How to Start an IV: An Essential Nursing Skill
Starting an IV is one of those nursing skills that can not really be taught in school. Some schools have those fake silicone arms with artificial veins but they usually have more track marks than an avid drug abuser. The only real way of getting good at IV insertions is to do them on real people in real situations.
Step 1: Supplies
The following is a list of supplies that I bring with me to any IV insertion.
IV angiocath (22g, 20g, and maybe an 18g)
IV start kit (if this is not available to you it just consists of a tourniquet, gauze, small Tegaderm, and alcohol prep)
Couple of saline flushes
Step 2: Prep
What I usually do is apply the tourniquet before I start with anything else so as to give the veins some time to plump up while I'm getting everything else ready. Now, if your prep is taking 5-10 minutes I would suggest not applying the tourniquet until you are ready to search. No patient enjoys having a properly tight tourniquet on for longer than necessary. Next, I'll prepare my IV extension by priming it with saline from a flush. This is what you will be attaching to the end of the newly placed IV so you want it close by and accessible. ED nurses love to skip this step and I have heard rumors that these extensions do not even exist in some emergency departments. I do not really understand why. If it is a time issue, it really only adds a couple of seconds to the insertion but makes using the IV so much easier. Finally, before I start searching, I'll peel open my Tegaderm and have it accessible as well. This is what will really be anchoring your IV to the skin.
Step 3: Location
The picture above is a wood burning representation of your typical arm veins. This is by no means a road map to finding veins on your patients, as everyone is different, but it is a good way to visualize what the layout of veins in the arm could look like. The areas I have circled in red are no-go zones unless during an emergency or no other access available. The hand is usually your go-to for anesthesiologists as it is easily accessible during a case. The antecubital or "AC" is a very easy site to get IVs but if you're infusing anything continuously through them expect the pump to alarm any time the patient bends their arm. The AC should really only be saved for emergency situations, otherwise, it is just lazy. The area in green is the forearm, specifically the underside or anterior portion of the forearm. These sites are usually fairly stable and can harbor some nice juicy veins. Now actually finding the vein is the hard part. You might have seen some people slapping the arm in an attempt to make veins more prominent but I don't really believe it. Some have told me it causes inflammation of the vein but I just think it increases the patient's blood pressure from being smacked around. Really, the only trick to finding a vein is being patient and knowing what a vein feels like. When pushing down on the skin with your fingertips you will notice a distinct difference in the rebound of the skin in places where veins are located. The area will be much more bouncy and you may even see the faint green color of the vein underneath. A trick that I use a lot is locating the easy to find AC and following it down as far as you can down the forearm. As you can see from the picture, several great veins feed into the AC. Once you have found a nice juicy vein you should follow it up and down to get a good mental image of what the veins orientation is. Veins are not always going straight up and down, they can go up and curve any which way and not knowing that can cause you to back wall the vein. Valves are another thing you have to be conscious of. Veins have valves which prevent back-flow of blood and present as bulges in the vein. Valves are a problem with IV insertion because they can sometimes prevent the advancement of the catheter. When you have found a vein, followed its orientation, and checked for valves, it is time for the final prep.
Step 4: Final Prep and the Stick
Once you have your vein you will begin to prep your site. Usually, I will put a towel underneath the patient's arm in case the vein is extra juicy and some blood escapes the IV while connecting the extension. Next, you will prep the site with the alcohol pad. At this point, there is no more touching the site with your gloved hand. Choose which needle you feel best matches the vein. Hey, if its huge throw an 18g in. You will be able to draw labs off that thing for a good while (as long as your institution allows). Remove the protective covering of the needle and locate the bevel or the side of the needle that looks like it has been cut off. This part will be pointing up during the insertion as shown in the picture.
When you are ready for the stick, it is good practice to use your non-dominant hand to anchor the vein both above AND below the site to prevent any rolling of the vein. You can do this with your thumb and index finger, making them into the shape of a C and holding the vein down in that fashion. Now for the actual stick. You want to be confident in your stick and penetrate the skin in a fluid motion so you don't torture the patient with an agonizingly slow poke. Your angle should be at 45 degrees for the initial insertion. Some people argue that 90 degrees is better but I feel like the chance of back walling is much greater with that approach. Once your past the skin, keep advancing the needle at the same angle until you hit the vein and see the "flash" or blood in the hub of the needle. This next part is very important and the reason why many IV insertions fail. Once you see the flash, KEEP ADVANCING. Now when I say keep advancing I mean maybe 1 or 2 millimeters. If you look at the picture above, the vertical line on the needle indicates where the catheter actually begins. If you advance the catheter right when you see the flash, there is a good chance of blowing the vein by forcefully pushing the blunt catheter through the lumen of the vein with no assistance from the needle. So calm your excitement from the flash and just nudge the needle in a bit more while dropping your angle further so as not to poke the other side of the vein.
Step 5: Advancing the Catheter and finishing up
Once you are ready to advance the catheter, pop off your tourniquet (sometimes I'll keep the tourniquet on just to give me some space but you'll have a lot more oozing from the hub when you take the needle out) and slide the catheter over the needle either using the index finger of your poking hand or your other hand. So now the catheter is in the vein it is time to withdraw the needle. Some people do this at the same time they advance the catheter but it is something that just comes with time. Hold the catheter steady while withdrawing the needle while also applying pressure to the proximal aspect of the arm. This is to reduce the amount of blood that oozes out. You want to apply this pressure before the end of the catheter to keep blood from entering the distal portion of the catheter. Holding pressure any farther acts just like the tourniquet you removed and pools blood all around the catheter. So the needles out, now you just need to attach the extension which is easily done with one hand. This is especially easy if you are still holding pressure at the site and stabilizing the hub of the IV. Just twist the extension on and flush the IV and attempt to draw back. A super awesome IV will do both. If your IV just flushes and does not draw back that is alright. It could just be up against a valve or the side wall. Just be sure to monitor the site for pain or rising of the skin (extravasation) while flushing. Clean up your site with the gauze and slap on your Tegaderm and your done. Just be sure to initial and date the site so everyone knows you are the one that placed that awesome IV. It really takes practice and trial and error. Do not be afraid to try and never turn down an opportunity. One of my previous charge nurses would not even consider helping me unless I tried twice before. In all honesty, I really only felt confident doing unassisted IVs until after I began doing ultrasound-guided IVs. You really get a feel for what puncturing a vein feels like and what the catheter is doing inside the vein which helps immensely when going in blind. In a future article I'll go over ultrasound guided IVs and why I think it is important to have at least one person on the unit capable of doing them.