I started working @ ER as a new grad this February and I am doing pretty well with everything EXCEPT starting a line!!! I know I am supposed to take my time, but I also need to draw labs before attaching the saline lock, so I need to do it pretty fast before blood hemolyzes. So far my score is 50/50 before I have to call my preceptor for help. Everyone is really anxious which does not help my own anxiety. I need help!!
So please~~ share some techniques/advices/experiences. I've asked around and the majority of the answers are: just do a lot of them and you'll get it.
Question1: I was taught to enter the skin at 20~30degrees, but I've seen a lot of people go about 15 degrees or lower. What do you guys do?
Question2: When you get a valvy vein, what do you do? Someone told me to just push through with the needle, but I ended up hurting the pt and had to try the other arm. What's your strategy?
Question 3: what is your favorite site for PIV? (besides ac) I don't like doing it on the hands b/c 1) it's painful and 2) i feel like it's going to blow easily.
Maybe my unit has fewer nurses with experience, but I found that I was pretty lucky with IVs, and now they come to me for help. As a new nurse there is nothing more gratifying than successfully starting an IV for another nurse in the last 10 minutes of the shift! I don't have any 'tricks" to add, except to say that the main reason not to rush is that most of the time the outcome is determined before you ever touch the needle to the skin - you either picked a good one, or you didn't - so take time and choose wisely. That said, there are somethings I can NOT do:
I have heard about "floating" an IV into a vein, and had ZERO success trying it. If a vein has valves, even if you manage to get flashback it seems more than likely it will blow. As others have mentioned, the back of the forearm often has a good vein, and it is usually long and straight! Hand veins seemed the easiest when I first started, but quickly became most of my misses, perhaps because they usually aren't straight, or because the patient makes little moves with their hands. One other thing: We don't use 24 gauge on my unit - the smallest is 22. I only resort to these if the pt is dry or an IV abuser. We sometimes do draw labs when starting an IV, just by attaching a 10cc syringe with a Luer-lock connector and drawing back to fill it - but I don't like doing it because it can be messy and all that manipulation of the cannula increases the chance of blowing the vein..
One thing I learned early on when considering a vein is to look at the length of the IV catheter, and figure out where you want to enter the skin so that the tip of the catheter ends up where you need it to -- like below valves, so you don't have to try to float through them.
It just takes practice. I worked as an ER tech for 3.5 years before I became an RN, and I've been a paramedic since 2003, so I've started a LOT of IVs -- heck, we had to have accessed veins successfully at least 75 times to graduate from medic school. Time and experience will make you a good "poker." :)
Sometimes gravity can be your friend -- let arms dangle, wrap them in warm blankets, etc. Also, sometimes using a BP cuff instead of a tourniquet can make veins appear that even the patients didn't know they possessed!
I have some regulars in the ER that request me for IV starts -- I have a good memory, and I know where their "good veins" are. One guy has nothing but knuckle veins left, and I can usually get a 22g in them -- but again, I have to visualize the length of the IV catheter correctly so I know where to enter the skin. Otherwise I end up against a curve or valve or a flippin' fork in the vein road.
I have also been largely unsuccessful in floating IVs through valves with some saline pressure ... it's worked a few times, but generally, not so much.
Where I work any nurse can take an "IV practicum" to practice, brush up or get over a dry spell. You spend 4-8 hours starting IVs for day surgery, scopes and intermittent transfusions. Most of those folks have pretty good veins compared to what you get in ER, but it gives you a chance to practice your technique, pick your veins and visualize the process. Plus you don't have the sense of urgency that adds pressure.
I really like to use butterfly needles caths. Maybe becasue my fingers are sort and fat, LOL. I have better control as I move the needle, and the cath forward. I also like that the cath is shorter, less chance of needing to float it through a valve. Plus it seems like the viens are less irritated by the shorter cath... but that could just be my bias.
We have a new anchoring system that I really like which makes even hand sites more stable..
nminodob
243 Posts
Maybe my unit has fewer nurses with experience, but I found that I was pretty lucky with IVs, and now they come to me for help. As a new nurse there is nothing more gratifying than successfully starting an IV for another nurse in the last 10 minutes of the shift! I don't have any 'tricks" to add, except to say that the main reason not to rush is that most of the time the outcome is determined before you ever touch the needle to the skin - you either picked a good one, or you didn't - so take time and choose wisely. That said, there are somethings I can NOT do:
I have heard about "floating" an IV into a vein, and had ZERO success trying it. If a vein has valves, even if you manage to get flashback it seems more than likely it will blow. As others have mentioned, the back of the forearm often has a good vein, and it is usually long and straight! Hand veins seemed the easiest when I first started, but quickly became most of my misses, perhaps because they usually aren't straight, or because the patient makes little moves with their hands. One other thing: We don't use 24 gauge on my unit - the smallest is 22. I only resort to these if the pt is dry or an IV abuser. We sometimes do draw labs when starting an IV, just by attaching a 10cc syringe with a Luer-lock connector and drawing back to fill it - but I don't like doing it because it can be messy and all that manipulation of the cannula increases the chance of blowing the vein..