Six Techniques To Nail The IV Every Time

Did you get the IV?

Sometimes it seems like your performance on the whole call can be reduced to the success or failure of the IV start. Rarely does the successful treatment of the patient hinge on a successful IV placement but sometimes it can certainly feel that way.

The best way to ensure that you’re ready when that make or break it IV start does come your way is to start a lot of them when the pressure is not on. If you wait until game day to practice, you’re a whole lot more likely to fail.

The single biggest factor that separates the IV virtuoso from the weekend hacker is practice and experience, so when the patient could use an IV, jump in there. The patient’s a kid. … Get in there. The patient is a frail, elderly woman on Coumadin. … Get in there. IVs are nothing to fear. Start practicing these six IV start tips. Before you know it, you’ll be an IV starting superstar.

1.) Pick your IV site in 12 seconds or less.

Sometimes we’re really looking for the best spot and sometimes we’re just stalling, but we tend to take to long to find the IV attempt site. It’s rare that the success or failure of an IV attempt hinges on finding just the right vein. It’s annoying for the patient and everyone else involved to watch you endlessly search for your IV site.

It’s not a halloween pumpkin.  You don’t need to search until you find the perfect one that speaks to you just right. Put your flashlight away. When 12 seconds has passed, pick the best site you saw, swab it up and go.

2.) Don’t just look, feel.

Sometimes the very best veins the patient has to offer aren’t visible to the eye. If you get in the habit of simply looking for veins your going to miss some great pickins’. Start by getting in the habit of feeling the good veins that you can see. With a little time, you’ll learn to feel the ones that aren’t visible as well.

Another trick for developing this skill is to learn to find all the veins in your own arm by feel. You can practice this while watching TV or sitting through Keanu Reeves movies. (Yes, he’s playing the same character in this one too.)

In case you were thinking it, no, feeling for veins doesn’t give you an extra twelve seconds. Feeling for veins isn’t an excuse to spend even more time massaging the patient’s arm when you should be making the IV attempt. Once you feel something that’s acceptable, grab that needle and go for it.

3.) Use solid traction.

A huge percentage of missed IVs are poor traction issues. Once you’ve decided on the exact point of entry, get in the habit of placing a thumb a few inches distal to the site and pulling traction. Pull harder than you think is necessary. The patient should feel a firm pressure. You’re trying to anchor down all that flesh and eliminate the possibility of movement.

We neglect traction because it makes advancing the catheter more difficult. Finding a spare digit to help advance the catheter off the needle can be hard with one hand busy pulling back on the skin. This isn’t an excuse to let go of traction at the moment of advance. Maintain that traction till the catheter is fully advanced.

One telltale sign that someone is guilty of chronic traction neglect is that they complain about patients “rolly veins”. “All my patients today have rolly veins”. No they don’t. You’re just not holding proper traction. All veins roll. (They’re round and suspended in tissue.) It’s your job to hold them still before you insert the needle.

4.) Use a shallow angle.

If you’re getting a brief flash in the chamber that stops before you have a chance to advance the catheter, you’re probably inserting the needle at an improperly steep angle. Some folks get the idea that they need to insert the IV needle at a 30 degree or even 45 degree angle. You’re not trying to dive bomb the vein there Red Barron. You’re trying to insert the needle tip within the vein.

Shallow out that angle. The closer the needle approximates the actual angle of the vein, the easier it will be to land the tip inside the vein where you want it.

5.) The catheter goes forward. The needle does not go back.

I see this one A BUNCH. (Sorry for shouting in here.) It’s even more common with the newer safety-glide type needle sheths. If you feel like you have good needle placement and you get a great flash but you just can’t advance the catheter without blowing the IV, this is probably your problem.

Once you’ve achieved proper needle placement and you’re ready to advance the catheter remember that the hand holding the needle does not move. Not an inch. Not a millimeter. The catheter needs to advance forward off the needle. The needle does not move backward out of the catheter.

The difference is subtle. From outside the vein (Where we happen to be sitting) the two moves look almost exactly the same. We try to advance the catheter but that first little push off the needle hub can be difficult. So, to help the catheter along, we move the needle hand back ever so slightly to get the catheter moving. As a result we pull the needle out of the vein before the catheter has a chance to find its home.

6.) Let the bad ones go.

Give yourself permission to fail sometimes. It’s not the end of the world if you miss an IV. Dispite what your partner tells you, nobody out there gets em’ all the time … nobody. And nobody learns good IV technique without blowing a few veins.

Pop off the tournequet. Pull out the needle and apologize to the patient. “I’m sorry, that one didn’t go where we needed it.” Then start looking for the next site.

IVs are uncomfortable for the patient. We didn’t get into this business to cause people pain and discomfort. That can make the sting of a missed IV even more difficult. Ultimately the patients pay for our failures. And some of them aren’t terribly gracious about it.

Learn what you can from the failed IV attempt, but once you drop that failed needle in the sharps box, forget about it. The previous failure has no bearing on your next attempt. Don’t let it haunt you. Document it. Include it in your hand-off report and own it, but don’t let it affect the next attempt.

Your last IV attempt is already in the history books. The next one is still a question mark. That makes the next one immeasurably more important. Go get the next one.

What other IV tips do you have? Why not type in a comment and let us know before you move on.

   

Related Articles:

Four Sloppy Iv Mistakes That You Should Avoid

Glucometer Errors

Five Assessment Findings That Should Concern You

Describing Pain

 

Comments

  1. These are great tips. I also encourage people to know where veins are anatomically. So if you don’t see them, you will have an idea where to try and feel for them as you mentioned.

    As an FYI – I have a free ebook “Uncovering Difficult IV’s” on my site. It’s in the free section and has other tips from field providers.

    Thanks for these.

  2. Tip 5 is like when you are stopped at an intersection and a car next to you slowly moves forward or backward and gives you the sense that you are moving.

    Thanks for the helpful tips.

  3. Sean Fontaine says:

    I read this at 34s yesterday morning when I was coming on shift, then a few hours later as I entered the Skyridge lounge to finish a report I heard, “Yeah she had rolly veins and I didn’t know you were going to take such a bumpy way into the hospital, if it wasn’t for that I would have had that line on her.” I couldn’t help smiling and laughing to myself as I sat down to finish my narrative. As always, thanks for having the balls to put yourself out there in the public forum, I’m still considering the guest post you suggested.

  4. Steve Whitehead says:

    Nice Sean …I’m glad my words turned out to be so prophetic. I’m still waiting on your guest post. get er done. (Is that phrase trade marked?)

  5. Steve, I just used this post in a training today and linked it from my new home. Great stuff as always.

  6. Ok so I just finished my IV Basic class. I’m covered in band-aides from the failed attempts of my class mates, but I can say I made a very large man cry during my first attempt. So it washes out. My question is this.

    What can I do to help advance the catheter in a more smooth, gentle and safer fashion? My finger kept missing the little tab on the catheter or it would bunch up before advancing under the skin. I have fairly large fingers.

    Any thoughts?

  7. “The catheter goes forward, the needle does not go back.” Thank you so much for putting that here. I was just getting the hang of IVs a few years back and I had the problem you describe a lot! I’m just now getting back into ems and I knew there was something I had learned in my prior short-lived ems days that helped me immensely. When I read your tip I knew that’s what it was. I don’t think that I would have remembered that and I’m so glad you posted it here. I already know it will help a ton and I have more confidence going in. Thanks!
    PS-Timmer, first I would make sure that you are not pulling the needle back after the flash.

  8. Anonymous says:

    Wow excellent tips, my favorite is number 5! Hit it right on the spot!

  9. Extremely helpful :) I am a culprit of #5.
    Thank you!!

  10. I am a culprit of #6. I tend to be very hard on myself. I am a recent RN grad and landed my first RN job where I have to start a lot of IV’s daily. I’ve been doing great and getting them in, but I can’t be too hard on myself….I can’t expect to make them every time. I have to remember to move on and not dwell on it. This article was very helpful for me. I’m going to go get the next one!!!! I can do this!!!!

  11. If you are careful and respectful of your patient, you will consider tip 1 useless. It sometimes takes a minute or more to get results for a successful first stick.

  12. One of the things I learned from a long time IV nurse was not to “dawdle” when advancing the catheter. I always advance really slowly after my flash, she told me this give you more time to “screw up” (her words) basically the more time I took the more time I had to make tiny changes in the angle I was holding my IV at or the direction I was advancing the catheter. Her instructions were to watch to make sure you got a good flash, meaning the blood filled the entire chamber, and then in one swift motion to push the catheter off the stylus until you hear the safety click in. I thought she was crazy until she made me try it, worked like a charm!

  13. N fletcher says:

    Great comments, well thought out.
    About 15 years ago, I started traction PROXIMAL to the IV site, considering that distal traction could stop venous flow into the chosen vein. Tourniquet pressure is very important too. When a vein is exceedingly difficult to find, a cuff set between the patient’s systolic and diastolic pressure will help your search greatly.

  14. 1. Have everything you need before you start.
    2. Know your fluids are good.
    3. A 22 ga. that works, is better than an 18ga-14ga that does not.
    4. If you need a 14 ga. you are over your head, and need additional help.
    5. IV fluids and catheters have a expiration date, and storage parameters.
    6. Think before you act.

  15. If you just can’t seem to feel the vein try these two tricks:
    1) BP cuff set between the patient’s systolic and diastolic pressure used as the tournequet (also mentioned above)
    2) Applying heat by using a wet wash rag or heating pad will pump the vein up
    Lastly, have confidence that you can do it!

  16. If a patient has had several IV’s and has a history of tiny veins, where failed attempts have been the norm, even by the most experienced nurses who are known to be the best, please listen to the patient! We know our bodies! Every time I have to have an IV, I tell them that I am an extremely hard stick. It’s so irritating and frustrating when the first words out of their mouths are, “We’re just going to look.” Yeah, right! They’re going to look for something that they THINK they can stick and ALWAYS have a failed attempt. This is when I get irate with them. Patients go to hospitals to feel better…not to be tortured to death! To start an IV on me, it must be a central line! I know of the risk for infection, but it is MY body and if I sign a consent, stating that I’ll take that risk, then this should be my right! I’m not some piece of meat! I’m a human being! Respect that and listen to me, because I know what I’m talking about, since after a half a dozen failed attempts that leave bruises all over me like I’m either a junkie or someone has beat me up, it ends up in my neck where it should have been put in the first place. Yes, I’m ranting because I’m sick of it!

  17. Asking the patient where his or her “good veins” are at is a good question to ask. patients knwo their own bodies better than we do.

  18. Bonnie,

    I’m sure you truly have difficult veins but if I had a nickel for every time I heard “I’m a hard stick” and then proceeded to get the IV, easily, on the first try, I’d be rich. That’s why we “have to look”. Looking doesn’t hurt you and depending on what department you are in, central lines are not put in willy-nilly. Give us nurses a break, and tell all those other people that are “hard sticks” to quit giving people like you (who actually are) a bad rep.

    Becky

  19. Angel sanchez says:

    Its not too bad, but there is a lot more tech that i used,learned from iv drugs users back in PR. In these country. They teach people to star iv in the AC,thats wrong that should be last option, so when pts doesent have good ante cubital vein they freacked out. We need to teach this nurses that doing an easy stick is not a best option.

  20. I also find that if the patient has large bulging veins before you put the tournequet then you will have a better chance in getting the iv without a tournequet. By applying the tournequet to these patients you are increasing the pressure and as soon as you get your flash the vein blows.

  21. I learned this trick from the awesome nurse I work with.
    If you accidentally go through a vein and start to see it blow and bruise. STOP! Put a lot of pressure on the site, at least 2 minutes of pressing down with your fingers on the blown site.
    After a bit, try and advance the IV. Sometimes the vein will heal itself and you can place the IV without having to stick again…
    This trick has worked q few times for me… but not always :)

  22. It also helps if before you even start the IV you move the catheter a little bit. Make sure not to slide it off the end of the needle, but by moving it a little it makes it easier to advance off the hub.

  23. Stephanie Massey says:

    Great tips. My first job out of nursing school was in the ICU. I hardly ever got to start IV’s because all the patients had central lines. I now am a charge nurse on a med- surg/SCU. I have become better at starting IV’s now because our patients don’t have central lines. We get kids, frail elderly patients, ANC everything in between. I have started more IV’s on med-surg than I did in my 2 years in ICU.

  24. AMEN #3 and Bonnie! Once you ask where others have had “good luck,” use serious traction and you’ll do fine. I have had success with small frails and super-dehydrated folks with traction AROUND the planned site – my palm up (stab all the way through the pt’s arm into your palm…) until the cath is in all the way (then let off traction and occlude).
    My favorite ‘hint:’. Don’t forget the non-arms. I’ve been called in by ‘the expert’ to start lines on 4ppd sun worshippers, and I tend to have better luck with veins in ‘odd’ places (medial aspect of distal lower leg, back side of arm [dorsal forearm or over the triceps – patient said this was super painful, but it was his last shot before a central line – he kept infiltrating… The painful one lasted almost 3 days], and don’t forget the feet! And, if it’s not for blood draws, try pediatric IVs – shorter and smaller, but great for the LOLs needing fluids and meds..

  25. As a relatively new grad working in the Sub ICU, I’ve learned a few things from the PICC nurses. Probably the best tip that I can give (aside from the great ones listed above) is to try floating the catheter in after flashback and after connecting the saline lock. You can use the ebb/flow of saline to glide your catheter in. Seems to work really well when there’s a valve hindering your advance. Also, when I don my gloves, I tear off the index finger so I can get a good feel for bounce back on those difficult to see veins.

  26. As an IV RN, the best advice & best practice (per the Infusion Nurse Society) is to always use the smallest gauge and shortest catheter length to achieve the prescribed therapy. A bigger IV catheter will not provide better therapy results (“bigger is better” theory) , but rather a smaller IV catheter in a larger vein will promote better blood flow around the catheter & reduce the risk of phlebitis & infiltrate.

  27. Hey!

    I really liked how you summed up all of the important tips – I’m a fourth year RN student and just started giving IV’s a few months ago and getting the hang of them slowly :) I really liked what you said about leaving the miss in the sharps box it’s definitely something that is still psyching me out

  28. I absolutely cannot stand to see providers ripping the tip of their glove. If their veins are that bad, and you need the access that badly, get a central placed. Otherwise, check your pride and realize that your palpation skills need improvement, and find someone else to try the stick. Gloves remove the majority (I’ve heard as much as 80%) of the blood from a dirty needle should you get stuck. You’ll remember from the chain of infection that the more pathogen you’re exposed to, the greater your chances of contraction. No stranger’s PIV is worth me getting hepatitis. The same principled peeve applies to not using transfer devices when they are available and instead opting for that 18g needle to fill those vials. Unnecessary exposure and reckless choices.

  29. Really listen to what the patient says, don’t just ask “where have they had luck before” with no intention of listening to the response. My response is inevitably “there is no particular place that’s better than another, whatever you can find go for it, most recently was here, don’t worry I won’t hold it against you, haha!” but when I follow that up by saying it’ll need to be a 22, that it usually takes 6-8 attempts, that I’m dehydrated, and that last time the infusion nurses needed an ultrasound just to start a regular line in my bicep, grabbing an 18 and saying “oh everybody says they’re a hard stick, don’t worry, I’ll get it” feels as if they’re not aware I’m an actual person who lives in this body. Confidence is great and it’s reassuring to the patient, but completely discounting years of experience in a chronically ill but calm and communicative patient becomes cockiness and always–every single time–leads to more failed attempts. Since I have a port now it’s not an issue, but the two things I always feared in an ER trip were EMTs/RNs who went straight for the jugular (literally) without trying anything else, and those who stopped listening once I said “I tend to be a hard stick” and didn’t take in the details that follow that.

  30. I am an RN with many years of experience and the only issue I have with these instructions is the 12 seconds rule. There has been many an IV that I have started just by being patient and finding a site. Granted I am not talking about the normal stick in the ER, I am talking about the hard sticks that do not have much left. I am sure the patient would rather a nurse take their time and find a site that works than having multiple IV sticks.

  31. Great article and the same advise I give to students. Traction and approach angle are the main culprits to failure. I wish you would of addressed the “I’m up against a valve” excuse when a cath won’t advance either. It is physiologically impossible to get stuck in a valve. A bifurcation maybe, but not a valve.

  32. the best tip i ever got when i was learning how to start an iv is to learn to visualize the vein. that doesnt mean you have to make sure that you can see it in front of you, but that you have an image in your head of where the vein is. i learned how to start ivs on cats and dogs. having now also done them on people i can tell you its alot harder. not only are you working with smaller veins ( i.e. sick dehydrated cats) but you also have to work around all the fur. i found that it was a very good way to learn and had no problem when it came to people!

  33. The best tip my preceptor ever gave me was to set yourself up for success. Your first attempt should always be your best attempt. Have all your equipment ready to go: cath unwrapped, fluid or lock ready, isolation site peeled off, good quick release knot in your tourniquet and a 4×4 open, just incase. No IV is so critical that the extra 30 seconds to set up will make a difference.

  34. musingmom says:

    ALso – proper tourniquet placement! The higher up, the better. And remember, some patients (HTN, little old ladies) can do better without a tourniquet at all.

  35. I alway get them piste and shoot for the big vein in the middle of the forehead

  36. I read this only to see what the big problem….. my daughter and I ( she is 8) have huge veins… nice and plump… and nearly clear skin… they show like big green , purple and blue tracks on our arms , legs and chest and jaw line for that matter…. she has been very sick this past year and have been hopitlized a good bit… we have both had problems with IV placements… and horrid blown veins…( blood spraying across your face is never a good thing , esp. when you are already sick… or in my case sick with worry) I needed to know what the problem was … what were these nurses doing that they were having such a hard time with our very visible veins. Thanks… I think it was the traction problem.

  37. As a patient who has had many many IV’s and many missed ones may I add that as a patient we are there because we are sick or hurt, and sometimes we do have bad veins the result of all of the strong antibiotics we have been on over the years, now I know am a hard stick and I am a patient person I am not hateful with you I lay there and bite my lip or whatever I have to do. But when you have stuck my 3-4 times and ea h time you have taken that needle or catheter and just dug and dug each time well then I start getting upset and NO PATIENT should ever be put through that, and I ask for someone else. We do have feelings and we are there because we are sick.

  38. Airbornemedic says:

    Iv’e found that in my time of starting IVs that the more you do, the better off you are. Not one thing is going to work every time. I see a lot of people getting hung up on that, ‘Well it worked last time, why didn’t it work this time?’ I have found that if I take the time to search for something I know I can hit, I can usually get it started without problems. It’s the ones that require one like yesterday that I have issues with. I’m getting better!

    I like the idea of using the blood pressure cuff, I learned this little jewel early in my life as I worked in an ICU with one hell of a nurse. I developed a bond with her, and we worked side by side, she taught me a lot of the things I took with me into the field.

    These are all great tips, the one thing I can say is that don’t doubt yourself, just because you have a few ‘bad’ or ‘missed’ sticks doesn’t make you a complete failure. Just forget about it and move on to the next one, I look at it as it happens, and go from there. I learned what not to do, take it as a teaching tool.

  39. Perhaps if you could know the difference between too and to…it would lend more credibility to your blog.
    “Sometimes we’re really looking for the best spot and sometimes we’re just stalling, but we tend to take to long to find the IV attempt site.”

    Try toooo long.

  40. What do you do if you can never get flash? I apply tq, clean site, then attempt cath insertion, but i’m having issues with not getting flashback. These are healthy pts in emt class who have huge veins that you should be able to hit no problem. Others do it fine. I insert the cath at a shallow angle directly over the vein, but i’m having huge issues and never seem to be getting flash. Any advice as i have no idea what i’m screwing up.

  41. you never get flash?? follow these tips because that is exactly what I do and I get it ALMOST every time…. sounds like you are having a hard time starting one….. it takes a ton of practice. but find the vein [don’t dwell on it], watch your angle, use traction, and go for it. And if you cannot get it on the SECOND TRY – ask someone else. no one wants to be a pin cushion or be dug in. :]

  42. Heather says:

    Do you think these techniques would transfer to animals too? I’m a vet tech student and IVs haunt my nightmares. I did learn a trick or two from my sisters who are both nurses. One says to use the lidocaine and not just for comfort but it keeps the vein from spazzing out and blowing. Another trick… For some reason bevel down seems to work better for me to get into the vein. I know, right? My other sister taught me that. She said the vein won’t collapse as easy. Works great for me on cats and smaller dogs with tiny veins.

  43. Linda Nicola says:

    My mom is a hard stick, and yes, no one believes her. The record bad is 16 tries before my mom called a halt. 13 is average. 4 is excellent. One person got it in one try!

    She’s 82 and has been this way her whole life. I’m going to print this out for next time.

  44. Warm moist compresses for 10 minutes to the arms. It works. I can’t even start to tell you how many “difficult no one can find my veins” IV I have started. Try it!

  45. for the past six months iam suffering in getg iv line
    i was a good iv pricker but now iam not able to
    iam failing in this procedure please what shall i do for this

  46. for the past six months iam not able to get iv in first pric so what will be the reson
    for that .i was a good iv inserter but now iam failing intgis procedures please .answer me.

  47. vicki clark says:

    Rolly veins is the main excuse I hear EVERY time an RN blows the iv. I watch lab, IV therapy, doctors, eats and icuu nurses put in it’s a draw blood. I can draw blood, start an iv, but nurses don’t want to listen when I say to anchor the vein or decrease your angle. Attitude.

  48. I’ve also noticed if someone’s veins tend to “blow” when you flush the line, check their potassium level. If it is too high, the stick is better without using a tourniquet.

  49. Thank you. This is the most helpful site I have found, that includes watching IV placement videos. I have tried 7 times, in the current practice that I work at, on the physician, and the first 6 were failed attempts! I am so embarrassed! I have no nerves about it, so I just need the practice and to build up the muscle memory I guess- so that my hands are quick and certain. I appreciate the tips, especially #5.

  50. STARTING AN IV: Betadine vs alcohol Pad??? Both are equally good antiseptics, but you must first ask if the patient is allergic to iodine!!! If he/she is, DO NOT USE BETADINE!

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