Speaking of IVs... Need help (long story longer)

snowfreeze, BSN, RN · May 16, 2005

Taking too long a time after placing the tourniquet on the arm can lead to blowing nice veins. I find a vein, then take the tourniquet off while I prep everything I need then put the tourniquet back on for less than 30 secs if possible.

With some tough septic patients I have had a co-worker hold pressure above my site by clamping their hands around the arm a few secs prior to inserting the needle.

An already traumatized vascular system is tough to access.

fourbirds4me · May 16, 2005

As soon as I get flashback I stop advancing the needle and thread the catheter. If you advance the needle too far with those big needles you can inadvertantly go through the vein or nick the side... that's the only thing I can think of that may be causing your problem. I also try to go for forearm or wrist veins because they are bigger and don't get in the way as much when the pt is moving around and/or pushing. I don't know how many times I've lost a hand vein during epidural bolus or during pushing.

daisybaby, LPN · May 16, 2005

I'm a new RN grad in LDR (December) and I have the same problems! After a few weeks of getting IVs stated just beautifully, I seem to have lost my mojo- I can't hit ANYTHING. My co-workers are great about helping me out (after 2 sticks, I will defer) but I really want to be able to do it all on my own!

The leaving-the-tourniquet-on-too-long is one of my problems,I think- I hadn't thought about that...

Any other hints/suggestions?

BENNETTRN · May 17, 2005

I am a newer nurse also, and like you at my previous job we generally used #22's, never had a problem then so why now. A really good nurse I work with told me I was waiting to long to advance the cath, the cath gets warm and wont move as easy and you have to push so hard then, that the vein blows. The second you get return advance the cath before the pts heat warms it up to much. I havent missed one since, except for a really hard stick, so I should say I havent missed one since, from blowing the vein! Good Luck

stevierae · May 17, 2005

Hi guys!
Some of you may remember that I started L&D in November, so I am still (what I consider) new. The thread on gauges of IVs inspired me to write.
On the unit I worked at previously, we started IVs, but usually 22 gauges with IV team backup for many of them (Gyn Onc, so many of them were bad veins or central lines). So I did learn how to start IVs, and was a resource IV nurse for the unit.
Now L&D is another story. I'd say I have about a 40-50% start rate (1st try) with the 18 ga needles we use. Probably 70% second try rate, and I don't try more than twice before getting another nurse into try. And I tell you, most of these veins look GREAT! I can't believe I don't get them, and then there are those I get that I didn't think I would.
It seems that I blow a lot of veins, which leads to bruising or bumps on the ladies' arms. I hate this. It's not that I miss most of the time (but of course I do sometimes do), it's blowing the vein.
So I'm looking for your help. I do as much observation and asking the other nurses as possible at work, but you can't always follow someone around when they start IVs. It's funny, bc sometimes they call me in to start the ones they miss and I can *usually* get them. Funny, huh?
What tricks of the trade do you have to share? Any websites with help? I mean, I don't want to keep "practicing" on folks, that's not fair to them. I know I could do this with a smaller needle, I just can't figure out what I'm doing wrong with the larger one.
The worst was this weekend when a coworker was my pt and I missed her huge veins twice. Felt a little better when a more experienced nurse came to try and hit it her 2nd time saying, "You stick like a preeclamptic!"
Thanks guys.

Are you using Insyte Auto Guard, by BD? If so, there are a few tricks I can share with you that make it more "user friendly"---I used to teach the product. I suspect that you are angling your catheter too much--if you are using this product, try to angle it about 15-30 degrees above the skin, and remember that a flash may take a bit longer. Also, you do not feel a customary "pop" when you enter the vein with this product, so don't expect one. Remember "low and slow" for your approach.

Go to the thread entitled "IV tips and tricks" under Emergency Nursing, and you will find those hints I posted previously, as well as several pages of other general IV hints and tricks.

Also, it's always easier to start an IV in you make an intradermal wheal using 0.5% or 1% Xylocaine (Plain.) You can buffer it with NaHCo3--usually 1cc. NaHCO3 (from a multidose vial) per 10 cc. of Xylocaine---you can also get your pharmacy to pre-buffer your multidose vials of Xylocaine used for that purpose. Once you have a wheal created, you can go through that same wheal to start your IV, and you can use the wheal to guide you in how much to angle your catheter. Make your wheal with a 30 gauge needle. Your patient will feel only that tiny stick--like a bee sting--instead of the more painful stick of the 18 G. IV stylet.

You can also use warm compresses to make the veins really pop out, or have the patient dangle her arm below bed level and pump her fist a couple of times. Stroke her hand gently across the back of the palm--don't "flick" the veins with your fingernails as you see some people do; it hurts and it's unnecessary--simply stroking will make those veins pop right up.

zambezi, BSN, RN · May 17, 2005

As soon as I get flashback I stop advancing the needle and thread the catheter. If you advance the needle too far with those big needles you can inadvertantly go through the vein or nick the side... that's the only thing I can think of that may be causing your problem. I also try to go for forearm or wrist veins because they are bigger and don't get in the way as much when the pt is moving around and/or pushing. I don't know how many times I've lost a hand vein during epidural bolus or during pushing.

This is basically what I do also. Except that when I get a flash, I try to level out the IV catheter and I take the tourniquet off before I advance the catheter. Taking off the tourniquet has really reduced the number of blown IVs that I have had. Also using a bp cuff instead of a tourniquet helps on occassion too. I almost never use hand veins, I usually go for the forearm...

stevierae · May 17, 2005

As soon as I get flashback I stop advancing the needle and thread the catheter. If you advance the needle too far with those big needles you can inadvertantly go through the vein or nick the side... that's the only thing I can think of that may be causing your problem. I also try to go for forearm or wrist veins because they are bigger and don't get in the way as much when the pt is moving around and/or pushing. I don't know how many times I've lost a hand vein during epidural bolus or during pushing.

Actually, it's better to advance the entire unit--stylet and catheter--perhaps another 1/8" once you have achieved a flash--THEN thread the catheter off the stylet, into the vein. In that way, you know the tip of your CATHETER (and NOT just the stylet) is actually in the vein.

This is a common mistake with many new to IV access--I remember doing it myself years ago--they are so happy to see a flash, that they hurry up and try to thread the catheter--and it buckles. It won't thread. They are confused, as there is blood in the flash chamber---what happened is that blood entered the flash chamber when the STYLET entered the vein--but the tip of the catheter itself was not yet in the vein.

BENNETTRN · May 17, 2005

Thanx everyone, you guys gave some great tips!!!1

endlesssummer1 · May 17, 2005

Please explain to me how to search for the Emergency Nurse I.V. tips and tricks. Thank You.

pebbles1977 · May 17, 2005

Thank you guys for all your hints! I will definitely try them. I was told by an IV nurse to advance the unit a bit after getting the flash before threading. I wonder sometimes if I'm at a bad angle doing that or what. What angle do you guys advance it at?

Also, to the one who asked about the ER IV thread. I found it, but had to go back through several pages of the ER board. It was pretty helpful, although they got off topic a couple of times. I'm not sure how to search for it specifically, but it's there. Of course I got sidetracked a few times by their stories! Fun reading. I'm addicted now! But just go back several pages, you'll find it.

Guys, please do keep your advice coming!

Hairstylingnurse · May 17, 2005

:smiley_ab great tips everyone, keep em coming.