Where have all the GOOD VEINS gone?

guzzebear · Jun 1, 2006

There are many great threads on IV start if you do a search....But here are some of the tricks I thought are really helpful.

1. I always look at both arms before I start. I tell my patient I only want to hurt once...so I have to look at all the veins.

2. I like the ones I can FEEL and see..but more feel. I got a hint on using the end of a pen to mark my spot if I a have loose skin...because once you clean the skin and keep the skin tight you can loose the vein.

3. We have warm blankets in the ER, so If I can't find anything....usuallly If I warm them up the veins come out....

dorimar, BSN, RN · Jun 1, 2006

Nah, it is not just you. The chronically ill are horrible sticks. I will add however, that i never allow 8-9 sticks. If you are unable to obtain access after 3-4 attempts by the best iv starter available, you should be informing the doc of need for central access or PICC.

jmgrn65, RN · Jun 1, 2006

our protocol is 2 sticks per nurse and the max. of 6 sticks,But there alot of people that are hard sticks because they have been in and out of the hospital, plus getting lab work done. I think it takes years to become very good. I think that I am very good at iv sticks I have been a nurse for 14 years and when I think back I didn't get good overnight, when I couldn't get a vien and asked who was a good stick I would try to pick up some of their techniques. If i recall correctly it took probably 5 years to become really good at it. So don't get discouraged, just keep trying. :)

Emergency RN · Jun 2, 2006

You also must realize that with everything, there is a point of diminishing return. When someone has really horrible veins, their clinical usefulness or productivity may be questionable, such that getting the IV or not becomes moot.

Assess the patients' overall clinical needs first. Such that if a patient's orders includes high frequency meds that are also very high dosage with widely abnormal pHs, then the chances of any IV lasting in them is almost zero. So, in essence, to struggle to achieve periph access in such patients may be a waste of time for you AND the patient. In such cases, It may be in the patient's best interests to forego the peripheral IV attempt and go straight to a picc or CVL.

Ralph

meownsmile, BSN, RN · Jun 2, 2006

We usually go 2 sticks then the best available goes for 2. If no access we start calling P-med to come and at last resort anesthesia to try.

Wrapping the arm in a warm blanket from a blanket warmer is usually a sure bet to get those veins to show themselves. Also if you can put the arm in a dependant position with the warm blanket, that works sometimes too.

Sometimes there just isnt an easy answer.

PCUSheryl · Jun 3, 2006

Clarification: I only stick the patient 2 times most of the time, 3 times when there is a shortage of nurses who are available to try. I have never stuck any patient 6-9 times. I meant that the patient ends up being stuck that many times, although even that many times is rare. But it DOES happen, and it's terrible for the patient.

I think there should be a policy that if a patient is stuck more than "X" number of times, we should seek a consult for PICC or central placement. That's something I can suggest at our next practice council meeting.

Thanks for all the good advice, keep it coming!

:nurse: Sheryl

PANurseRN1 · Jun 3, 2006

I've found that lack of success often comes from not taking enough time to really assess the veins. Often, people will stick the first one they see. That doesn't always work. In addition, not taking the time once the stick has been done is a problem. Just because you (not "you" personally) don't get an immediate flashback does not mean you're not in. Take a little time, reposition, and check again. I'm not suggesting to keep digging, but sometimes just pulling back and repositioning does the trick.

Also, if you feel tentative, your sticks are going to be tentative and you're probably not going to get it. You have to go in with the mindset "I am going to get this IV."

I have people dangle their arms over the side of the bed while I'm getting my things together. I also will use the warm compresses if needed. But the one thing that made the big difference for me was to just slow down and take my time. When I worked in the ED and we needed to get a line in STAT, that was different, of course.

And just realize that some days even the best "stickers" can't hit the broad side of a barn.

sabRN2b05, BSN, RN · Jun 4, 2006

I have been a nurse for 2 years and work in a stepdown unit. Most of my patients are elderly, have chronic diseases like CHF, CAD, DM, COPD. Many of them have had numerous hospitalizations for exacerbations of these diseases. They are usually what we call a "hard stick" and several IV start attempts are necessary.
I usually try twice, get another RN (veteran) to try, sometimes we even call ICU nurses (my heroes!!!...just an aside...accepted a position there a couple of weeks ago - waiting on a transfer date!!!).
Anyway, our docs are good at ordering PICC's for pts like this. All we have to do is ask.

Iloveveins · Jun 4, 2006

It's so much better for our patient's to be proactive...Think ahead to what type of venous access device is the most appropriate. At our 300 bed hospital we've developed an Early Vascular Access program. The patient gets stuck twice, if unsuccessful then or if the patient isn't able to keep a PIV for the 72 hours we can insert a midline without a MD order. The patient is so much happier, meds aren't delayed and venous damage is limited. Venous damage increases the risk of Upper extremity DVT (VTE), so we don't do the patient any good to "keep trying"!:)

WV_heart_RN · Jun 4, 2006

i am in exactly the same situation!! you are so right. it is a self-esteem buster at times.

we do our own ivs and lab draws on our floor. the iv team and lab techs get irrate with us when they have to come to our floor because they know we are supposed to do our own. but what to do when you just can not get access?

it is policy that every patient on our floor have iv access. so someone has to get an iv in!! but here of late it is getting harder and harder to do. i will try only if i think i can get it. if i look and say "no way!!" then i get someone else!

vampiregirl, BSN, RN · Jun 4, 2006

I guess I'm wondering if anyone else working with similar patients is having similar problems with IV starts. Do I need some more education or training on IV's? (My gosh, I have done so many, and I've watched probably hundreds) Any and all honest suggestions are welcome.

No, it's not you. I work part time for an EMS service, and we have been encountering the same thing. In addition to the diseases themselves and the effect on circulation, add in possibly dehydration, scar tissue from previous IV/ VP's, and the damage to veins from previous meds (repeated doses of steriods, just as one example). And I'm starting to see individuals with a history of IV drug abuse middle aged and older.

At least for me, the more tough unsuccessful IV sticks I have, the more frustrated I get, the more discouraged I get, etc. You probably don't need more training, just more reassurance and confidence. Good luck!