Special questions about putting in IVs?

nightingale, RN · Jun 29, 2006

There is no need to rush; it sounds like you may not be piercing fast enough (again, do not rush until you gain comfort).

I betcha we will hear from some expert Nurse who can walk you through their technique. Good luck to you!

tridil2000, MSN, RN · Jun 29, 2006

I am wondering why putting IV's in pts is such a "easy" job for the ER staff?
I have been doing this for a little while and I still don't understand why I cannot get the technique down.
My main question is :
When I insert the needles, most of the time, I don't get flash back. I know I have not "hit" the veins. I always, almost 99% of the time, I will have to fish for the veins and finally get a flash back.
Do you insert your needle on the top and middle of the vein? Or do you go from the side? or do you do it like you are hooking the vein up from the skin? I have seen some people did that and it looks like a good technique. What have I done wrong? how come I can never get a flash back right away after I insert the needle?

if the vein is plump and juicy, (lol for lack of better word!) do not angle too deeply... just pierce the skin at about 35' and aim. visualize the vein... aim for it.

if the vein is thin and more superficial, pierce below the site you want, also at only 35', and try to 'land the tip in the vein' as you insert about a 2cm or 3.

always make sure the vein is staight and at least as long as the catheter you're using.

"how did the nurse get so good at ivs? practice, practice, practice."

EricJRN, MSN, RN · Jun 29, 2006

When I first started sticking, I got feedback on two issues which helped me a lot. First, make sure the tourniquet is snug and you wait a little bit to let the veins pop up before making your decision to stick one. Second, make sure you're pulling the skin taut just below the intended site, anchoring the vein before you try to hit it.

papawjohn · Jun 29, 2006

Hey LuvBuble!!!

Love your handle!!!

Here's how I've taught many newbies to start IVs--first, put the tournequet around your own arm.

You will soon (probably) see or (almost certainly) feel the veins. Your Pt's anatomy is very much like yours. (That may or may NOT be a comfort-eh?)

Now, having selected a vein that promises a long life and no 'bent-elbow occlusions' and similar problems--put your left (or--politically correct--non dominant) index finger on that vein and (as someone suggested) VISUALIZE. You should have an image of that needle going straight up that vein. Like Captain Kirk would have said: "Make it so, Mr Scot." And just do it.

You will very quickly get a reputation as the best IV nurse around and have many more opportunities to practice.

Papaw John

vampireslayer · Jun 29, 2006

I can SO RELATE! I remember saying, over & over, when I first started: "why can't I do this? It's not brain surgery!". I just couldn't get my IVs...I still have bad days, but then again there are days when I get everything, and I LOVE having that pt who says last time they were in our ER they got stuck 7 times before someone got the IV, and I get it 1st try!

Some things that helped me:

* sit down while you stick. Somehow the steadiness added by sitting really helped me a lot. I felt steady standing up, but once I started sitting down to do it, I started getting LOTS more of my IVs.

* that "hook" thing you're talking about...yes! That's really a way to grab the vein quickly before it rolls away from you. I do that, without really thinking about it. When people tell you to stick quickly them IMMEDIATELY lower the angle, that's what they're doing, is that "hook" thing.

* make sure that you've got the catheter into the vein before you try to advance it...often you'll stick the needle in, but the plastic catheter is a few millimeters below the tip of the needle. Take a look at them, esp. the bigger gauges, like an 18, the plastic catheter is a ways down the needle...you can have the needle in the vein, but the catheter isn't quite in yet.

* I always go from the top, but sometimes the darn thing rolls away from me and I end up off to the side...just keep the catheter inserted, take a deep breath, and start over with a quick stick toward the vein, but without removing the cath from the insertion point.

I know how frustrating it is! Believe me I've been there. It honestly does just take practice. I started out trying the AC veins all the time, thinking that they would be the easiest because they're so big...but found out that often they turn below the surface in a direction I'm not expecting and I couldn't get the darn thing to advance. Try hand veins and forearm veins...those ones you can see a good long length of nice straight vein.

Good luck!

VS

PedsER-RN, BSN, RN · Jun 29, 2006

i am wondering why putting iv's in pts is such a "easy" job for the er staff?
i have been doing this for a little while and i still don't understand why i cannot get the technique down.
my main question is :
when i insert the needles, most of the time, i don't get flash back. i know i have not "hit" the veins. i always, almost 99% of the time, i will have to fish for the veins and finally get a flash back.
do you insert your needle on the top and middle of the vein? or do you go from the side? or do you do it like you are hooking the vein up from the skin? i have seen some people did that and it looks like a good technique. what have i done wrong? how come i can never get a flash back right away after i insert the needle?

practice, practice, practice!

one thing i didn't see mentioned (or maybe i overlooked it): try starting with a very flat angle; a problem i repeatedly had was going too deep and then having to pull back and flatten out-once i started flat from the beginning i got a lot more iv's.

if you have a rolly one, take your free hand, and using your thumb and index finger, put one on each side of the vein and pull the skin taught. this braces the vein and makes it a lot harder (although not impossible) for it to roll.

remember that you don't have to insert the whole needle (esp. true for fragile veins); once you get the bevel in you can start threading.

remember, nobody's perfect-we all miss from time to time; practice and you'll get better.

:balloons:

Luvbuble · Jun 29, 2006

I can SO RELATE! I remember saying, over & over, when I first started: "why can't I do this? It's not brain surgery!". I just couldn't get my IVs...I still have bad days, but then again there are days when I get everything, and I LOVE having that pt who says last time they were in our ER they got stuck 7 times before someone got the IV, and I get it 1st try!
Some things that helped me:
* sit down while you stick. Somehow the steadiness added by sitting really helped me a lot. I felt steady standing up, but once I started sitting down to do it, I started getting LOTS more of my IVs.
* that "hook" thing you're talking about...yes! That's really a way to grab the vein quickly before it rolls away from you. I do that, without really thinking about it. When people tell you to stick quickly them IMMEDIATELY lower the angle, that's what they're doing, is that "hook" thing.
* make sure that you've got the catheter into the vein before you try to advance it...often you'll stick the needle in, but the plastic catheter is a few millimeters below the tip of the needle. Take a look at them, esp. the bigger gauges, like an 18, the plastic catheter is a ways down the needle...you can have the needle in the vein, but the catheter isn't quite in yet.
* I always go from the top, but sometimes the darn thing rolls away from me and I end up off to the side...just keep the catheter inserted, take a deep breath, and start over with a quick stick toward the vein, but without removing the cath from the insertion point.
I know how frustrating it is! Believe me I've been there. It honestly does just take practice. I started out trying the AC veins all the time, thinking that they would be the easiest because they're so big...but found out that often they turn below the surface in a direction I'm not expecting and I couldn't get the darn thing to advance. Try hand veins and forearm veins...those ones you can see a good long length of nice straight vein.
Good luck!
VS

Oh, you just answer one question that I have for today IV experience.

I tried to insert at AC and I couldn't even advance b/c of the tricky direction the vein was going. You can visualize where that darn thing goes until you actually advance the catheter.

Thanks, great info.

htrn · Jun 29, 2006

My favorite technique is to choose a vein that has two veins joining into one. I put the turniquet on, sit on a stool and raise the bed so that I am aiming up. I put a wheel of 1% lidocaine intradermally (my preference as I am a needle wuss and freak out whenever I have to have IVs done:chair: ) - anyway, I put the wheel between the two veins just below where they join - picture and upside down Y and put the wheel between the two prongs. I instert into the wheel at a very shallow angle and advance through the valve at the juncture of the two viens.

The Y vein is not always an option, but it's my first choice if I have the option.

One thought:idea: , can you go to surgery for a day and start IVs on their preop patients for a day? That really helped me get enough practice and with the experienced nurses, CRNAs and MDAs around to give me their pointers it really helped.

Luvbuble · Jun 29, 2006

practice, practice, practice!
one thing i didn't see mentioned (or maybe i overlooked it): try starting with a very flat angle; a problem i repeatedly had was going too deep and then having to pull back and flatten out-once i started flat from the beginning i got a lot more iv's.
if you have a rolly one, take your free hand, and using your thumb and index finger, put one on each side of the vein and pull the skin taught. this braces the vein and makes it a lot harder (although not impossible) for it to roll.
remember that you don't have to insert the whole needle (esp. true for fragile veins); once you get the bevel in you can start threading.
remember, nobody's perfect-we all miss from time to time; practice and you'll get better.
:balloons:

i always start with a flat angle and that makes it difficult for me to have my non-dominant (left) thumb to pull the skin taut. when i try to pull the skin taut below my insertion site, the left thumb will be in the way of the angio cath. how do you hold the skin? do you hold pt's skin by graping their hand from below? when you say," using your thumb and index finger, put one on each side of the vein" does it mean you pretty much grap onto the pt's hand from below and kind of pull the skin down? but wouldn't the vein go flat as well? wouldn't it be harder to stick if the vein is flat?

Happy-ER-RN, RN · Jun 30, 2006

I always start with a flat angle and that makes it difficult for me to have my non-dominant (left) thumb to pull the skin taut. When I try to pull the skin taut below my insertion site, the left thumb will be in the way of the angio cath. How do you hold the skin? Do you hold pt's skin by graping their hand from below? when you say," using your thumb and index finger, put one on each side of the vein" does it mean you pretty much grap onto the pt's hand from below and kind of pull the skin down? But wouldn't the vein go flat as well? Wouldn't it be harder to stick if the vein is flat?

Sometimes I use my left index finger to pull the skin taut from above the vein and maybe at the same time pull down with my left thumb--but not right below the vein, I kind of pull to the left. Either that or I just use my left thumb to pull it taut from below the vein, I just put my thumb down low enough so it is not in the way of my angio angle. When I do a hand (which I usually avoid, I hate all those tendons in there it just grosses me out) I hold their hand with my left hand, bend their fingers toward their palm and put my left thumb on the knucle below where I am sticking and pull the skin taut from there. You will not be able to see the vein as well after pulling the skin taut sometimes but it anchors the vein so you can hit it easier. You just have to know where you are going to stick before you pull the skin--sometimes I make an imprint with my finger nail right along the vein, this works especially well when you have to do blood cultures and you can't touch your site.

PedsER-RN, BSN, RN · Jun 30, 2006

i always start with a flat angle and that makes it difficult for me to have my non-dominant (left) thumb to pull the skin taut. when i try to pull the skin taut below my insertion site, the left thumb will be in the way of the angio cath. how do you hold the skin? do you hold pt's skin by graping their hand from below? when you say," using your thumb and index finger, put one on each side of the vein" does it mean you pretty much grap onto the pt's hand from below and kind of pull the skin down? but wouldn't the vein go flat as well? wouldn't it be harder to stick if the vein is flat?

if i'm starting it on the hand, then just have your thumb to the side of the iv and pull the skin taught. you may have to move your entrance point slightly b/c it may pull the vein to the side a little. depending on where the vein is, you can also hold hand skin taught by putting your thumb on the hand below the vein and then pull tension until your thumb is below the first knuckle.

as for the thumb/index finger thing, i guess i was a little unclear in that i didn't specify that i usually use this for forearms/ac's. since most iv's i start are on babies and kids (and an occassional adult), their skin tends to be tight and doesn't require as much tension to be held as an older adult.

this may make the vein go a little flat, so you may have to adjust the amount of tension you apply.