger and use that consistently. If you are able to access the veins you see then you can get the ones that you only feel with a bit more practice. You do not want to ever limit yourself to only those veins as you are wasting a valuable resource for the patient.If you start feeling around you will also get to know where those veins are and they do follow a predictable pattern in most people,although there are some variations. So this is how you can get a vein you only feel.

1. Locate the vessel and make sure it is soft and has some bounce to it. Avoid areas of flexion and the wrist..about 60 % of lawsuits related to IV therapy are in that wrist area...go slightly above or below it.

2. Set up everything as usual..hand hygiene and prep of course..JUST before you make the puncture..feel the vein again..you need to be VERY accurate here...so you need to be holding your traction with your non-dominant arm and feel with a finger on your dominant hand...IF you let go of the traction by the time you make the venipuncture things could shift...so you need to re-locate vessel after you have applied your traction...so feel and line the cannula up and puncture the skin...do not make the mistake of going too deep just b/c you can only feel the vein...if you have lined things up properly you should pop into that vein in no time. Sometimes I have to stop advancing and/or pull it back and feel for it again. You sometimes nick it on the way out and lose it this way so it is important to line it up really well

3. Sometimes the veins you can only feel tend to have thick walls..so an old trick of mine is to access from the top of the vein..I actually get on top of it and at a very low angle,almost flush..then when I know I am top of it...I increase the angle ever so slightly and do a very short controlled jab into it..this technique also works well if you are forced to use a vein that leans towards being sclerotic (sometimes that is our only choice for the time being)

[vamedic4, EMT-P]

No worries, it will come with practice. There was a time when I couldn't hit water if I fell off a boat when it came to IVs. The more you do the better you'll get.

Now, as to the question: I don't focus on veins that I can just "see". I have to feel them. I'm lucky enough to have sensitive enough fingers to feel deeper veins in our little population. Sticking veins that you only have a visual of can lead to problems, as many of these are not exactly as they seem. While it may seem that they are just below the surface, they may be deeper than you planned...and that may lead to a dig for a vein you thought was "right there".

iluvivt 's post is very informative, and she's spot on. Sometimes when you're looking at a vein and someone sees something you don't, it could be because the angle you're looking at is different, the lighting is different..et cetera. It's hard sometimes to come to a concensus that what you see might actually be a vein at all. And remember, starting IVs is all about location. One eighth of an inch to the left or right of a vein can be the difference between starting a good IV and missing completely or digging until someone threatens to stick you with a needle.

Try to feel the skin for the veins.

Follow the veins with your fingers up/down the extremity.

Make sure the area of the vein you are going to start the IV in is as straight as possible. Crooked veins are tricky and not very reliable.

As iluvivt said, bouncy and soft veins are the best to access. I can't tell you how many times I've seen kids and adults scream out in pain because someone tried in vain to access a tendon that they felt sure was a vein. Can you say OUCH?

Don't be surprised if a vein you just felt "disappears" after inserting the needle. This happens. You have to reassess the site, feel again for the vein. I always wipe the area again with alcohol because it helps to keep the site clean but also because I feel the vein better when it's wet than I do when it's dry. You may have to adjust your angle of attack from shallow to deep or from side to side. If you have to do this, try to do it as slow as possible to minimize discomfort for the patient.

Believe in yourself. You'll get it.

[IVRUS, BSN, RN]

"JUST before you make the puncture..feel the vein again."

I agree with iluvivt, but please remember that if you are placing a short term peripheral IV catheter, only touch the site again IF you've maintained sterility of your sterile gloves. i.e. You'd have to start with a sterile IV start kit so that you could prep the site, assemble the equipment and then don the sterile gloves that come out of the kit... and if you do NOT touch anything so as to contaminant your gloves you can re-touch the site. However, if you haven't maintained the sterility of your gloves, DO NOT retouch the cleansed area.

[IVmama58]

If you would like to develop finer palpation skills to be able to feel the veins try this. Take a phone book or yellow pages book. Place a single strand of your hair between 2 pages and practice feeling for it. Add additional pages one at a time and keep practicing to fine tune that ability to palpate even the veins you feel are impossible! It really works! Good luck!