I am a relatively new nurse, less than 6 months, and one thing I noticed that I am still really struggling with is IV insertion. I was looking into taking a course offered for nurses at a local university. The summary of the program stated that it was incorporating information from the Infusion Nurses Society 2010 Standards of Practice, instead of the 2016 edition. Does it matter? Does anyone happen to know the differences between the two editions?
Doing IV starts is just an experiential thing. Classes are good for (kind of) showing you various techniques or doing part of an inservice training to allow you to start a line in a different location (say, External Jugular for those of you that consider that a central line). You still have to do the starts to get good at doing them. You will have periods where you can't get a line on anything and you'll have periods where you can't seem to miss. The thing to remember is that veins do have a kind of bounce to them and they don't pulsate. That being said, I've had instances where the patient's tissues perfectly mimicked a vein and it was but a bit of fat...
Know your landmarks and most people's veins don't vary much from what's "standard" so finding a good vein can usually be done simply because you know where the veins should be. Once you feel that bounce, start tracking that vein so you know which direction it goes. Some go straight up the arm, some have a kind of diagonal path.
Once I know which direction the vein goes, I usually anchor the vein by pulling a little downward and leftward (I'm right handed) so that the only way the vein can "roll" is right into the needle. I also try to start fairly shallow to get under the skin and also to keep from perforating the back side of the vein if it just happens to be a fairly flat vein. If not, I then go a little deeper and once I'm in the vein, I shallow out again to nearly parallel to the skin and advance another 2mm. This usually gets the catheter itself into the vein.
Also, I spend more time looking to find possible sites to use than I do actually sticking. Once I find the site, I'll loosen the tourniquet, prep the skin where I'll do the stick, make sure my equipment is assembled and ready, then I reapply the tourniquet and go for it. I'm actually pretty aggressive when it comes to actually doing the stick. I do the stick knowing that I'll get it on my first try. If I don't, that's OK, but I'll get it on this try. I also won't stick people more than I absolutely have to and there are people that I can tell immediately that are well beyond my ability to find a vein that I'm allowed to use...
SLAPPING the vein is counterproductive and one gloving IT is just plain wrong. When one "Slaps" the skin over the blood vessel, this causing undue pain to the pt and often results in vessel spasm. Two fingers tapped lightly above the Venipuncture site will release Histamine and cause the vessel to dilate, but do NOT do a four finger slap.
In addition, you must wear PPE, like gloves when coming in contact with all blood and body fluids, to say that that is the way you've been taught, and that you cannot turn around this bad practice is putting yourself at risk for exposure. We want you around Farawyn.... Please reconsider.
I've been putting in IV's consistently for the past 15 years in out patient surgery. (Well...the consistently part came has been the past 4 - 5 years.) I have no specific knowledge of the Infusion Nurses Society Standards of Practice for any year? I am sure any recent year would be fine. The basics of putting in "just" a regular IV are pretty much standardized over the past 15 years? As opposed to a PICC or other more advanced catheter options.
You Tube is great for educational teaching videos, there are many about inserting IV's.
I was not a natural born IV starter. I've went through years of tears. I've learned several of tricks, variations of techniques,that work for me. Don't give up. The number one, kind of duh trick, is take the time to pick a good vein, that means warm up the patient as much as you can.
You can see in your own hands. Stand in a cold shower, look at your veins, put the water on hot, see what your veins do.
INS publications come every 5 years, so 2011 was the previous publication, and now, 2016, in January to be exact was the last publication. Yes, many hospital RN's and LPN's have no clue what INS is, much less know their standards, but if anyone happens to be brought into a court of law for any IV related incident, INS will suddenly become very relevant. There are some significant changes that will affect your practice that have occurred int he last 5 years. One of them is to allow the short term, less than three inch IV catheter to dwell indefinitely in the absence of complications. A major change has been in what new research states can infuse into a peripheral vein. Before January, for a medication to infuse into a peripheral vein terminating in the arm, the osmolarity should be less than 600 and the pH should have been between 5 and 9. Now, the osmolarity has changed as newer research shows that up to 900 osmolarity is safe to infuse into that short term, peripheral IV catheter, and the pH should not be EXTREME. These ar ejust a few of the changes. www.ins1.org is their website.
You can also practice, I mean, "insert" new IVs on confused, debilitated, aphasic patients when you get a chance. As AkulaHawkRN stated, you get more success by being aggressive with your sticks. Don't be timid in sticking a vein. That leads to the veins rolling a little more than
you want. Anchor and support the vein, then pull the skin taut inline with the vein and give a firm and quick thrust forward.
You only get better with practice. I took a course in ultrasound guided insertions of angiocaths and even that took a while to get me settled into a comfort zone. But I did "insert" new angios in my confused, debilitated, aphasic patients when I had the time and got decent at placing them.
Specializes in Early Intervention, Nsg. Education.
I whole-heartedly agree that experience is the best teacher with hand-eye skills like starting IV's. When I went back to acute care after working at a LTACH full of patients with CVL's, I asked to be scheduled to work in outpatient surgery/day stay for a week. After 3 days I could practically throw the cannula like a dart towards some of these big guys going in for screening colonoscopies. Score! [emoji41]
On a different note, if you have a patient who has long term venous access, ask them where their best (or "least crappy") peripheral veins are if you need to draw peripherally or provide additional access. I have had CVL's continuously for the past 11 years. The antecubitals are totally off the list. Not that that stops people from insisting that I let them try, even though I know what the outcome will be. I have a few "decoy veins" that look good, feel good, but are so scarred that I know that not even the best Vein Whisperer could get anything out of it. However, I have a couple really awesome peripheral veins that few people even attempt because they're felt rather than seen. I'd suggest adding patients with long term venous access and parents of kids with CVL's to the very exclusive "find that elusive vein" club along with IV drug users. Before my own health problems got to the point of needing permanent access, I was amazed by people who knew where to find their best veins. Nowadays, I have a much different perspective. [emoji6]
I was extremely needlephobic all through nursing school (go figure) and still hate needles... So you can only imagine what I felt when I worked 5 months and didn't stick a single IV in. I avoided it like the PLAGUE. Month 8 of nursing, a fellow nurse tells me, "the people that are really good on this floor also had a first time and first fear and failed sticks. You won't be good if you don't try every time." Such a boost of confidence and the same day I stuck 2 IV's, one on an old man that was usually only ultrasound stick for everyone else. Ever since then I happily stick (or try to stick) everyone I possibly can. You'll learn what works for you and what doesn't, but only by sticking a lot. And you probably won't fail as much as you succeed. ðŸ˜
You can also practice, I mean, "insert" new IVs on confused, debilitated, aphasic patients when you get a chance.
But I did "insert" new angios in my confused, debilitated, aphasic patients when I had the time and got decent at placing them.
So are you telling us that you use vulnerable patients as your practice "dummies" without their permission and you choose the ones who can't speak presumably so they won't rat you out?!! How on earth do you think that is acceptable at any level? And admitting it on a public forum? What is wrong with you? There was another person in history that did exactly what you are doing. It didn't end well for him.
Another suggestion that our facility occasionally uses, if available, see if you can spend a day in Pre-op or the ED. Just spend the day starting IVs. If that could be available to you, ask your manager if you can. I know we've done this with a couple of our new grads when they were hired into the ED. I know one of them got about 35-40 sticks in a 12 hour shift.
Yup we have plenty of opportunities in pre-op or same day surgery. For me, I spend more time than most of my co-workers with vein selection (they have more experience). I like to look at both arms (if no restrictions) and feel without gloves before deciding on a vein. We have to use big needles- 20 minimum & 18s on hearts. So I want to make sure that I know exactly where I'm going before I stick.
I do think the only thing that helped me was hands on practicing. Even now, if I am unsure, I will ask for help from a co-worker for vein selection. Just to make sure I'm choosing the best vein that can support the gauge needle we use. I really try to avoid unnecessary sticking and sticking someone if I really don't feel and/or see something.
Specializes in Med Surg/ICU/Psych/Emergency/CEN/retired.
SLAPPING the vein is counterproductive and one gloving IT is just plain wrong. When one "Slaps" the skin over the blood vessel, this causing undue pain to the pt and often results in vessel spasm. Two fingers tapped lightly above the Venipuncture site will release Histamine and cause the vessel to dilate, but do NOT do a four finger slap.
In addition, you must wear PPE, like gloves when coming in contact with all blood and body fluids, to say that that is the way you've been taught, and that you cannot turn around this bad practice is putting yourself at risk for exposure. We want you around Farawyn.... Please reconsider.
As you are an IV infusion specialist, you are respected as the expert. However, after ten years in EDs, three of them Level I trauma centers, I can attest that my colleagues, many with more ED experience than I, and I shared all the tricks that we knew to help get that line NOW. The semantics of using the work "slapping" may have sounded too aggressive. A two finger "slap" will suffice.Your points are well taken. It is helpful for anyone, including those learning how to insert IVs, to hear your input.
A point that I forgot to bring up previously. Most people have a really good vein in at least 1 of 4 places. Their index fingers or their thumbs. This is not intended to be cruel or a punishment to patients that I thought were rude. This is literally sometimes the place of last resort prior to a central.
Oddly enough I actual had frequent flier that would come in, ask for me and then ask me to stick the vein in his thumb. This was due to fact I'd typically be able to hit that vein in one stick rather than his normal 7 or 8 sticks. Also recently had a lady that was unresponsive(but protecting her airway), that one of our team couldn't get a 2nd line in with the U/S. So she got an 18G in her thumb, which we then pressure bagged 0.9 through. Finger IVs work, as an (almost) last resort. I've intubated at least 1 person I can recall for certain with a finger IV and that was it.
I'm the nurse they call for difficult IV starts. It is one of my job duties and I'm good at it. However, if a patient is being stuck six, seven, eight times, IMO the correct thing to do is notify the physician of the difficulty. Often a picc or midline is a better choice for the patient. I was called on Sunday morning because a patient who needed 3 units of blood, a protonix drip and another IV for emergency use had only one IV that had taken 6 sticks to obtain. No brainer. Call the doctor. I placed a triple lumen picc line rather than put the poor guy through continued sticking. Part of our job as nurses is to advocate for our patients. Doctors do not know there are IV start difficulties unless we tell them. I know I do not want myself or a member of my family to go through the discomfort of repeated sticks. Why would I do it to someone else?
A point that I forgot to bring up previously. Most people have a really good vein in at least 1 of 4 places. Their index fingers or their thumbs. This is not intended to be cruel or a punishment to patients that I thought were rude. This is literally sometimes the place of last resort prior to a central.
Oddly enough I actual had frequent flier that would come in, ask for me and then ask me to stick the vein in his thumb. This was due to fact I'd typically be able to hit that vein in one stick rather than his normal 7 or 8 sticks. Also recently had a lady that was unresponsive(but protecting her airway), that one of our team couldn't get a 2nd line in with the U/S. So she got an 18G in her thumb, which we then pressure bagged 0.9 through. Finger IVs work, as an (almost) last resort. I've intubated at least 1 person I can recall for certain with a finger IV and that was it.
yes you can start an IV in what I call an alternate location such as a finger, thumb, shoulder, inner wrist etc and in an emergency you may have to, I know I have, but if this is all you can find the Pt probably needs better access such as a midline or a picc line.
akulahawkRN, ADN, RN, EMT-P
3,533 Posts
Doing IV starts is just an experiential thing. Classes are good for (kind of) showing you various techniques or doing part of an inservice training to allow you to start a line in a different location (say, External Jugular for those of you that consider that a central line). You still have to do the starts to get good at doing them. You will have periods where you can't get a line on anything and you'll have periods where you can't seem to miss. The thing to remember is that veins do have a kind of bounce to them and they don't pulsate. That being said, I've had instances where the patient's tissues perfectly mimicked a vein and it was but a bit of fat...
Know your landmarks and most people's veins don't vary much from what's "standard" so finding a good vein can usually be done simply because you know where the veins should be. Once you feel that bounce, start tracking that vein so you know which direction it goes. Some go straight up the arm, some have a kind of diagonal path.
Once I know which direction the vein goes, I usually anchor the vein by pulling a little downward and leftward (I'm right handed) so that the only way the vein can "roll" is right into the needle. I also try to start fairly shallow to get under the skin and also to keep from perforating the back side of the vein if it just happens to be a fairly flat vein. If not, I then go a little deeper and once I'm in the vein, I shallow out again to nearly parallel to the skin and advance another 2mm. This usually gets the catheter itself into the vein.
Also, I spend more time looking to find possible sites to use than I do actually sticking. Once I find the site, I'll loosen the tourniquet, prep the skin where I'll do the stick, make sure my equipment is assembled and ready, then I reapply the tourniquet and go for it. I'm actually pretty aggressive when it comes to actually doing the stick. I do the stick knowing that I'll get it on my first try. If I don't, that's OK, but I'll get it on this try. I also won't stick people more than I absolutely have to and there are people that I can tell immediately that are well beyond my ability to find a vein that I'm allowed to use...