How to Start IVs Like a Boss

One skill that every nurse should have in their arsenal is being able to start an IV for any patient, at any time.

Here’s a master list of compiled knowledge and tips that you can use to become a genuine vein whisperer:

UPDATE: This article is part of a mega thread on IV insertion on the Nursejanx Forum: Click here to check it out!

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Be comfortable & relax before you start

This applies to everyone from EMTs, to paramedics, doctors, and nurses working in any type of setting.  It’s the same in a calm hospital setting as it is in the back of a bouncing ambulance, helicopter, or otherwise on the fly.

Some say to sit, some say to raise the bed up to your height and stand (if you can).  It’s all about your preference, so you do you.  You need to be comfortable to spend some time and be able to be dexterous in that position.

Take a deep breath and relax.  Talk to your patient to make it less stressful and tense for the both of you.  If you’re nervous and shaking you’ve already lost the battle before you’ve even uncapped the needle.  So keep calm and stick on.

 

Talk to your patient

Besides trying to calm and reassure your patient who’s about to have a needle in their arm, this is a good opportunity to discuss previous IV sites.

Sometimes patients know where they have good veins, and where others have tried and failed.  It can’t hurt to get more info.

 

Wear tight gloves

Some say just tear the tip off the glove, but that’s really not necessary, not to mention dangerous.  Just wear tight gloves and you’ll be alright.

If you absolutely have to feel without gloves, at least put some on after you’ve located a vein before you play with needles.

 

Go by feel

Veins that you can feel are nice and spongy are typically better veins to throw an IV in.  They are likely going to be sturdier than superficial ones that you can see but cannot really feel.

 

Go by sight

But hey, this world ain’t perfect, and sometimes you can’t feel a thing.  In this instance, you may be able to place an IV by seeing a smaller superficial vein.  The good news with this method is that your target is in plain sight, and should be relatively easy to aim at.  Just know that it’s probably going to be a very shallow vein, and its chances of blowing are probably higher.

 

Choose the right size IV catheter for the vein

Don’t try to shove an 18 in some little old lady with a tiny superficial hand vein that you can’t even feel, but can barely see through her paper-thin skin.  You need to select an IV gauge that is appropriate for the vein that will be accommodating it.  The catheter should always be smaller than the vein you’re inserting it into, otherwise, you’re going to blow it.  And just FYI, 22’s are not the end of the world.

 

Aim shallow before going deep

Putting a needle into a vein is kind of like cutting hair… you can always take it further, but you can’t always go back.  It’s better to aim shallow and take a little longer to hit the vein than it is to go in at too deep of an angle and end up going right through and blowing it.

Always start shallow, and slowly keep going deeper until you strike gold.  Also keep in mind that if you can see a vein, then it’s not all that deep.

 

Bevel down

Typically you should go in bevel up, but occasionally you may need to go bevel down.  The rationale is that for shallower veins where you keep puncturing all the way through, you need to reverse the bevel angle to avoid it.

 

Know the anatomy

This comes with practice and experience but you will begin to learn where to look for common veins.  Sometimes finding veins is easy, but most often it isn’t, so knowing exactly where to start looking is helpful.

 

Anchor the vein

Pull the skin taut around the vein in question so the bugger doesn’t move or “roll” on you.  If you need to re-evaluate your position once you’ve stuck, ease up on your grip and see where the vein is in reference to the needle.  Then pull tight again and keep going.

 

Advance the tip of the IV slightly after the flash

When you get in the vein, you will have a little bit of blood but the needle is slightly ahead of the catheter.  You should insert another few millimeters of the needle in before attempting to slide the catheter in so that it too is in the vein with the needle.  Otherwise, you risk blowing the vein, or it not threading.

 

Pop the tourniquet immediately after the flash

Better yet, if you can avoid tourniquets all together, then that’s great.  But for most people, you’ll need to put the tourniquet on to see anything.  The instant you have a flash of blood in your IV chamber, you need to get rid of the pressure.  The longer that stays, the higher the chance of the vein blowing under the stress.

 

Use a BP cuff as a tourniquet

If you work in an area with vital monitors on the walls, place the BP cuff on the arm and hit the “venipuncture” setting on the monitor.  Most patients agree this is a much more comfortable tourniquet, and it’s better at making veins pop up.

If you don’t have automatic BP machines with a venipuncture setting, you can still use a manual cuff and set the pressure to around the patient’s diastolic BP, which is usually around 55-65mmHg.

 

Chloraprep and alcohol swabs

Chloraprep and alcohol really piss veins off.  It makes them irritated and they dilate which is perfect for you to strike!

 

Warm compress

Peripheral veins shrink when people are cold because the blood leaves the periphery and returns to the core.  Warm the arms with blankets, compresses, k-pads, whatever you have, and you will get bigger better veins to poke.

 

Tapping

Tapping is a polite way of saying you’re striking the patient gently on the skin over the veins.  It will trigger inflammation in the area and make the veins pop up.  You probably shouldn’t try this on patients who are pissed off, or confused though.

 

Gravity

Let the arm hang off the bed for a while, and the blood will pool and expand the veins.  Whenever possible make sure the arm is below the heart level… gravity is your good buddy.

 

Fist pump

Tell the patient to make a tight fist, then relax, and repeat a couple of times in quick succession.  The reason for this is twofold.  One, you will encourage more blood-flow to the area with some muscle flexion, and two, you will be able to differentiate between a vein (which shouldn’t change much in feeling during this action) vs. something else like a muscle, tendon, ligament, or bone (which will probably change in feeling quite a bit during this action).

 

Avoid valves

Valves make it damn near impossible to thread an IV thru.  You can use floating techniques but it’s probably best to avoid the issue if you can.  Look for where veins join together (good probability of a valve there), and “knots” on the vein that you can see and feel.

You can also run your finger up the vein, pushing the blood out on the way back towards the patient while holding down pressure on a distal piece of the vein so it can’t refill with blood.  Where the blood flows back to and stops, you know there lies a valve.

But if you get good at floating in IVs, valves aren’t so scary 😉  Check out this article and video on valves, How to Test a Vein for Valves.

 

Navigating IVs through tortuous veins

Sometimes you find that you have great blood return because you’re in the vein, but you just can’t thread the catheter in all the way.  If the vein is twisty and tortuous, you can try rolling the catheter from side to side while simultaneously pushing and pulling it in and out.  This can sometimes help you get the catheter around some of the twists and turns in the veins if they’re not nice and straight.

 

Ultrasound and AccuVein

These are not your typical tools for IV starts but may come in handy for the ultra-hard sticks.  Usually, if you cannot get an IV without these devices, the patient probably needs a central line anyway.

 

IV Floating techniques

If you find that you are unable to fully advance the catheter, odds are you’ve run into a valve, or the vein turned.  Try twisting/rolling the catheter if it’s curvy, but if it is straight, back up just a bit, and try to float it.  There are two forms of floating.

One involves slowly and gently pushing on the flush as you are threading the catheter in.  This can help thread IVs that are just not going in without a good bit of force.  You should only be doing this if you have already gotten a flash and blood return because otherwise, you’re not in the vein.  So step one, get the IV in the vein and get your beautiful blood return.  Then connect your flush and pull back making sure you still get good blood return.  At this point, start gently pushing saline in, while slowly advancing the catheter until it is fully inserted into the hub.  This is my favorite method of floating, and I’ve had 100% success with it.

The other method is quite the opposite and involves pulling back on the flush until you get good blood return and maintaining that suction pressure as you advance the catheter forward.  This is done to keep a valve “open,” so that you can thread a catheter through it.  Some people swear by this method, but I prefer the first method.

Check out this article and video on IV floating, How to Float an IV Through Valves.

 

Practice, practice, practice

Get to know who is good at placing IVs where you work at and every time someone needs an IV go with that person to start it.  Watch a few, then try a few, and with more and more experience you will see yourself rise to become the next IV boss.

UPDATE: This article is part of a mega thread on IV insertion on the Nursejanx Forum: Click here to check it out!

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