Friday Flash Card Episode 1: Build A Strong Vein Game - IV Starts 101

Who doesn't love starting IVs?! Honestly, it's one of my favorite skills to complete and teach in the ER. Starting IVs can be the most intimidating BUT rewarding skills in nursing! IV insertion is part art, part science, and 100% practice. Whether you're a nursing student shaking as you hold that first catheter or a seasoned nurse chasing that perfect flashback, I've got some tips for you!

Set Yourself Up For Success

Before you even place that tourniquet, preparation is key. Make sure you have ALL your supplies at the bedside: gloves, IV catheter, IV start kit, flush, extension tubing, tape, cleanser, etc.

Once your supplies are ready, start your assessment in looking for that perfect vein! Keep in mind, patients who are dehydrated or have certain medical conditions may be more difficult. Most patients will tell you they're a hard stick (sometimes it's true, I'd say >50% it's false due to poor technique) but don't let that scare you, instead, say "Challenge Accepted"! (Just don't make the patient a pin cushion, if you fail after 2 attempts, get another nurse to help)

Vein Selection

1. Place the patient in a position of comfort for YOU, odd angles and poor access can decrease your chance of success

2. Review vein anatomy before IV insertion 

3. Consider IV use and potential limitations.

4. Pick an IV catheter that’s appropriate for the desired use. To be respectful of patient’s veins, pick the smallest size possible to accomplish the needs of the IV. If you don’t have to put in a 16g, don’t! If you need it, you need it! (See chart below for IV size recommendations- this will be patient specific, if you are unsure, please ask the RN prior to insertion)

   

5. Ask the patient if they have an arm they prefer. Some patients may have limited vein real estate due to restricted extremities (cancer, fistulas, etc).

6. Make sure to look and feel. In my experience, I can usually feel more veins than I can see.

7. Go for straight bouncy veins. (Veins should not pulsate - if you feel that it's an artery- stay away)

8. Look for the uncommon vein: look at the forearm or wrist (especially if they wear a watch), hand, back of the arm, etc.

9. Avoid joints, valves, and areas near previous attempts. Unless the patient is going for a CT with contrast - I avoid the crook of the arm (AC) at all costs. The patient will be constantly bending their arm and no has time to constantly deal with downstream occlusion alarms on the IV pump!

10. Start low (in the hand) and work your way up the arm.

Technique Tips

When I started out as a brand new baby nurse in the ER my mentor, John Williams, taught me a 6 step technique and I still use it to this day (it's how I teach too)!. After you've got your supplies set up and the tourniquet on, you're ready:

1. Hold the catheter with your dominant hand, putting your thumb and middle fingers on the sides of the catheter below the sliding mechanism to advance the catheter off the needle. (There is usually a grippy area on the catheter to place your fingers). This position allows your pointer finger to be free to advance the catheter and your ring and little finger to stabilize your hand on the patient.

   

2. Use your other hand to hold traction on the skin below your vein insertion site so you don’t poke yourself. Pull the skin TAUGHT - Most of the IV starts that I see in my students who are unsuccessful is because they don't have a good anchor on the skin. Anchoring the skin prevents the skin moving and the vein “rolling”. Don’t press down too much as you will occlude the vein all together.

3. Insert your needle/catheter into the skin

   Enter the skin at “sharper” angle approx. 30degrees from the level of the skin. *Once you have entered the skin, drop your angle to almost flush with the skin.

4. Enter the vein at a flat angle (almost flush with the skin).

5. Once you see a flash, STOP. Advance the catheter 1-2mm more. STOP.

6. Using your index finger, slide the catheter off the needle and retract the needle back into the safety device. *Make sure to advance the catheter ONLY. If you advance the needle also- you risk going through the backside of the vein and "blowing it". In most needles, there will be a one-way valve in the needle to prevent bleeding out of the catheter hub (but put a towel down just in case!).

   * Remember these steps: Needle tip into skin, flatten needle angle- move needle into vein, advance SLIGHTLY, hold everything steady and advance catheter into vein.

7. Attach the J-loop IV extension tubing to the end of the catheter.

8. If labs are needed, use the syringe or vacutainer to remove 5-10cc of blood. *If labs don’t need to be collected, flush the J-loop before connecting to the catheter so you don’t infuse air into the vein.

9. Once blood is collected, remove the tourniquet.

10. Secure the IV by using a transparent dressing, keeping the hub of the catheter visible.

11. Flush the IV line with saline.

Document your IV insertion.

Final Thoughts

I've started IVs in every condition: shaking hands, crying babies, trauma patients, and scared adults covered in tattoos. Sometimes it goes beautifully, sometimes it doesn't! Just keep practicing! Just like everything else, if you don't use your skills, you'll lose your skills.

New grads- keep asking questions and don't be afraid to fail. BE CONFIDENT, patients can smell fear. If they ask if it's your first IV start, say "The first one of the day". One of my nursing instructors told me (before my first IV start mind you): "People who say they have a 100% IV start success rate have either only done 1 IV or they're lying. No pressure, now let's go start that IV". After >20yrs in healthcare, my IV success rate isn't 100% but I'd venture to say it's >90% and that's after THOUSANDS of IV starts. Just keep learning and mastering your craft- before you know it you'll be the one they call to get that difficult IV stick or the one to teach the new RN.