Although you may know how to insert a peripheral IV catheter; if you are having trouble starting IVs on patients with “difficult” veins- you are not alone. Getting an IV catheter started with one attempt and without any undo patient anxiety can be difficult to accomplish at all times. Not being able to find or choose a good vein site in my estimation is 60 to 70% of the problem most nurses have starting an IV. In this post, I have listed 8 tips to finding veins.
The first 2 tips are pretty basic – we sometimes need reminding that the basics are done for a reason.
1. Assess the patient’s veins with the tourniquet in place!
Although you may see the veins well without a tourniquet on; applying one will still make a difference and it may even show an alternative location better than the one you’ve found without it . Have the patient lower their hand below heart level and open and close the fist- flexing their muscle (strong like an weight lifter- not flaccid like, um my great grandmother). Next it is important to have the patient relax the fist and arm prior to the venipuncture. Ok, I am off my soapbox.
2. Check your tourniquet application.
If you have difficulty identifying a vein; it may simply be your tourniquet application. ALWAYS check this first. A too tight or too loose tourniquet can cause veins not to distend. If the tourniquet is too tight; you cut off their arterial circulation (always check their pulse and coloring). A too loose tourniquet = no blood pooling to distend the veins below it. Check and re-apply the tourniquet
3. Warm up the arm
Use instant warm packs applied to the IV area for 5 and even better: 10 minutes prior to prepping the skin. Always test the warm pack to avoid burns prior to application. Use of preset commercial devices like this are preferred to old methods of warming up towels and such in microwaves- there is too much of a risk of burns, and many employers forbid use of techniques like this in their policies.
If you’re working in home infusion- have the patient take a warm shower and cover their arms with long sleeves just before your visit, or if that is not possible run warm running warm water at a sink over their arm at the visit (not hot, test it carefully & again avoid burns!)
4. Hydrate the patient
Whenever possible, and not contraindicated- have the patient drink non-caffeinated fluids prior to the IV start. Even 3 cups can make a big difference in a dry patient. The old standby of encouraging 8 cups of fluid/water a day can be followed when time permits prior to the IV start.
5. Use palpation to find veins
In addition to visualizing veins, it is important to palpate using your index and third finger pad to evaluate the vein’s resilience, patency, valves, size. Is the vein straight, soft and bouncy (refills fast), and large enough to accommodate the catheter needed for the IV therapy? Or is the vein thin, flat (does not refill well), thready, hardened, irregular in shape, or have bumps (valves along the path chosen)? You’re looking for the latter of course.
6. Use visualization devices when available
Current Infusion Nurses Society (INS) Standards of Practice support use of visualization devices when performing IV insertion procedures. Devices like transilluminator lights and ultrasound machines decrease the number of venipuncture attempts made on patients with difficult venous access. However, the average non-PICC team nurse is not trained in using ultrasound for vascular access. Yes, old school nurses will tell you that a flashlight or other light works too, but they can cause burns. Devices made specially for visualizing veins are designed for that purpose and are much safer. There are a few on the market- the devices I favor lately for pricing, size, and ease of use are the Veinlite pocket devices.
7. Use a blood pressure cuff on a low setting
Instead of a tourniquet for patients with really poor access, try using a manual blood pressure cuff on a low setting around 60 mm Hg or less (below the patients diastolic BP, check it prior to application). Use a kelly clamp on the tubing used inflate the cuff to allow for easy deflation by opening the clamp once the catheter is in place.
Use good judgement, and caution as you may want to avoid using this technique in patients with delicate skin and/or fragile vessels (vessels with a potential to blow easily from the extra pressure). Examples of this are patients on anticoagulants who bruise &/or bleed easily, patients on steroid therapy, or patients who have paper thin skin that may tear easily.
Open the kelly clamp to deflate the cuff once you have visualized a blood return in the catheter flash back chamber and have partially advanced the catheter- ensuring the catheter is in good position. You can continue to advance the catheter after the BP cuff has deflated. Also with this technique as with use of a tourniquet; monitor the patients circulation to ensure they have a radial pulse and the arm/hand is not discolored and remove the BP cuff if indicated.
8. Prevent vein “rolling”
You thought you found a good vein, but then it wasn’t in the same spot after you performed the venipuncture. Often patients will tell you “my veins roll”, and they’ll tell you this because that is what nurses have told them. Hold traction on the skin below the IV venipuncture site, using the thumb side of your non dominant hand is best for most sites. Pull the skin downward to prevent the vein from moving above as you perform the venipuncture. Keep the hand and fingers holding traction lowered enough to keep out of the way of performing the venipuncture. I will post pictures to this area as a sample soon.
What is that you said? Did you say, but the vein disappears when I hold the skin taut? Yes that often happens; you simply release the skin long enough to re-visualize where the vein is for a second or two (or just keep a nifty transilluminator in place instead), and reapply traction again to perform the venipuncture. If you hold the skin appropriately 99% of the time; the vein will not roll. Again use good judgement and caution, do not hold the skin so tight that you hurt the patient or cause a skin tear!