Tiny vein tips for IVs

delrionurse · Dec 28, 2024

Tweety said:

This has been a game changer at my facility. The problem is our vascular access team will prioritize central lines and get to us when they can and they leave at 3pm.

This is part of the systemic problem. Hospitals are 24hrs/7 days. IV starts and hard sticks are 24/7 and are not box up in a bubble that only come in 7am-3. There is no consideration for nurses who work beyond these hours. They are told to 'wing it', instead of consideration for good patient care. Instead they are told 'come on, someone can do it', even though other nurses have their own mess, instead of considering there is a 6:1 ratio, on tele, blood transfusions, emergencies, etc...

Tweety, BSN, RN · Dec 29, 2024

delrionurse said:

This is part of the systemic problem. Hospitals are 24hrs/7 days. IV starts and hard sticks are 24/7 and are not box up in a bubble that only come in 7am-3. There is no consideration for nurses who work beyond these hours. They are told to 'wing it', instead of consideration for good patient care. Instead they are told 'come on, someone can do it', even though other nurses have their own mess, instead of considering there is a 6:1 ratio, on tele, blood transfusions, emergencies, etc...

100% agree. While the Rapid Response Nurse can do ultrasound guided IVs they are busy with emergencies 24/7. It sucks and delays care.

AnnieOaklyRN, BSN, RN, EMT-P · Dec 29, 2024

delrionurse said:

This is part of the systemic problem. Hospitals are 24hrs/7 days. IV starts and hard sticks are 24/7 and are not box up in a bubble that only come in 7am-3. There is no consideration for nurses who work beyond these hours. They are told to 'wing it', instead of consideration for good patient care. Instead they are told 'come on, someone can do it', even though other nurses have their own mess, instead of considering there is a 6:1 ratio, on tele, blood transfusions, emergencies, etc...

Oh I get it, BUT with that being said a good majority of us do vascular access nursing, not just because we like it, but because it's usually a day/evening job with no nights, unless you are at a large academic facility! My team works until 1900, except on holidays and weekends, we work until 1500. They have talked about expanding us to the overnight shift, but a majority of us have said we will quit if nights become required. All but two of us are in our late 40s and 50s, and one in her 60s and nights just isn't doable anymore, as you get older your body is MUCH less tolerate of changes to your sleep habits, and most VAT nurses tend to be on the older side as it's a good job to wind down your nursing career. I cannot sleep during the day no matter how tired I am and no matter what I do to darken the room, I tried night shift to get a labor and delivery/ postpartum job and just couldn't adjust to it. Anyway, long story long, I think a majority of your experienced VAT nurses would move on to something else if nights became a requirement. My previous hospital where I worked IV team worked until 1am, but after I left for greener pastures, the manager could not find anyone else that was willing to work 1pm to 1 am, so she changed that shift to 11am to 11pm, and still couldn't find anyone, so they finally made their hours 9a to 9pm and managed to recruit people to work. There are of course the morning/day shifters who start at 5 am, that's def not for me, anyway you see my point.

Some of the limitation in our facility is that the only other departments that have regular access to an US machine to do IVs is the ICU, ED, and PACU. The nurses in the ED and ICU pick up the slack on night shift, as do some of the night supervisors because they have access to our office and the machine. We have worked tirelessly to get as many ED and ICU nurses trained to do USG IVs as are willing, especially night shifters. A majority of IV starts are not urgent and can wait until the am when we arrive in the AM, if no one is able to do it on the over night. As others have said, it is ultimately up to the provider to get access if it is urgent and no one is able to get a PIV, whether that is approving an IO to be placed or placing a central line or an EJ, that's up to them.

-T

Pearybrown1 · Jan 1

I seldom use tourniquet on small and frail vessels. I lower the arm below heart and rub entire arm for several minutes until it attacks fluid w/o raising vien pressures. Go in real slow.

Mickeyii · Jan 9

Are you putting the tourniquet on so tight that you're restricting blood flow? You need to allow arterial blood flow into the limb but restrict the venous flow out of the limb so the veins will plump up. Also, if they're too over inflated they might blow when the needle hits it so don't over do. When I started IVs on old ladies with bulging veins I usually didn't even use a tourniquet.

Jessica Jackson · Feb 7

I've been the queen bee of the IV in my ER for over a decade. For tiny veins use a 22 or a 24 gauge. Plump it up by hanging off the bed if possible or warm it up, be patient and wait for it to plump up alot of old people and sick kids are dehydrated. And make sure you pin the vein with a finger above where your sticking and a little traction spider webs like to roll and blow easy. Sometimes I even need to hold traction from above and below to keep a vein from rolling. Stick just under the skin and when you get flash advance it just a hair further so the actual catheter is in the vein before you thread not just the very tip of the needle, thread slowly and gently. However, most patients have better veins deeper so learn to stick by feel go for a vein you can feel over one you can see every time. But sometimes unfortunitly all there is is spider webs. Most patients have 2 or 3 good veins in the ac. The side of the wrist. The side of the forearm on the thumb side. If veins are terrible lower look high. Alot of times they have a decent one in the bicep or shoulder or chest wall..... Im an ER nurse in an emergency I will put a line wherever I can get one. I've seen a 24 gauge in a shoulder save lives several times. also if your facility has a portable ultrasound machine learn to use it/ get certified to use it. It's a godsend for a patient with no surface veins. I hate the vein finder if your not good at sticking by feel its a tool but for me I can find any vein that thing can I prefer the ultrasound for finding much deeper more stable veins. When sticking babies or small children- Lots of holding help and I like to stick next to the vein and wait a few seconds after im through the skin to stick the vein from the side, they stop fighting so hard and breathe after a few seconds usually which will help keep those little veins from collapsing. Also for older babies 5 months+ and toddlers I like to look in the foot first. They have great feet veins alot of times and they won't try to mess with it as much. Out of sight out of mind. Hope this helps. Getting really good at ivs takes time, practice and it is an art.

mariaconcetta · Feb 7

Thank you so much for all your tips! I learn so much from nurses like you!!

Leader25, ASN, BSN, RN · Feb 7

topical lidocaine sounds good but I have seen too many fail on infant circs,I use my own infant transilluminator which can be used on an adult hand and it still helps you view,but for the most part it is the search inspect for a vien that should take up 90%of the process.

AnnieOaklyRN, BSN, RN, EMT-P · Feb 13

Jessica Jackson said:

I've been the queen bee of the IV in my ER for over a decade. For tiny veins use a 22 or a 24 gauge. Plump it up by hanging off the bed if possible or warm it up, be patient and wait for it to plump up alot of old people and sick kids are dehydrated. And make sure you pin the vein with a finger above where your sticking and a little traction spider webs like to roll and blow easy. Sometimes I even need to hold traction from above and below to keep a vein from rolling. Stick just under the skin and when you get flash advance it just a hair further so the actual catheter is in the vein before you thread not just the very tip of the needle, thread slowly and gently. However, most patients have better veins deeper so learn to stick by feel go for a vein you can feel over one you can see every time. But sometimes unfortunitly all there is is spider webs. Most patients have 2 or 3 good veins in the ac. The side of the wrist. The side of the forearm on the thumb side. If veins are terrible lower look high. Alot of times they have a decent one in the bicep or shoulder or chest wall..... Im an ER nurse in an emergency I will put a line wherever I can get one. I've seen a 24 gauge in a shoulder save lives several times. also if your facility has a portable ultrasound machine learn to use it/ get certified to use it. It's a godsend for a patient with no surface veins. I hate the vein finder if your not good at sticking by feel its a tool but for me I can find any vein that thing can I prefer the ultrasound for finding much deeper more stable veins. When sticking babies or small children- Lots of holding help and I like to stick next to the vein and wait a few seconds after im through the skin to stick the vein from the side, they stop fighting so hard and breathe after a few seconds usually which will help keep those little veins from collapsing. Also for older babies 5 months+ and toddlers I like to look in the foot first. They have great feet veins alot of times and they won't try to mess with it as much. Out of sight out of mind. Hope this helps. Getting really good at ivs takes time, practice and it is an art.

Please do not put PIVs in the chest, that is not the standard of care, and could get you sued if a large infiltrate occurs!! IO or ultrasound, pick one of those instead!! If you cannot find a PIV site in the arms, have the provider put in an EJ, or use ultrasound or an IO. Not worth getting sued and causing significant damage to a patients breast tissue or chest wall, when there are other safer options! Also remember if YOU put the IV in, you could be on the hook if the patient suffers significant damage and injury from an infiltrate, even if they are no longer your patient.

Also please do not place IV's in ambulatory infant's/toddler's feet, or adults for that matter, as you risk damaging nerves and tendons! Also not worth the risk of getting sued, if they are that sick place an IO, give them some fluids and check again for veins. Ultrasound is the best option for both adults and pedi patients, but I realize that isn't always an option in every ER. If you absolutely have to get an IV in a foot of a child that is at an age where they can normally ambulate, get a provider order to cover your ***. You are still on the hook if you do damage, but most hospitals have policies in place against foot IVs in walking patients without a specific order.

Also when you place IVs in the AC on a patient who will be admitted you are setting them up for an infiltrate and/or phlebitis in a short time, not to mention constant pump beeping!! I realize that in certain emergency situations that's the only option, but if it's not an emergency please take the time to look in the forearms for other veins that are not in a bendy spot, same thing with hand veins, try to avoid them, they to tend to infiltrate quickly and cause significant irritation and pain for admitted patients. When you place AC IVs you are also eliminating multiple decent vein options in their forearm since fluids/meds will now infiltrate out the previous AC IV if an IV is placed just below that site. I loathe people who think they are great at IVs and the only place they put them in is the AC! Please don't be that person!

Annie

MiCULove · Mar 17

Awesome tips!