Rolling Veins: A Quick Guide to Being a “Good Stick"

"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.

What are Rolling Veins?

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.

1. 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. 
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. To prevent infection, never palpate directly over the area you just cleaned.
9. 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.
10. 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.
11. 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.
12. 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.
13. If you are getting labs, you can connect your transfer device, and lab tubes and blood should flow freely.
14. 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.

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