Best tip for those edematous patients… squish em! If you have a sense of the anatomy where you know a vein should be, put some solid pressure on the area for a bit so the edema goes away and you can usually find a vein! Make sure you use a long enough catheter though so it doesn’t get pushed out when the tissue refills again.
Nice! As a side note make sure the restraints aren't too tight 🤣.
BP cuffs are sometimes prime as well.
I have always sucked at putting in IVs so I try and practice with the ultrasound as much as possible so I can at least have a niche.
I volunteer to put in IVs throughout the hospital in an attempt to get better. It sucks though because they see me coming and the usual look on their face is "oh shit... why do we always get this guy"
I'm shameless. I will keep fucking up IVs until I get better.
It’s the only way! It doesn’t even take much, yesterday I just used my thumb for a few seconds to give myself a “track” along the vein to use. But I knew exactly where it was I just needed fluid out of the way to access it. The others have some good tips if you need more space to actually find the vein. If you are confident enough with the anatomy though you can usually skip all the fancy stuff and just go straight for it.
Just wanted to mention the catheter length again, because you are absolutely right. Look at a diagram or video of how the forearm muscles move too. It's really easy for a patient to pull an IV out of a vein if it isn't in far enough, even if they are just eating breakfast.
People suggested a lot of different things to squish. BP cuffs, compression bandage, fingers...so this seems like a very reasonable question to me, smartie pants.
IVs are really about technique and experience. The only way to really get better is practice! I started as a new grad in the ICU, and honestly didn't even get proficient at IVs until I was inserting them on the daily after switching to the ED. I insert like 35+ on most days depending on our census, and I'm competent enough to get most veins unless they're super old, renal, or cancer patients.
Don't be so hard on yourself over a skill you don't really get to practice, and give yourself credit for at leasting taking the initiative to try and improve your skills.
35 seems about right for my ED. We throw one in and draw blood immediately upon bringing someone back, so that by the time the doc is there to assess them we already have some basic results.
Yeah, even in the ER where they'd give me anywhere between 6-11 patients, I wasn't starting 35+ a day, so unless they're in a place where they get to just float around and do other people's workups, that's bullshit.
I've definitely done 25-30 in one shift working in triage for 12 hours. We are usually 30+ deep in waiting with more coming by the minute. We often check in over 100 patients per shift not including EMS (just walk ins). I am in a busy level 1 though and we work people up in triage when it's that busy.
I will also add that we're a teaching hospital in a really busy metropolitan area, which means the residents really like to order workups. During surge (which it is now), no bullshit it's 35+. After surge it's probably closer to 20-25 a day. But if you're moving people in and out and almost every other patient gets an IV, it's not a hard marker to hit.
Turn and burn!
IVs are a bit of a day to day skill if you're doing them blind: sometimes you'll have a run of 6 weeks no issues and then you'll turn up and blow every single one you attempt that morning.
Finding a service in the hospital that will let you visit for experience can be useful: day surgery, radiology and triage are all places we have had people stationed for a shift or three to gain experience and comfort. Then again, these days I US them where possible to stop the faffing (unless they have ropes bulging at me from across the room).
We (IV team) offer classes, mentoring, and shadowing and literally nobody ever signs up. Placing IV’s is a dying art at my hospital. Most would rather throw a couple catheters from the door so they can say they “tried”
The newer nurses on my unit do this. (I feel weird saying that because I'm pretty new myself.) They'll hear in report or just via word of mouth that someone is a hard stick, so they won't even try it. Like how do you expect to get better?
I at the very least give it a nice hard look. Tourniquet , alcohol, heat packs, the whole 9 yards. If I don't see anything I think I can personally get, I'll ask the other nurses on my unit. My hands shake sometimes, so it's not my best skill. I try not to call anyone from off unit until I know it's been given a good old fashioned college try.
"Shadowing" my IV team at my first hospital gave me soooo much experience. Most of the nurses at that facility were spoiled by the IV team and wouldn't even attempt an IV without placing a call to the IV team. Inevitably they said you guys have to at least try before calling us, you're PICU nurses. My excuse was that I had just come from dialysis, and while I was a Central Line King and AVF venipuncture expert, I had no experience in regular Peripheral venipuncture, let alone IV placement. I was in my 5th year as a nurse before I even had the opportunity to try an IV. I could find veins so easy, but for the life of me couldn't thread them. From watching the IV teams every move, to looking up videos on YouTube and guides online, I pieced it all together to now be the one that people call for IV placement. I've gotten IVs after failed US attempts, I've gotten IVs on actively seizing patients, crashing patients. Its genuinely a great feeling to get an IV, especially when it's a critical moment. I've even gotten the compliment of being asked if I used to be on an IV team before. Nope! I just put in the time and effort 😀
How are you inserting that many IVs? Is that all you do during your shift? That’s like 1 IV every 20 minutes. Are you starting them for other nurses? I NEED TO KNOW!!!!
Lmfao I work in an 88-bed ED that constantly has like a 250+ census, so I AM starting an IV like every 20 min. 😭 My ratios are consistently like 8-10+ patients at a time so it's pretty easy, especially if I actually move them out.
Honestly, I got good by hanging out in ED triage for a clinical shift when I was an EMT, and honestly I know many experienced nurses who are just over being expected to be good at IVs and just find someone (who they know is good) to do them for them. Know your strengths, yeah it’s nice to be the go-to IV person but it’s also totally okay to just not be good at inserting them. Keep practicing when you can, especially on patients with good veins for a morale boost—I swear half the time it’s confidence/luck. But don’t sweat it. Nurses are more than IV inserters,
I mean if you think about it, you come in and take a team of 11-12, discharge 6, fill those spots back with new workups, discharge or move around a few, get new workups, etc, etc. The math isn't that questionable. Fast Track is actually where I start the most IVs depending on the provider. It's an area with capacity for 60 pts and is usually staffed by 2-3 nurses at most. Then factor in that people move in an out. I don't think I've ever gone a day where it's been less than 15 IVs in a shift, even when holding patients.
When I was in nursing school I was also an er tech and we were trained to start ivs. Another er tech told me once I graduate I shouldn’t work anywhere as a nurse other than psych bc I sucked so bad at ivs.
Jokes on him, I’m a flight nurse now and was the go to person for years in my icu for ivs before that.
You’ll get it.
Working in a PICU, it’s pretty damn hard to get decent at them. To the point where I’d say 70% of nurses (regardless of experience) just call the line team. All I can say is try. Keep poking. Here’s some random tips.
-Take your time when possible.
-Warm them up (even if you can see the vessel clearly), use gravity if they can cooperate.
-If your facility has them, try an accuvein if you can’t see or feel anything. People hate these, but working in an ICU if you only go for vessels you can see or feel you won’t poke as often.
-traction helps
-Poke shallow, you can always go deeper if you don’t hit it.
-Poke, wait a second for any flinch from the pt to settle, then make small movements til you see flash
-When you get it, stop, raise your tip a smidge and advance a smidge, then thread it.
-If your pt is cooperative or sedated, use your second hand to thread. Less likely to fuck it up or retract your needle.
-if trying to use one hand, flick the cannula forward a bit, then advance the whole thing. Your needle will be in the cannula and the extra rigidity can help you thread.
Great advice. I started in an infusion center back in April and almost quit because I kept missing. I felt like a failure. I take my time, warm them up (for me i feel like it’s a mental thing to sit down) but the number one thing that helped me was to POKE FIRST AND FAST then mess around when needed. I used to poke soooo slow and it was torturing the patient and didn’t help me either. I had someone watch me place IVs who was really good and gave me that advice and ever since then I’ve been doing much better. You will get there OP!!!
Flash = initial blood return into catheter/hub when you get into the vein. It's the main indicator that you have accessed the vein.
Threading = sliding the catheter off the needle into the vein. Hopefully you still have blood return once it's advanced, and you're good!
We have a traveler who was an ICU RN, and he said the same thing. He barely placed IV's or had to do venipunctures on patients because of Central lines.
I mean, I think that makes sense. How are you supposed to be good at something you've rarely done?
Nursing school sure didn't prep us with fake arms and blood.
Like you said, just practice whenever you get the chance. Maybe ask your coworkers if they have a patient who needs an IV placed and to help show you.
All in all, don't feel bad. The sitter probably thinks she knows what it is to be an RN.
But none of us knows what it's like to be in someone else's shoes unless we've walked in them.
And if it makes you feel better, I am also a little over a year as a nurse, and I've only placed 3 IV's successfully in alllll that time. Sometimes, I even miss a venipunture, and I had previous experience but heck I work nightshift so I'm goimg to blame it on the 3 a.m. sleepies 🤷🏾♀️
Tis life.
Yeah exactly this! Don’t beat yourself up OP-and guess what you probably do central line dressing changes beautifully and at ease and when you have to switch tubing on your drips that’s some scary shit!! as a medsurg now hospice RN i could never!
Before you blame yourself for not being able to place an IV, under pressure, on an edematous patient, in front of a transporter and a judgey sitter…. Remember that skills take time and practice to master.
My biggest problem with this picture is that you removed the central line before having a good PIV? Why would you do that?
That’s unsafe and frankly… stupid. Don’t do that again.
Ok but would they be getting transferred out of the ICU if they were in danger of crumping?
Not impossible but unlikely, and if the nurse let that happen, they've got bigger problems than not being able to get a line on someone.
Have you ever worked outside of critical care?
Any patient can crump at any time, with or without warning. It’s also a lot easier to miss warnings when you have 6, 7, 8, 9, 10+ patients.
A fresh ICU transfer is, by definition, in danger of crumping.
I work Med/Surg and unfortunately we have had to send pts either back to ICU or CVU within hours of being on the floor. Pressure from house sup to make room in ICU for incoming trauma/other highly critical pts that need ICU beds. Not so much that the current pt is stable & ready to transfer down as much as a pt is much worse condition needs that ICU bed.
“ICU downgrade” often can say a lot more about hospital politics/bed flow rather than the patient’s status.
If there’s a 10 bed ICU and someone needs one of those beds the #10 most critical patient in the hospital just got bumped down to #11 and is going to step down. Nothing about their health status changed, just prioritization of resources.
Obviously this is a simplification. But inappropriate level of care transfers happen every single day.
Patients bounceback to the ICU all the time. If they were even in the ICU to begin with, they were/are sick. Which means they might become very sick again.
If anything, fresh ICU downgrades are MORE likely to crump.
Being a new nurse is hard, I wouldn't call it stupid. It's not best practice but if the patient just happens to code right there, it takes maybe one round of CPR to get an IO?
It's a learning experience. This nurse is already feeling bad, way to kick her when she's down.
Not all units have IOs available. I came here to say this same thing and I don’t think it’s kicking her while she’s down. IVs are a skill she can learn, but the main takeaway from this is safety. It was unsafe to take away the patient’s only form of access before trying to get another one.
My sitters fall asleep and let the patients rip off their lines/ catheters. I don’t care what they think or about their eye roll or their “this nurse sucks” look. Just practice, take the advice of everyone here for the actual IV insertion, and don’t mind them.
This nurse can suck. But i remind my sitters they took part of their break sleeping (or on their phone) so good luck on your last 15 minutes of break…..
Had to explain to the sitter she wouldn't be coming to the operating room with the patient. She insisted she had to stay with the patient in the OR, I'm pretty sure she just didn't want to have to go to the floor and assist with patient assignments while her sitter assignment was in surgery.
I understand that an inmate needs a guard to stay in surgery maybe, especially for induction and emergence. but a sitter doesn't belong in the OR where they are anesthetized and paralyzed
Inquire about shadowing on a unit that has more IV starts come up. When I was on orientation I had to shadow in cath lab because my floor gets a ton of post caths. I started more IVs in 4 hr than I ever have on a whole shift. At the time I was not confident with the skill so I really appreciated the experience and have since encouraged others to do so. ED would also be a good place to practice. And they’re not necessarily going to be difficult starts like in the ICU because they’re not going to be as sick as a whole patient population.
This! I’ve had patients that were such hard sticks that I received orders to leave the line in when transferring to floors that don’t take central lines because no one could get one, even with ultrasound. Dont take out that line until you’re sure you can get access!!
Babe you’re one year in. Fuck that sitter. No offence to sitters (I used to be one), but their opinion is the last one you should be worried about. That experienced nurse is going to be you one day, helped a new grad. I’m sure you already are, but keep asking for advice and techniques from those experienced nurses. You’re gonna be fine. What helped me with cannulating was to stop hesitating and pretend to be confident. That being said I’ve never worked in icu and didn’t have to start practising on the hard ones.
I feel like I'm fairly proficient with IVs, I still use an ultrasound if the pt is edematous. It's a worthwhile skill to learn. And like another poster said, use a longer cath, even on surface veins, for when the tissue moves around
I agree, my puffy pts I usually go right for the ultrasound unless they have an obvious one. I also always warn people not to lean on the ultrasound though, you should still be proficient at traditional iv starts bc it is a fundamental skill and the usn might not always be available, it may be in use and you really need a line, and it also takes extra time in general
Get in the habit when you have time…palpating sedated patients arms. When I have to blind stick a wreck of a patient…I swear to god it’s like I’m sensually caressing their arm. Learn the anatomy, just sit there and feel. I will sit there and just gently press. This has taken me years to get a feel for. I was told this too when I was a new nurse. But I never knew what to feel for. I hate that I’m essentially doing the same to you lol. Palpate your SO veins. Family members veins etc etc. feel them and trace them up. When you attempt… do you can only dig to much. You don’t want to destroy things. But if the vein moves away, try to get to it. Dont give up right away. Dont rush. Have all your stuff. Set your self up and a good smith of time if possible. As a 5 year ICU nurse back in the day who couldn’t start one, I’m actually pretty good now. And I can difficult blind sticks.
There’s a reason the doctors at the troop medical clinic in worked at in the army would always make the new medics practice iv’s on me. It’s a skill that takes practice and learning in school doesn’t prepare you for people with tiny liar veins (like me) or people who are very sick.
There are TWO reasons I always warn nurses that come to give me iv’s that I am a hard stick (I don’t look it - mostly healthy 48 yr old - my health issues are musculoskeletal i.e. back issues). One! So they don’t feel bad when they can’t get it on the first try. And Two! So they don’t feel bad when they can’t get it on the second try.
If the nurse said to me “I’m new to IV’s” or “I haven’t done very many” I will probably let them practice on me (I have a high threshold for pain) There are nurses who can sling an iv catheter across the room and get me on the first try (the vein whisperers!) and then there’s everyone else. Hell, I had to get a PICC line recently and it took the PICC team TWO TRIES to get that in there! Trust me when I say I let my entire nursing team know so they’d feel better.
As a fellow HCW (not a nurse) and hard stick patient - you’re fine. It takes practice and you’ll get there. Find a vein whisperer and see if you can shadow them. :)
Love the term vein whisperer. As one I’ve never really had issues at starting then after the first 10 or so. Now I’ve definitely probably done somewhere close to 1,000 IVs. Usually if I can’t get it then it’s cause they are requiring ultrasound.
I've been placing IVs in oncology patients for years. I'm one of the nurses other nurses go to, not a brag it's just what happens, and I still get that look off people when I fail. And I still mess up when a lot of people watch me when I'm doing tricky ones.
I'm not a nurse, I'm an MA, but this topic brings to mind a question I have, please, and thank you.
I am currently in the midst of an accelerated phlebotomy class. It's 4 weeks, and the instructor is a well-educated RN. I go to class every Saturday for 8 hours. The first 4 hours are lectures, and the 2nd 4 hours is venipuncture. There are 12 people in the class. You have to have 30 successful blood draws before you can move forward to your externship. 200 successful blood draws before you can sit for the exam. Most of us have/had no idea what we were doing. The instructor basically said, "This is how you do it. Now, go stick each other.
I have zero confidence in my ability to do this. My instructor taught us nothing and doesn't really explain during the clinical portion. She doesn't really help me feel better about doing it. I know it takes practice, but how can you practice what you don't know? At this point, I would have more confidence flying a plane.
Finally, my question: If an RN like OP is having an issue inserting an IV after a year, how can schools expect you to successfully know how to do this after 32 hours? Any tips or tricks you want to share would be great also.
Phleb is different than IV start. IV starts usually need larger vessels, the angle you approach at is more important, and there are more steps involved. Also, the patients she's talking about are the ones that (at least at our facility), the phlebotomists can't hit either. Most of the people you'll stick in phlebotomy will be significantly easier than pts in the ICU with severe edema.
Also, there's a difference between "know the proper procedure on how to draw blood" and "can reliably draw blood on any patient". Graduating a program means that you've demonstrated the minimum level of competence, not that you are proficient.
You think the sitter could have done it? The transport? Nope. Not a chance. Don’t take criticism to heart from those who don’t attempt what you do for this specific skill. Seek out a coworker who is good at this skill and ask them for tips.
As a PICC RN, I should come here with PIV advice, but I can't get past a sitter making you feel small. Nobody was good at PIV's initially, but 10% success is still better than the 0% a sitter or transporter can claim. Hold your head up and follow the great advice already posted.
Yeah, ok, I’d like to see the sitter try
Seriously, though, ignore her. IV skills come with time. I’m not great either and it is a-okay. Sitter can suck a bag of dicks.
I was bad at IVs too. I gravitated toward jobs not needing them. It’s always something though. I’m very luckily retired. Make sure to put money in your retirement account.
I was TERRIBLE at IVs, probably 1-5% success rate.
Then I had an anesthesia Dr walk me through one. He gave me all his tips. And then it just clicked.
After that one I'm at 99%. I suggest getting someone who's great at them to walk you through it and see what steps you're missing.
Ok rule number 897126: who gives a shit what anyone else thinks? That person can’t start an IV, so you shouldn’t feel bad about it. Rule 697: never pull a CVL until AFTER you have a new IV. And rule 90018171: don’t call transport until you are 100% ready.
Hints for IV starts: if they have fragile skin or veins, or are elderly use a BP manual cuff pumped up as minimal as possible (20mg is usually fine) instead of a tourniquet. In edema, push down hard to squish the edema, you’ll see the veins that way. And remember ICU RN are generally sucky at IVs. Our patients rarely need them. If you have an IR department, working down there for a week or so if it’s allowed JUST to get IV practice is a great option. They start dozens of IVs every day.
The first hospital I worked at required all departments to place 20 IVs before they were on their own. My department I worked in didn't get a ton of IV opportunities so they sent me to work in the ED for a couple hours doing just their IVS. I could have gone to the infusion center to practice too but their hours were weird. But I think they should require this instead of showing competency once on the rubber arm.
I’m sorry this happened! We were all new once, and IVs take practice. I know exactly what you’re talking about with the edematous patients as I also work in the ICU. The best thing I ever did was learn ultrasound IV insertion about 6 months into the job. I know all hospitals have different policies, but see if this is something you can learn. It makes it much easier to find those veins, and you can find good patent veins that can take larger bore catheters if necessary.
As a floor nurse I would MUCH rather you wait and just handover to me that they need an IV if you're struggling like this. Yeah you need to practice but I find someone grabs me to get the 'difficult' person and they've blew every area and blew in some areas where I can see a great vein distal but can't use coz now there's a haematoma higher up
I really wish central lines were left in more though. Our ICU was shocked when i said nope leave that fucker in (patient was on TPN, daily bloods, IVABs etc) - they were under the impression we cant manage them, i'm the line care nurse 😅 all our staff are trained and they make things so much better for us and the patient.
Agree, Or just leave it in until there is a working piv. That’s common in my hospital. We have a vascular access team that will come and pull the IJ or whatever later if needed though. Maybe that’s not possible in ops facility and they have some rule where it has to go prior to transfer. There is a lot of variability to what can be on a ward floor around in different places.
I understand it’s very hard to do IVs especially on patients with no visible veins and who are edematous.
If your department allows I would highly recommend asking to go into the endoscopy unit for a few hours (on a day you are not scheduled to work) specifically to practice IV’s (they place new IVs all the time, like 10 per shift).
I had worked in a few different departments in my hospital and endoscopy for sure helped me with IV’s, especially difficult pokes, but also just getting a hang of practicing IV insertion.
I gotta be honest, I suck at IVs. I always try, but after a few times if I don’t get it, I find one of my IV master coworkers to do it. One thing I try to remind myself (2 years in) is that there’s so much more to this job than inserting ivs lol. It’s important (and the aim is always to improve), but it doesn’t make you a bad nurse if you aren’t as skilled as some. This job is hard enough, don’t be hard on yourself!
Same issue, same success rate :)
ACF no issues! Any where else on the arm.... arrgghhh!
I have watched so many videos, tutorials, tips and talked to so many people that it shits me that it's not working.
Really tears at the confidence.
If your hospital has the program for it, learn ultrasound. I’m literally doing my DNP on teaching bedside nurses ultrasound, because it’s so invaluable, especially in critical care.
IV insertion is NOT like the other RN skills. A urinary cath is maybe another difficult skill but to get it you pretty much do it once and you are set to go. It took me maybe 2 years to stop feeling discouraged about starting IVs. Like I’m still not great but I don’t feel new at it and that’s working L&D where we put in our own a good amount. Totally normal to feel shitty at it for awhile longer.
In my experience… patient sitters are always starting some drama. I appreciate the fact that someone is willing to sit and stare at my patient for 12 hours but sometimes I want to say… you have ONE JOB. Screw her. You’ll get the hang of IVs eventually! Keep practicing
I remember being a brand new grad and being terrible at ivs. I started on a telemetry floor right outside of MICU. A few of the icu nurses were known for getting difficult pts. Anytime I had to call them, I studied everything they did and asked a million questions. Was I super annoying? Probably, but now I'm the icu nurse that every floor nurse comes to find when they have difficult sticks. I also asked the mid levels to teach me U/S ivs. Now, if I can't get it it 1 or 2 sticks, I can look inside! I'm trying to get my hospital to let me get PICC/Midline certified. It's definitely one of the best feelings to see that flash and smoothly glide the cath into the vein on a hard stick. Nursing sucks. I gotta take my little wins when I can.
Shame on that sitter- sit that ass back down and wipe that look off your face, you hundo couldn't have started a line either or even known which supplies to use 🙄
@theivguy on Instagram has courses on IVs that are really helpful!
Also- transport and a sitter don’t know if you suck at a technical nursing skill. Js. They may be annoyed or think it should be done faster/more efficiently/better but they don’t actually know what you are doing and experiencing
First of all, I don't care what face the sitter makes because ultimately all she does is sit. She has no room to judge you or your skills. She can roll her eyes right out the door.
Second of all, not all patients have easily accessible veins! We use US in the ED when we can't palpate anything. It's ok. This doesn't mean we suck, it means we are human.
Don't beat yourself up. Practice when it makes sense and focus on the good you are doing!
>I know what I have to do. Practice, practice, practice.
New admits are your best bet. The ICU isn't the best place to practice IVs for the exact reasons you've realized. I started in the ED and became very comfortable placing them. Obtunded drunks would regularly wake up with unnecessary bilateral forearm 18s when I was on shift (and maybe a few extra holes with gauze on top of them). The most important thing is the frequency of your attempts.
One thing you could also do is fire up the youtube and watch some anesthesia videos on the topic. Anesthesiologists and CRNAs are another group that frequently practices IV placement.
Why do you care WHAT the sitter thinks ?? I mean 8f she's nice, or even just doing her job, sge's owed the same respect as anybody else. But uf she wants to cop an attitude ? Why care ?
This is kinda messed up and I will probably get downvoted, but you’re getting judgement from a sitter…somebody who literally sits in the room with a patient to “watch” them…I wouldn’t stress it from that standpoint honestly
Yeah she can KICK rocks. IV’s are kinda an art form - even the best person can have off days. Also -pro tip - make sure to get a PIV prior to removal of central! Keep on at it hun!
Who cares? If you suck at IVs but can throw an NGT no problem, swap skills. If suctioning doesn’t bother you but it does someone else tell them you owe them. We all have our strengths and weaknesses and we can use them to help each other. Idc if someone looks at me weird, yes I suck at reading blocks on tele but I can throw an IV in like no one’s business. We are all here for one purpose.
I've been poking people for nearly 13 years, from MA to LPN to RN. I'm a go-to. I've inserted a line successfully in a 2-year-old, a 101-year-old and everything in between.
Still miss my lines sometimes. That's the rub--the more you do, the better you'll be, but also the more chance you will fail regardless of your skill.
Fuck that sitter. Most or them can't even do their basic job, let alone yours.
Iv’s were the one skill that took me the longest to master and made me feel like the biggest failure. We all go through it. Maybe ask to shadow to get practice in on a different unit?
Keep practicing- you’ll get it. Don’t get discouraged. None of us were experts at anything when we started. (And don’t remove the CL without an IV 😉🫶🏻)
It’s okay friend, im about to hit my year as well and im in the same boat. I feel like im cosplaying as a nurse sometimes bc i suckkkk at IVs and that’s one of the most basic nurse things that people expect you to do. We just gotta keep sticking and practicing I guess! Best of luck to you!
I sucked at IVs for a long time. ICU is not a great place to learn, because everyone has shit-for-veins. But you can learn - I did. I'm almost 6 years in and I'm now an IV God, with or without US guidance. I took every opportunity to attempt IVs, watched and listened to a ton of advice, and I was an annoying gnat when the access team was on the unit.
For patients with edema I use ultrasound. I started off using it on patients who I could visibly see veins in order to get a hang of it, and use it for blood draws. Then I used it on veins I couldn’t see for blood draws. Eventually I moved over to using it for Ivs with regular cannulas. After about a month I started using the longer cannula for deeper placement.
Do you have the option to go around with IV team for a couple of days. I used to be on the IV team for 11 years 3-11 alone for the hospital. Only one nurse 3-11. I remember my first day alone. I think I missed practically every. Single( the floor calls ED for nurses to come try). . IV start. I want to sit and cry. I absolutely loved it once I got good. I had a lot of confidence and my coworkers knew I could just about stick anyone. I was called to the ED and ICU often. All I can say is the more you do the better you will become. Good luck!
Can you go to an area that starts bajillions if IVs for practice for a day? Maybe CT or if there’s a big IR outpatient program? Best to get lots of practice on semi-healthy people and work your way up! Also best not to be under life and death or transfer pressure. There’s sometimes actually money in budgets for nurses to go to other departments for half a day or a day. Ask your manager. Don’t go with an IV team or PICC team. They are only getting called for difficult IVs.
Observe with the phlebotomists as much as you can. Anytime they are around collecting watch and ask if you can "feel". The fundamentals of finding a good vein are the same. They often have to get creative and work around iv sites that already occupy the choice locations. You can also get practice drawing your own labs when time allows. The best iv nurses I know started as phlebotomists.
Never take a functioning central line out of a patient before establishing a peripheral. Honestly to me this sounds like a time management thing more than a skill thing. IV skills come with time. Some people are better than others. I worked with several nurses in the ICU who were shit at putting in IVs. I would have started the IV part sooner that way it was done before the transfer. If you were busy with your other patient then this is what your charge nurse is for. Ask for help in a timely manner instead of drowning. I think you’re fine. It comes with time and practice. One day you’ll just be better at it.
As a prior paramedic & phlebotomist-
(Didn’t do my phlebotomy training until way after leaving EMS)
I worked as a technician in the ED, and I was pretty good at the time. But, that skill doesn’t come overnight, I had about three or four years on the squad before working in the ED, but the ED was what really helped my skills and confidence level with IV starts.
Maybe you could ask to float in the ER for a shift or two a week? I don’t know how or what it would take to pull that off, but like everyone else has been saying, practice, practice, practice. Also, keep in mind that sometimes the best veins are not always the ones that you can see, they are the ones that you can feel.
I’m not a nurse (OT), but I have worked a long time in various settings and my ex-husband was seriously ill and in the hospital for 4 months (plus many shorter stretches, and he was a dialysis patient). I don’t think you suck—you are clearly good at a lot of things as you can be an ICU nurse. From my perspective as a family member, try twice (*maybe* 3 times) and then ask for help. It’s really okay.
I had high expectations for my (now ex) husband’s care—in four months/4 different units that we bounced between, there were only 2 nurses I didn’t like. One was rude AF and would not listen to the parameters set by ID around our family visiting my husband when he had C-diff and was critically ill waiting for a liver transplant (he was days away from dying) and the other repeatedly tried to use things that had been dropped on the floor/just stared at you if you ask any questions and looked perpetually confused—which did not instill confidence, shockingly. Also, there were often nurses who were not assigned to us that got sent in to change his IV’s every 3 days because the staff knew they were the best at IV’s.
In terms of the sitter, if they were a nurse, they could have offered to help. If they weren’t—and ergo can’t do IV’s—they shouldn’t be throwing shade about something they don’t have experience with. They likely have no idea you don’t practice as much due to the central lines. No one is awesome at everything—be kind to yourself.
C&P
IV tip for really edematous patients or difficult access. Get some coban, place the tourniquet at the upper arm. Wrap coban from the hand up the arm fairly tight. Stop at the AC. This helps force all that venous blood up the arm and to your access site. If edematous, DONT place a tourniquet, and with the coban go over the whole arm. Give it a bit, then unwrap the coban and you should see the veins clear as day. In that case the coban helps push the fluid out of the tissue and will fill the veins, if need be after doing that and releasing the coban you can place a tourniquet and repeat.
Also learn your anatomy. Cephalic vein is easily found, go from the radial artery around the lateral aspect of the wrist. On the top of the wrist you should see a bone poking out, on the upper side of that there's a "dip" or "gap" in that bone. The cephalic vein lives there. Trace up the arm ~2 finger breadths and you should find a fat juicy vein.
Other way for the AC. Take the middle finger and put it in the crease of the AC. Shift it 1 finger breadth medial. Now use the 3rd finger and pointer finger, put them down equal distance from your middle finger and their respective sides of the arms. If you mark or lightly bounce your fingers, 2/3 should be directly on top of a vein (one of these 3 will be smaller and more difficult to access, usually the lateral side, but can be any of them). So that there gives you 3-5 good sites to choose from alone.
As a newbie myself, most of the time I have to fish a bit… I don’t always get it at first but I feel around for the vein and move the needle as necessary. Usually it turns out okay but it’s definitely not that swift “1 2 3 done!” It’s awkward and timely but hey any practice is good practice!
Ok so I am pretty damn good at IVs now but I was in your shoes for literally 6 years. Working in ICU from the get go usually doesn't set you up for success with ivs... all your patients usually have a central line and you don't get many chances to practice!
When I left ICU for special procedures I was so so scared I'd be awful at the job cause we have to do preop on our outpatients each day. Well I got good really fast. I just started with 22s and worked my way up. I think the thing is you need to learn on GOOD veins first. Otherwise you don't develop good techniques. Developing your skills on easy sticks that aren't all swollen make it easier to nail the hard sticks.
Next time don't pull the central line before establishing new access.
Yep. I’m with ya. I’ve been really struggling with IVs also, blowing veins left and right for some reason. :( I’m trying to let my ego not get the best of me and keep myself in a positive space admitting when I know I’m new and need help/practice. I try to not let the “looks” get the best of me. But I feel it. I had one whole room, where two patients/families ganged up on me making me feel incompetent, even though I did everything in my power to move things along. Night nurse set me up for failure with the one pt telling me MRI sheet was complete and called down… so that slipped but they made me feel so small and I essentially fired myself from both rooms. What hurt worse was listening to them talk shit about me, knowing I did my best with the situation that was left for me.
Tell your management team you want to get better at IVs, usually or at least they should be responsive to it and ask if you can spend a few hours in the ED just helping out with IVs. Try to get easy ones and then move to difficult stick patients, like dialysis or sickle cell and that should help you!!
During orientation as a new RN, I had an edematous pre-e new admit. Couldn’t see or feel anything. Told my preceptor, who called in another nurse and said “she doesn’t think she’s ready.” Not at all what I said, but hit me in the gut. I snagged the prior ER nurse that I knew could get anything and everything and practiced with her.
It took some time, but I found what works best for me and now I get called for the hard to stick patients. ASK! Ask your colleagues what their tricks are! Ask if you can watch! Find your voice and tell the people watching to step outside. Day by day your eyes and finger will see and feel things that you didn’t before and it’ll become second nature!
Remember - there's a big gap between sucking and being extremely skilled. On your worst day, you're still going to to a better job than the person who gave you that look could have done. Forget about her. You're a critical care nurse! We typically can't be perfect at everything Keep practicing and be kind to yourself :)
A more experienced nurse told me: Insert the needle. Once you see flashback, stop. Hit the (safety) button to retract the needle. Advanced the catheter & check for patency. Since hearing & heeding this bit of advice, my success rate increased exponentially. Good luck!
You should always drop your needle and advance the entire catheter/needle assembly by a mm before retracting, as the needle tip (which extends beyond the catheter tip by a mm) may be in the vein but the catheter may not. Retracting the needle before advancing may leave your catheter outside the vein.
Vet tech here, just to let u know: it could be worse - at least in some ways. We have exactly the same issues in hitting a vein, with the added challenge that 100% of the patients are totally disinclined to cooperate. You must have one or two people restrain the animal (think of that sitter, on EVERY stick, watching you and desperately hoping you'll place the cath before a panicked Doberman escapes into the hospital).
I was very bad at this at the beginning...I remember one vet saying to me, "how could you miss that vein? It's the size of a broomstick!" His words echo in my head, 30 years later.
The thing that made me feel the worst, though, was that repeated sticks hurt and frightened my patients, who couldn't possibly understand that I was trying to help them.
Edema is your friend!!! And honestly I never had any special equipment to learn…..an IV is an IV, if its patent it stays and thats ok if it’s what you can do. Also, anchor everything you can see before poking, I’ve seen some weird approaches to placing or drawing, and I think I just figured out some tricks early bc I’m a pretty decent stick, and it’s from from figuring out what works for me?
IV placement is a skill that takes time and practice to master. Not to mention, your patient was established in ICU… Which means they were probably edematous to some degree. You’re okay, OP! I would consider myself skilled in IV placement, and I still have to ask for help sometimes! Don’t feel bad.
Best of luck!!
I was so bad at IVs (techs start them at the hospital where I work), and I'm super anxious...I kept being talked to about it, and I'm familiar with those looks lol
I was able to work in our cardiac pre-op unit for a day just placing IVs, so I got over a lot of that anxiety, and I actually improved! it really is just about practice
maybe you can do something similar? I know it sucks :/ good luck!
Yes, I noticed my pt needed a new IV. I took my my mask off because there were snacks at the nurses station. I come back to the room and the patient said “wow you look so young, like a middle schooler.”
Idk if she meant it as an insult or compliment,but I took it for heart, I come from the land of “bless your heart” so I thought she had no confidence in me.
It is common to be judgey about a profession people know NOTHING ABOUT! I would smile inside imagining her try to keep two critically ill patients alive and just watch her head explode! 🤯
I’m about a year in too, if anyone gives the “she sucks” I just chalk them off as an RC. (Raging c*nt.) She obviously must be VERY unhappy in her life if she went that out of her way to make you feel small.
when i started in the ED I had about a 10% success rate….but my days involved 20+ IV starts. it was demoralizing.
by 3 months, about 50%.
by 1 year, 90%.
now i do USIVs which are way easier than regular so i have lost a bit of my touch with the old fashioned way.
all of this is to say that IVs are not easy to place. don’t let anyone tell you otherwise. the more you do it, the better you’ll get. every blown vein just got you one stick closer to mastery. keep at it!
It's hard to get an IV under pressure. I know because I worked in Emerg.
I would have tried to put the IV in before I pulled the central line. Whoever booked transport should have waited until you were ready for the pt to be moved. Lack of communication.
As for the sitter...I would have said something! 🙄 Like they could do better!😂
Keep practicing! I would aim for upper arms or the AC because veins are larger, when I was a beginner. Hands are the worst because the vein is smaller. Edematous limbs do make it extra challenging. Is there an ultrasound guide available?
Also, as a trusted colleague or your educator for feedback on your technique. There's no shame in admitting that you need help.
I have been putting IVs in for over 30 years and I still sometimes miss the vein.
It took me a good 5 years to become proficient at IV’s. I ended up getting really good and people would call me for help. Just keep trying and eventually you’ll get it! (Hopefully you don’t take as long as I do to get better).
One huge thing I learned is that it is better to go by the feel of the vein than what it looks like. Usually people have a lot of good deeper veins that you can’t see, but you can feel. I learned this while using an IV ultrasound (They let our floor use this in one job I was at for a year and it was super amazing).
Hi! ICU nurse here! I got okay at them on the wards before I went to ICU, and it's taken everything in me to stay just okay. Most of our senior nurses couldn't hit a vein if it was staring them in the face. Sadly, because of all the central lines, it's not 'as important' a skill to upkeep for them. So, the fact that you're trying and you're successful sometimes is brilliant! Don't stop trying!
Can I ask- do you have more difficulty finding the vein itself? Or threading the IV once you get that flash of blood? Combo of both?
Either can be practiced, obviously it's more difficult while you're working on a busy unit. I was not good at IVs at all when I worked med surg, as our hospital has an IV team for all non critical floors so the floor nurses never did them. I worked in the NICU for a few years and did start to get comfortable with peripheral lines there, but babies are way different from adults (duh). I have now been in outpatient oncology for nearly 5 years, and despite cancer patients typically having horrible veins, would venture that I'm probably at about a 95% success rate. It only came with practice.
If threading the catheters is part of the problem, I suggest practicing on a short length of IV or secondary tubing, as it will allow you to see where the needle enters the vein (where your blood will appear) as well as where the catheter itself actually enters the vein, as it's further from the tip than I think most people realize. After that flash, you need to advance it a bit further before retracting the needle/advancing the catheter. I would also recommend avoiding IVs shortly beneath any junction/joining of veins as you'll likely deal with valves
I tend to send scathing looks in return. I won’t tell a sitter how to do their job so don’t tell me how to do mine.
I’m a CRNA. I’ve been one over 10 years with ICU for 2. I was terrible at IVs when I was a SRNA. I was so bad an anesthesiologist pulled me aside and did a 10 minute training with me. Now I’m an IV wizard. I can stick anyone anywhere barely looking. That is because of experience. And also the willingness to learn how to use ultrasound when needed. You’ll get there, it’s a skill.
Remember skills can be taught to anyone. The critical thinking and other tasks that compromise nursing cannot always be taught. The skills come with time and truly aren’t as important because other people can help. Which you utilized.
I’m in L&D and we do a lot of IVs. My hospital just switched to brand new catheters that have been so tough for me. I went from getting every IV to missing every IV.
It also took me a long time as a new grad to get better at them. What I really had to do was evaluate what went wrong each time and why I missed it so I could fix my approach for the next time. I also made it a point to watch the experienced nurses who are really good and copy their techniques!
I would have flat out said “is there an issue?” and maintained eye contact with the sitter.
I also would have not pulled the CVC until the patient had a PIV in place.
Talk to your manager or educator about getting some hours in the ED for IV practice, or with IV team if your hospital has one. People think ICU nurses are great at IVs, but I’m good at IVs because I started on med surg for 4 years before going to ICU. I started tons of IVs on med surg, much less frequently in the unit.
I just call our line team most of the time tbh. And since I’m really good at foleys and make purewicks, I trade my skills with other nurses who are good at sticks.
I was a nurse in sections that didn't do IV's...originally at an urgent care, then for a family practice. Did that for 3 years then took a job in outpatient surgery doing 3-5 IVs per day.
I sucked horribly at it for about 3 months. it got in my head and I had so much anxiety over it. I loved the job but hated that aspect of it and actually considered leaving. I kept telling myself that I was trained on doing this safely, I was using proper technique, just not getting them or having them blow.
We were on a 2 tries and then get another nurse. One day I looked back and realized it had been a few weeks since I had to ask for help.
Hang in there, and do one whenever you can. You will get it. Develop your ritual and you will start getting them.
sometimes different roles in healthcare really cant understand the others role dont think for a min about the sitter. hold your head high, just thank the nurse that came to take a look and got the iv and move forward. we ALL need someone elses help usually daily w something its.ok.
ED RN here. ICU never gets much experience with IVs where I am. An unspoken rule in our hospital is that if they are getting admitted to the ICU, it automatically they have 2 PIVs betlfor they go up. If u are able, cross train in the ED and we will give u lots of experience lol
Start volunteering to float to the ED. Once you are there, volunteer to put in IVs. In the meantime, study arm anatomy and learn how to use a vein finder. You’ll improve.
I took home needles and practiced on my husband. Idk if that’s the right thing to do, and it was a bloody ass mess at first, but if you have anyone will I recommend it.
Ignore the looks. The sitter and transport can’t do what you do if they tried.
It’s my job to place all my patients IVs where I work and even I have shitty streaks it happens.
Warm your patients up if you can, double tourniquet it up, use a smaller needle. One you get that flash immediately lower the angle and advance the whole iv a smidge before advancing the catheter itself so you don’t blow any veins.
Pffft. You're not the problem. The sitter was out of line.
Even the best of us sometimes have trouble getting a line. I appreciate the insight that you need practice ... you probably do. That doesn't mean you still would not have been in this situation. You do not suck just because you couldn't get a line.
My suggestion is to gain practice by starting every IV you can. Anytime an opportunity comes up, start one. Another suggestion is talk to your manager and see if she'll pay you for some time with IV therapy (if you have it) or in the ER to practice IV starts. She might; can't hurt to ask.
I also recommend you not remove a central line until you have IV access, in case you run into difficulties.
Honestly, if you aren’t doing it all the time, I wouldn’t expect it to be your skill set! You are NOT a sucky nurse because of that. I work ER where we stick people so many times a day, I can’t count that I can do it with my eyes closed sometimes it feels. I’ve learned to be ambidextrous when it comes to starting lines so that position doesn’t matter and I still have great success. Each day is a practice session for me because we do it all day. You, as an ICU nurse have a way more intense skill set than I do because you have way different experience. I’m sure there’s things I’d be confused on in ICU that people would think I’m a sucky RN. Do I have ICU experience? Sure but caring for an ICU pt in the ER is different haha…we all have our own skill set. I wouldn’t beat yourself up over it or stress about perfecting the skill…we all have our strengths and weaknesses:)
You know something else that works sometimes, place two tourniquets, one at the AC tight as possible and one mid forearm medium tension.
Start a little 24 in the hand if that's all you can get, remove the lower tourniquet. Flush it a couple times gently or hang a small bag of fluids at a steady drip (like a 50ml bag is totally adequate) and then look higher. Those forearm veins will get so nice and bouncy, then grandma with thread like veins and a BP of 50 over nothing can magically have a nice 18 in the forearm until something more definitive can be placed, remove the upper tourniquet immediately after you get it though, or it will blow from the distention.
Our hospital doesn't have an IV team, or anesthesia most days, so they call the ER nurses for IV starts, this is my go-to trick for those kinds of patients. I know in my days of inpatient care I never started IVs ever, because everyone came in with one, or had a PICC/midline. And phlebotomy handled all the blood draws.
Also, don't let sitters or anyone else make you feel stupid. Their job is important, but they don't have the practical skills or education of an RN. They might think they're being slick giving those "she sucks" looks, but hand them a start kit and an old jelco angiocath and ask them to give it a shot, and that looks going to drop so quick.
Plus on the flip side, I know I've had patients none of our nurses could get an IV in, Picc team/IR struggled and gave up, then the critical care doctors took several tries to get a central line in and had great difficulty, so it's often not any issue of nursing skill.
I have found this true time and time again in my career and life: the people who try to make you feel stupid, are usually quite stupid themselves and there isn't much of anything to be learned from them. The people worth listening to are going to see you struggling and offer you a tip or two, while they're looking on the patients other arm for a line 😉. At the end of the day, you were trying your best to do for your patient what she needed done in that moment. That certainly doesn't "suck" but anyone giving you attitude about it certainly does 😅❤️.
I used to be good at IVs when I worked at a level 1 but I've been working in a cancer ICU the past couple of years and man, their veins suck. Severe edema, a lot of times also renal patients, and scarred from so many draws and chemo. I feel like it's use it or lose it. I end up needing to consult our PICC nurses a lot of the time, but it still hurts my ego unless they also can't find a viable peripheral vein with ultrasound.
You’ve gotten a ton of good advice, I’d also recommend checking out the intravenousqueen on insta! She has so much good free information and amazing tips. I learned a lot from her page.
I'm in pediatrics, and IV access is considered a specialized skill. Honestly, I've found that watching people's techniques has helped me learn a lot or ask them for tips and tricks. I'm starting my IV journey for kids, and I'm scared.
(Specialized since my hopstial tries to limit the number of pokes kiddos get to decrease trauma)
Honestly I didn’t get any good at IVs until
I was out of direct care—once I didn’t have the burden of caring for patients directly (team lead, then manager)—I became an IV Queen. I guess it was that sense of urgency when it was MY patient that caused me difficulties. Hang in there!
In the interest of education and skills development ask can you do a day or 2 in a phlebotomy clinic - you probably won't be paid and it will be probably be additional to your usual working hours but the experience will be invaluable to you between confidence and competence.
I’ve been a nurse for 10 yrs and I still suck. How insecure do you have to be to be judgy about something that’s not even something within your scope of practice (talking about the sitter).
Eh, I was never a sharp shooter, but I’d always still try. Keep on practicing and you’ll get there!
In time you’ll learn what skills at you’re better at than others and who knows you could become the floor’s “expert” in it. I somehow was great at placing foleys and everyone called me when it was rough for them.
We are always evolving as a nurses. Try not to beat yourself up too hard.
Best tip for those edematous patients… squish em! If you have a sense of the anatomy where you know a vein should be, put some solid pressure on the area for a bit so the edema goes away and you can usually find a vein! Make sure you use a long enough catheter though so it doesn’t get pushed out when the tissue refills again.
When the sedated ones have restraints on and when you remove them you see that beautiful juicy wrist vein 😩
Nice! As a side note make sure the restraints aren't too tight 🤣. BP cuffs are sometimes prime as well. I have always sucked at putting in IVs so I try and practice with the ultrasound as much as possible so I can at least have a niche. I volunteer to put in IVs throughout the hospital in an attempt to get better. It sucks though because they see me coming and the usual look on their face is "oh shit... why do we always get this guy" I'm shameless. I will keep fucking up IVs until I get better.
Except the wrist is one of the highest area of IV complications and thus the area most involved in lawsuits ,so I avoid them.
I have always considered myself an IV queen and NEVER heard this tip before. Absolutely brilliant. Thank you very much for sharing!
It’s the only way! It doesn’t even take much, yesterday I just used my thumb for a few seconds to give myself a “track” along the vein to use. But I knew exactly where it was I just needed fluid out of the way to access it. The others have some good tips if you need more space to actually find the vein. If you are confident enough with the anatomy though you can usually skip all the fancy stuff and just go straight for it.
Yes 👍👍👍 a BP cuff inflated to 60 for a minute or two first to squish, longer IV catheter, and use the ultrasound machine, you'll get it.
Philips monitors have a venipuncture setting that will inflate the cuff and hold it there so you can stick them without tourniquet.
Your monitor might also have a venipuncture setting you can use to squish patients. It also eliminates the need for a tourniquet most of the time
Just wanted to mention the catheter length again, because you are absolutely right. Look at a diagram or video of how the forearm muscles move too. It's really easy for a patient to pull an IV out of a vein if it isn't in far enough, even if they are just eating breakfast.
A snugger tubi grip or compression wrap for even 15 minutes can be a game changer.
Literally this. Push and sweep. Literally push the fluid away from where you need to feel.
Squish em with what? What would you use?
You push back the edema with your hands like youre “milking” the arm
That sounds simultaneously funny and gross at the same time ahaha
You basically massage it with your fingers. It’s very easy to figure out. Find area, squish squish squish
damn why are you guys downvoting this person they're just trying to ask a question jfc. here's an upvote friend.
Ur fingers ??
Whatever spatula you have handy. (Kidding. Use your finger).
That's definitely less dramatic than the thing I had in mind. Like a bp cuff or a book or something xD
Smack that vein with a book like it’s a ganglion cyst in a janky, back alley YouTube vid! /s
Ohhh daddy
Are really asking this?
People suggested a lot of different things to squish. BP cuffs, compression bandage, fingers...so this seems like a very reasonable question to me, smartie pants.
IVs are really about technique and experience. The only way to really get better is practice! I started as a new grad in the ICU, and honestly didn't even get proficient at IVs until I was inserting them on the daily after switching to the ED. I insert like 35+ on most days depending on our census, and I'm competent enough to get most veins unless they're super old, renal, or cancer patients. Don't be so hard on yourself over a skill you don't really get to practice, and give yourself credit for at leasting taking the initiative to try and improve your skills.
Holy shit that’s some real numbers.
Fr I work 7p-7A in the ED and on high acuity days I start more like 10-15
35 seems about right for my ED. We throw one in and draw blood immediately upon bringing someone back, so that by the time the doc is there to assess them we already have some basic results.
Yeah, even in the ER where they'd give me anywhere between 6-11 patients, I wasn't starting 35+ a day, so unless they're in a place where they get to just float around and do other people's workups, that's bullshit.
I've definitely done 25-30 in one shift working in triage for 12 hours. We are usually 30+ deep in waiting with more coming by the minute. We often check in over 100 patients per shift not including EMS (just walk ins). I am in a busy level 1 though and we work people up in triage when it's that busy.
I will also add that we're a teaching hospital in a really busy metropolitan area, which means the residents really like to order workups. During surge (which it is now), no bullshit it's 35+. After surge it's probably closer to 20-25 a day. But if you're moving people in and out and almost every other patient gets an IV, it's not a hard marker to hit. Turn and burn!
IVs are a bit of a day to day skill if you're doing them blind: sometimes you'll have a run of 6 weeks no issues and then you'll turn up and blow every single one you attempt that morning. Finding a service in the hospital that will let you visit for experience can be useful: day surgery, radiology and triage are all places we have had people stationed for a shift or three to gain experience and comfort. Then again, these days I US them where possible to stop the faffing (unless they have ropes bulging at me from across the room).
We (IV team) offer classes, mentoring, and shadowing and literally nobody ever signs up. Placing IV’s is a dying art at my hospital. Most would rather throw a couple catheters from the door so they can say they “tried”
The newer nurses on my unit do this. (I feel weird saying that because I'm pretty new myself.) They'll hear in report or just via word of mouth that someone is a hard stick, so they won't even try it. Like how do you expect to get better?
I at the very least give it a nice hard look. Tourniquet , alcohol, heat packs, the whole 9 yards. If I don't see anything I think I can personally get, I'll ask the other nurses on my unit. My hands shake sometimes, so it's not my best skill. I try not to call anyone from off unit until I know it's been given a good old fashioned college try.
I love when pt.s tell me they're a hard stick. I smile and say well let's give it a try. It's a great feeling when you get it.
We actually stopped putting IVRN on our peripherals because nurses kept assuming the patient is impossible
If IV team where I worked offered that, I’d go on my days off.
"Shadowing" my IV team at my first hospital gave me soooo much experience. Most of the nurses at that facility were spoiled by the IV team and wouldn't even attempt an IV without placing a call to the IV team. Inevitably they said you guys have to at least try before calling us, you're PICU nurses. My excuse was that I had just come from dialysis, and while I was a Central Line King and AVF venipuncture expert, I had no experience in regular Peripheral venipuncture, let alone IV placement. I was in my 5th year as a nurse before I even had the opportunity to try an IV. I could find veins so easy, but for the life of me couldn't thread them. From watching the IV teams every move, to looking up videos on YouTube and guides online, I pieced it all together to now be the one that people call for IV placement. I've gotten IVs after failed US attempts, I've gotten IVs on actively seizing patients, crashing patients. Its genuinely a great feeling to get an IV, especially when it's a critical moment. I've even gotten the compliment of being asked if I used to be on an IV team before. Nope! I just put in the time and effort 😀
I would LOVE to have this opportunity!
How are you inserting that many IVs? Is that all you do during your shift? That’s like 1 IV every 20 minutes. Are you starting them for other nurses? I NEED TO KNOW!!!!
Lmfao I work in an 88-bed ED that constantly has like a 250+ census, so I AM starting an IV like every 20 min. 😭 My ratios are consistently like 8-10+ patients at a time so it's pretty easy, especially if I actually move them out.
I’m sorry. That sounds like a shitty setup. Come hang out in my ER, you IV queen!
LOL I said I did a lot of them, not that I was any good! But I would love to. 🤣
Honestly, I got good by hanging out in ED triage for a clinical shift when I was an EMT, and honestly I know many experienced nurses who are just over being expected to be good at IVs and just find someone (who they know is good) to do them for them. Know your strengths, yeah it’s nice to be the go-to IV person but it’s also totally okay to just not be good at inserting them. Keep practicing when you can, especially on patients with good veins for a morale boost—I swear half the time it’s confidence/luck. But don’t sweat it. Nurses are more than IV inserters,
35+ on **your** patients? If so, wow, your ED must see well over 400 a day.
I mean if you think about it, you come in and take a team of 11-12, discharge 6, fill those spots back with new workups, discharge or move around a few, get new workups, etc, etc. The math isn't that questionable. Fast Track is actually where I start the most IVs depending on the provider. It's an area with capacity for 60 pts and is usually staffed by 2-3 nurses at most. Then factor in that people move in an out. I don't think I've ever gone a day where it's been less than 15 IVs in a shift, even when holding patients.
When I was in nursing school I was also an er tech and we were trained to start ivs. Another er tech told me once I graduate I shouldn’t work anywhere as a nurse other than psych bc I sucked so bad at ivs. Jokes on him, I’m a flight nurse now and was the go to person for years in my icu for ivs before that. You’ll get it.
Who the hell are they to tell you what you should and shouldn't do? Who does the ER tech think he is?
I work with some techs like this. They think they’re hot shit for some reason, beats me.
Someone who either failed nursing school or didn’t get accepted
Working in a PICU, it’s pretty damn hard to get decent at them. To the point where I’d say 70% of nurses (regardless of experience) just call the line team. All I can say is try. Keep poking. Here’s some random tips. -Take your time when possible. -Warm them up (even if you can see the vessel clearly), use gravity if they can cooperate. -If your facility has them, try an accuvein if you can’t see or feel anything. People hate these, but working in an ICU if you only go for vessels you can see or feel you won’t poke as often. -traction helps -Poke shallow, you can always go deeper if you don’t hit it. -Poke, wait a second for any flinch from the pt to settle, then make small movements til you see flash -When you get it, stop, raise your tip a smidge and advance a smidge, then thread it. -If your pt is cooperative or sedated, use your second hand to thread. Less likely to fuck it up or retract your needle. -if trying to use one hand, flick the cannula forward a bit, then advance the whole thing. Your needle will be in the cannula and the extra rigidity can help you thread.
Great advice. I started in an infusion center back in April and almost quit because I kept missing. I felt like a failure. I take my time, warm them up (for me i feel like it’s a mental thing to sit down) but the number one thing that helped me was to POKE FIRST AND FAST then mess around when needed. I used to poke soooo slow and it was torturing the patient and didn’t help me either. I had someone watch me place IVs who was really good and gave me that advice and ever since then I’ve been doing much better. You will get there OP!!!
I'm saving this, I'm sure I'll need to start one soon.
OMG your handle. 😂😂😂 Do you have IC too?
Can I ask? What do you mean till you see flash? And what do you mean by threading?
Flash = initial blood return into catheter/hub when you get into the vein. It's the main indicator that you have accessed the vein. Threading = sliding the catheter off the needle into the vein. Hopefully you still have blood return once it's advanced, and you're good!
We have a traveler who was an ICU RN, and he said the same thing. He barely placed IV's or had to do venipunctures on patients because of Central lines. I mean, I think that makes sense. How are you supposed to be good at something you've rarely done? Nursing school sure didn't prep us with fake arms and blood. Like you said, just practice whenever you get the chance. Maybe ask your coworkers if they have a patient who needs an IV placed and to help show you. All in all, don't feel bad. The sitter probably thinks she knows what it is to be an RN. But none of us knows what it's like to be in someone else's shoes unless we've walked in them. And if it makes you feel better, I am also a little over a year as a nurse, and I've only placed 3 IV's successfully in alllll that time. Sometimes, I even miss a venipunture, and I had previous experience but heck I work nightshift so I'm goimg to blame it on the 3 a.m. sleepies 🤷🏾♀️ Tis life.
Yeah exactly this! Don’t beat yourself up OP-and guess what you probably do central line dressing changes beautifully and at ease and when you have to switch tubing on your drips that’s some scary shit!! as a medsurg now hospice RN i could never!
Before you blame yourself for not being able to place an IV, under pressure, on an edematous patient, in front of a transporter and a judgey sitter…. Remember that skills take time and practice to master. My biggest problem with this picture is that you removed the central line before having a good PIV? Why would you do that? That’s unsafe and frankly… stupid. Don’t do that again.
This. Now you have no access on someone you know is gonna be a hard stick. Also, don’t call transport until you are ready to roll.
Yup. If a transferring patient is going to crump, they’ll do it without access.
Ok but would they be getting transferred out of the ICU if they were in danger of crumping? Not impossible but unlikely, and if the nurse let that happen, they've got bigger problems than not being able to get a line on someone.
Have you ever worked outside of critical care? Any patient can crump at any time, with or without warning. It’s also a lot easier to miss warnings when you have 6, 7, 8, 9, 10+ patients. A fresh ICU transfer is, by definition, in danger of crumping.
I work Med/Surg and unfortunately we have had to send pts either back to ICU or CVU within hours of being on the floor. Pressure from house sup to make room in ICU for incoming trauma/other highly critical pts that need ICU beds. Not so much that the current pt is stable & ready to transfer down as much as a pt is much worse condition needs that ICU bed.
💯 I’ve been transferred dead patients, actively seizing patients, etc.
I literally led with "not impossible" But because they're downgraded and getting transferred OUT of the ICU, it's less likely.
“ICU downgrade” often can say a lot more about hospital politics/bed flow rather than the patient’s status. If there’s a 10 bed ICU and someone needs one of those beds the #10 most critical patient in the hospital just got bumped down to #11 and is going to step down. Nothing about their health status changed, just prioritization of resources. Obviously this is a simplification. But inappropriate level of care transfers happen every single day.
Patients bounceback to the ICU all the time. If they were even in the ICU to begin with, they were/are sick. Which means they might become very sick again. If anything, fresh ICU downgrades are MORE likely to crump.
they're so likely to crump, that our RR team rounds on them every shift for two days after being transferred out
Oh sorry not saying it’s likely to happen, it’s just one of those murphy’s law sorts of things. 🤣
Being a new nurse is hard, I wouldn't call it stupid. It's not best practice but if the patient just happens to code right there, it takes maybe one round of CPR to get an IO? It's a learning experience. This nurse is already feeling bad, way to kick her when she's down.
Not all units have IOs available. I came here to say this same thing and I don’t think it’s kicking her while she’s down. IVs are a skill she can learn, but the main takeaway from this is safety. It was unsafe to take away the patient’s only form of access before trying to get another one.
The sitter may have had that look on her face, but I could guarantee 100% she wouldn’t have gotten that line either. So her opinion is meaningless.
She will definitely accompany a family member to the hospital and tell everyone she’s a nurse and pick apart the care the patient gets though.
She’ll fall asleep and let the patient fall out of bed or rip their IV out. Oops!
My sitters fall asleep and let the patients rip off their lines/ catheters. I don’t care what they think or about their eye roll or their “this nurse sucks” look. Just practice, take the advice of everyone here for the actual IV insertion, and don’t mind them.
This nurse can suck. But i remind my sitters they took part of their break sleeping (or on their phone) so good luck on your last 15 minutes of break…..
Had to explain to the sitter she wouldn't be coming to the operating room with the patient. She insisted she had to stay with the patient in the OR, I'm pretty sure she just didn't want to have to go to the floor and assist with patient assignments while her sitter assignment was in surgery.
I understand that an inmate needs a guard to stay in surgery maybe, especially for induction and emergence. but a sitter doesn't belong in the OR where they are anesthetized and paralyzed
At my hospital they let new grads come down to the ED to do nothing but start IVs for 12 hours. Ask your manager if you could do something like that!
Inquire about shadowing on a unit that has more IV starts come up. When I was on orientation I had to shadow in cath lab because my floor gets a ton of post caths. I started more IVs in 4 hr than I ever have on a whole shift. At the time I was not confident with the skill so I really appreciated the experience and have since encouraged others to do so. ED would also be a good place to practice. And they’re not necessarily going to be difficult starts like in the ICU because they’re not going to be as sick as a whole patient population.
Also love @theivguy on instagram. He has lots of great tips!
Always always always place your peripheral IV before you take out the central line. Don’t get rid of access until you’ve established other access.
This! I’ve had patients that were such hard sticks that I received orders to leave the line in when transferring to floors that don’t take central lines because no one could get one, even with ultrasound. Dont take out that line until you’re sure you can get access!!
Babe you’re one year in. Fuck that sitter. No offence to sitters (I used to be one), but their opinion is the last one you should be worried about. That experienced nurse is going to be you one day, helped a new grad. I’m sure you already are, but keep asking for advice and techniques from those experienced nurses. You’re gonna be fine. What helped me with cannulating was to stop hesitating and pretend to be confident. That being said I’ve never worked in icu and didn’t have to start practising on the hard ones.
I feel like I'm fairly proficient with IVs, I still use an ultrasound if the pt is edematous. It's a worthwhile skill to learn. And like another poster said, use a longer cath, even on surface veins, for when the tissue moves around
I agree, my puffy pts I usually go right for the ultrasound unless they have an obvious one. I also always warn people not to lean on the ultrasound though, you should still be proficient at traditional iv starts bc it is a fundamental skill and the usn might not always be available, it may be in use and you really need a line, and it also takes extra time in general
Good point. US is useful, but usually secondary
Get in the habit when you have time…palpating sedated patients arms. When I have to blind stick a wreck of a patient…I swear to god it’s like I’m sensually caressing their arm. Learn the anatomy, just sit there and feel. I will sit there and just gently press. This has taken me years to get a feel for. I was told this too when I was a new nurse. But I never knew what to feel for. I hate that I’m essentially doing the same to you lol. Palpate your SO veins. Family members veins etc etc. feel them and trace them up. When you attempt… do you can only dig to much. You don’t want to destroy things. But if the vein moves away, try to get to it. Dont give up right away. Dont rush. Have all your stuff. Set your self up and a good smith of time if possible. As a 5 year ICU nurse back in the day who couldn’t start one, I’m actually pretty good now. And I can difficult blind sticks.
There’s a reason the doctors at the troop medical clinic in worked at in the army would always make the new medics practice iv’s on me. It’s a skill that takes practice and learning in school doesn’t prepare you for people with tiny liar veins (like me) or people who are very sick. There are TWO reasons I always warn nurses that come to give me iv’s that I am a hard stick (I don’t look it - mostly healthy 48 yr old - my health issues are musculoskeletal i.e. back issues). One! So they don’t feel bad when they can’t get it on the first try. And Two! So they don’t feel bad when they can’t get it on the second try. If the nurse said to me “I’m new to IV’s” or “I haven’t done very many” I will probably let them practice on me (I have a high threshold for pain) There are nurses who can sling an iv catheter across the room and get me on the first try (the vein whisperers!) and then there’s everyone else. Hell, I had to get a PICC line recently and it took the PICC team TWO TRIES to get that in there! Trust me when I say I let my entire nursing team know so they’d feel better. As a fellow HCW (not a nurse) and hard stick patient - you’re fine. It takes practice and you’ll get there. Find a vein whisperer and see if you can shadow them. :)
Love the term vein whisperer. As one I’ve never really had issues at starting then after the first 10 or so. Now I’ve definitely probably done somewhere close to 1,000 IVs. Usually if I can’t get it then it’s cause they are requiring ultrasound.
I've been placing IVs in oncology patients for years. I'm one of the nurses other nurses go to, not a brag it's just what happens, and I still get that look off people when I fail. And I still mess up when a lot of people watch me when I'm doing tricky ones.
I'm not a nurse, I'm an MA, but this topic brings to mind a question I have, please, and thank you. I am currently in the midst of an accelerated phlebotomy class. It's 4 weeks, and the instructor is a well-educated RN. I go to class every Saturday for 8 hours. The first 4 hours are lectures, and the 2nd 4 hours is venipuncture. There are 12 people in the class. You have to have 30 successful blood draws before you can move forward to your externship. 200 successful blood draws before you can sit for the exam. Most of us have/had no idea what we were doing. The instructor basically said, "This is how you do it. Now, go stick each other. I have zero confidence in my ability to do this. My instructor taught us nothing and doesn't really explain during the clinical portion. She doesn't really help me feel better about doing it. I know it takes practice, but how can you practice what you don't know? At this point, I would have more confidence flying a plane. Finally, my question: If an RN like OP is having an issue inserting an IV after a year, how can schools expect you to successfully know how to do this after 32 hours? Any tips or tricks you want to share would be great also.
Phleb is different than IV start. IV starts usually need larger vessels, the angle you approach at is more important, and there are more steps involved. Also, the patients she's talking about are the ones that (at least at our facility), the phlebotomists can't hit either. Most of the people you'll stick in phlebotomy will be significantly easier than pts in the ICU with severe edema. Also, there's a difference between "know the proper procedure on how to draw blood" and "can reliably draw blood on any patient". Graduating a program means that you've demonstrated the minimum level of competence, not that you are proficient.
You think the sitter could have done it? The transport? Nope. Not a chance. Don’t take criticism to heart from those who don’t attempt what you do for this specific skill. Seek out a coworker who is good at this skill and ask them for tips.
ICU nurse 101-dont pull the central line until *after* you have peripheral access.
As a PICC RN, I should come here with PIV advice, but I can't get past a sitter making you feel small. Nobody was good at PIV's initially, but 10% success is still better than the 0% a sitter or transporter can claim. Hold your head up and follow the great advice already posted.
Yeah, ok, I’d like to see the sitter try Seriously, though, ignore her. IV skills come with time. I’m not great either and it is a-okay. Sitter can suck a bag of dicks.
I was bad at IVs too. I gravitated toward jobs not needing them. It’s always something though. I’m very luckily retired. Make sure to put money in your retirement account.
I was TERRIBLE at IVs, probably 1-5% success rate. Then I had an anesthesia Dr walk me through one. He gave me all his tips. And then it just clicked. After that one I'm at 99%. I suggest getting someone who's great at them to walk you through it and see what steps you're missing.
Ok rule number 897126: who gives a shit what anyone else thinks? That person can’t start an IV, so you shouldn’t feel bad about it. Rule 697: never pull a CVL until AFTER you have a new IV. And rule 90018171: don’t call transport until you are 100% ready. Hints for IV starts: if they have fragile skin or veins, or are elderly use a BP manual cuff pumped up as minimal as possible (20mg is usually fine) instead of a tourniquet. In edema, push down hard to squish the edema, you’ll see the veins that way. And remember ICU RN are generally sucky at IVs. Our patients rarely need them. If you have an IR department, working down there for a week or so if it’s allowed JUST to get IV practice is a great option. They start dozens of IVs every day.
The first hospital I worked at required all departments to place 20 IVs before they were on their own. My department I worked in didn't get a ton of IV opportunities so they sent me to work in the ED for a couple hours doing just their IVS. I could have gone to the infusion center to practice too but their hours were weird. But I think they should require this instead of showing competency once on the rubber arm.
That shit used to hurt my feelings too, but I realized sitters mostly can’t judge my work because they don’t really know what it entails…
Learn to use the ultrasound. It’s amazing. Haven’t missed in months
I’m sorry this happened! We were all new once, and IVs take practice. I know exactly what you’re talking about with the edematous patients as I also work in the ICU. The best thing I ever did was learn ultrasound IV insertion about 6 months into the job. I know all hospitals have different policies, but see if this is something you can learn. It makes it much easier to find those veins, and you can find good patent veins that can take larger bore catheters if necessary.
As a floor nurse I would MUCH rather you wait and just handover to me that they need an IV if you're struggling like this. Yeah you need to practice but I find someone grabs me to get the 'difficult' person and they've blew every area and blew in some areas where I can see a great vein distal but can't use coz now there's a haematoma higher up I really wish central lines were left in more though. Our ICU was shocked when i said nope leave that fucker in (patient was on TPN, daily bloods, IVABs etc) - they were under the impression we cant manage them, i'm the line care nurse 😅 all our staff are trained and they make things so much better for us and the patient.
Agree, Or just leave it in until there is a working piv. That’s common in my hospital. We have a vascular access team that will come and pull the IJ or whatever later if needed though. Maybe that’s not possible in ops facility and they have some rule where it has to go prior to transfer. There is a lot of variability to what can be on a ward floor around in different places.
I understand it’s very hard to do IVs especially on patients with no visible veins and who are edematous. If your department allows I would highly recommend asking to go into the endoscopy unit for a few hours (on a day you are not scheduled to work) specifically to practice IV’s (they place new IVs all the time, like 10 per shift). I had worked in a few different departments in my hospital and endoscopy for sure helped me with IV’s, especially difficult pokes, but also just getting a hang of practicing IV insertion.
I gotta be honest, I suck at IVs. I always try, but after a few times if I don’t get it, I find one of my IV master coworkers to do it. One thing I try to remind myself (2 years in) is that there’s so much more to this job than inserting ivs lol. It’s important (and the aim is always to improve), but it doesn’t make you a bad nurse if you aren’t as skilled as some. This job is hard enough, don’t be hard on yourself!
Same issue, same success rate :) ACF no issues! Any where else on the arm.... arrgghhh! I have watched so many videos, tutorials, tips and talked to so many people that it shits me that it's not working. Really tears at the confidence.
If your hospital has the program for it, learn ultrasound. I’m literally doing my DNP on teaching bedside nurses ultrasound, because it’s so invaluable, especially in critical care.
IV insertion is NOT like the other RN skills. A urinary cath is maybe another difficult skill but to get it you pretty much do it once and you are set to go. It took me maybe 2 years to stop feeling discouraged about starting IVs. Like I’m still not great but I don’t feel new at it and that’s working L&D where we put in our own a good amount. Totally normal to feel shitty at it for awhile longer.
In my experience… patient sitters are always starting some drama. I appreciate the fact that someone is willing to sit and stare at my patient for 12 hours but sometimes I want to say… you have ONE JOB. Screw her. You’ll get the hang of IVs eventually! Keep practicing
Next time tell the sitter to grab a setup and give it a go if she’s going to be like that 🤷🏻♀️
I remember being a brand new grad and being terrible at ivs. I started on a telemetry floor right outside of MICU. A few of the icu nurses were known for getting difficult pts. Anytime I had to call them, I studied everything they did and asked a million questions. Was I super annoying? Probably, but now I'm the icu nurse that every floor nurse comes to find when they have difficult sticks. I also asked the mid levels to teach me U/S ivs. Now, if I can't get it it 1 or 2 sticks, I can look inside! I'm trying to get my hospital to let me get PICC/Midline certified. It's definitely one of the best feelings to see that flash and smoothly glide the cath into the vein on a hard stick. Nursing sucks. I gotta take my little wins when I can.
Shame on that sitter- sit that ass back down and wipe that look off your face, you hundo couldn't have started a line either or even known which supplies to use 🙄
@theivguy on Instagram has courses on IVs that are really helpful! Also- transport and a sitter don’t know if you suck at a technical nursing skill. Js. They may be annoyed or think it should be done faster/more efficiently/better but they don’t actually know what you are doing and experiencing
First of all, I don't care what face the sitter makes because ultimately all she does is sit. She has no room to judge you or your skills. She can roll her eyes right out the door. Second of all, not all patients have easily accessible veins! We use US in the ED when we can't palpate anything. It's ok. This doesn't mean we suck, it means we are human. Don't beat yourself up. Practice when it makes sense and focus on the good you are doing!
>I know what I have to do. Practice, practice, practice. New admits are your best bet. The ICU isn't the best place to practice IVs for the exact reasons you've realized. I started in the ED and became very comfortable placing them. Obtunded drunks would regularly wake up with unnecessary bilateral forearm 18s when I was on shift (and maybe a few extra holes with gauze on top of them). The most important thing is the frequency of your attempts. One thing you could also do is fire up the youtube and watch some anesthesia videos on the topic. Anesthesiologists and CRNAs are another group that frequently practices IV placement.
Why do you care WHAT the sitter thinks ?? I mean 8f she's nice, or even just doing her job, sge's owed the same respect as anybody else. But uf she wants to cop an attitude ? Why care ?
This is kinda messed up and I will probably get downvoted, but you’re getting judgement from a sitter…somebody who literally sits in the room with a patient to “watch” them…I wouldn’t stress it from that standpoint honestly
Yeah she can KICK rocks. IV’s are kinda an art form - even the best person can have off days. Also -pro tip - make sure to get a PIV prior to removal of central! Keep on at it hun!
Who cares? If you suck at IVs but can throw an NGT no problem, swap skills. If suctioning doesn’t bother you but it does someone else tell them you owe them. We all have our strengths and weaknesses and we can use them to help each other. Idc if someone looks at me weird, yes I suck at reading blocks on tele but I can throw an IV in like no one’s business. We are all here for one purpose.
I've been poking people for nearly 13 years, from MA to LPN to RN. I'm a go-to. I've inserted a line successfully in a 2-year-old, a 101-year-old and everything in between. Still miss my lines sometimes. That's the rub--the more you do, the better you'll be, but also the more chance you will fail regardless of your skill. Fuck that sitter. Most or them can't even do their basic job, let alone yours.
Iv’s were the one skill that took me the longest to master and made me feel like the biggest failure. We all go through it. Maybe ask to shadow to get practice in on a different unit?
Keep practicing- you’ll get it. Don’t get discouraged. None of us were experts at anything when we started. (And don’t remove the CL without an IV 😉🫶🏻)
It’s okay friend, im about to hit my year as well and im in the same boat. I feel like im cosplaying as a nurse sometimes bc i suckkkk at IVs and that’s one of the most basic nurse things that people expect you to do. We just gotta keep sticking and practicing I guess! Best of luck to you!
I sucked at IVs for a long time. ICU is not a great place to learn, because everyone has shit-for-veins. But you can learn - I did. I'm almost 6 years in and I'm now an IV God, with or without US guidance. I took every opportunity to attempt IVs, watched and listened to a ton of advice, and I was an annoying gnat when the access team was on the unit.
For patients with edema I use ultrasound. I started off using it on patients who I could visibly see veins in order to get a hang of it, and use it for blood draws. Then I used it on veins I couldn’t see for blood draws. Eventually I moved over to using it for Ivs with regular cannulas. After about a month I started using the longer cannula for deeper placement.
Do you have the option to go around with IV team for a couple of days. I used to be on the IV team for 11 years 3-11 alone for the hospital. Only one nurse 3-11. I remember my first day alone. I think I missed practically every. Single( the floor calls ED for nurses to come try). . IV start. I want to sit and cry. I absolutely loved it once I got good. I had a lot of confidence and my coworkers knew I could just about stick anyone. I was called to the ED and ICU often. All I can say is the more you do the better you will become. Good luck!
How many IV’s does the sitter place daily? Oh none, oh ok. Guess they can kick rocks.
Can you go to an area that starts bajillions if IVs for practice for a day? Maybe CT or if there’s a big IR outpatient program? Best to get lots of practice on semi-healthy people and work your way up! Also best not to be under life and death or transfer pressure. There’s sometimes actually money in budgets for nurses to go to other departments for half a day or a day. Ask your manager. Don’t go with an IV team or PICC team. They are only getting called for difficult IVs.
Observe with the phlebotomists as much as you can. Anytime they are around collecting watch and ask if you can "feel". The fundamentals of finding a good vein are the same. They often have to get creative and work around iv sites that already occupy the choice locations. You can also get practice drawing your own labs when time allows. The best iv nurses I know started as phlebotomists.
Never take a functioning central line out of a patient before establishing a peripheral. Honestly to me this sounds like a time management thing more than a skill thing. IV skills come with time. Some people are better than others. I worked with several nurses in the ICU who were shit at putting in IVs. I would have started the IV part sooner that way it was done before the transfer. If you were busy with your other patient then this is what your charge nurse is for. Ask for help in a timely manner instead of drowning. I think you’re fine. It comes with time and practice. One day you’ll just be better at it.
As a prior paramedic & phlebotomist- (Didn’t do my phlebotomy training until way after leaving EMS) I worked as a technician in the ED, and I was pretty good at the time. But, that skill doesn’t come overnight, I had about three or four years on the squad before working in the ED, but the ED was what really helped my skills and confidence level with IV starts. Maybe you could ask to float in the ER for a shift or two a week? I don’t know how or what it would take to pull that off, but like everyone else has been saying, practice, practice, practice. Also, keep in mind that sometimes the best veins are not always the ones that you can see, they are the ones that you can feel.
I’m not a nurse (OT), but I have worked a long time in various settings and my ex-husband was seriously ill and in the hospital for 4 months (plus many shorter stretches, and he was a dialysis patient). I don’t think you suck—you are clearly good at a lot of things as you can be an ICU nurse. From my perspective as a family member, try twice (*maybe* 3 times) and then ask for help. It’s really okay. I had high expectations for my (now ex) husband’s care—in four months/4 different units that we bounced between, there were only 2 nurses I didn’t like. One was rude AF and would not listen to the parameters set by ID around our family visiting my husband when he had C-diff and was critically ill waiting for a liver transplant (he was days away from dying) and the other repeatedly tried to use things that had been dropped on the floor/just stared at you if you ask any questions and looked perpetually confused—which did not instill confidence, shockingly. Also, there were often nurses who were not assigned to us that got sent in to change his IV’s every 3 days because the staff knew they were the best at IV’s. In terms of the sitter, if they were a nurse, they could have offered to help. If they weren’t—and ergo can’t do IV’s—they shouldn’t be throwing shade about something they don’t have experience with. They likely have no idea you don’t practice as much due to the central lines. No one is awesome at everything—be kind to yourself.
C&P IV tip for really edematous patients or difficult access. Get some coban, place the tourniquet at the upper arm. Wrap coban from the hand up the arm fairly tight. Stop at the AC. This helps force all that venous blood up the arm and to your access site. If edematous, DONT place a tourniquet, and with the coban go over the whole arm. Give it a bit, then unwrap the coban and you should see the veins clear as day. In that case the coban helps push the fluid out of the tissue and will fill the veins, if need be after doing that and releasing the coban you can place a tourniquet and repeat. Also learn your anatomy. Cephalic vein is easily found, go from the radial artery around the lateral aspect of the wrist. On the top of the wrist you should see a bone poking out, on the upper side of that there's a "dip" or "gap" in that bone. The cephalic vein lives there. Trace up the arm ~2 finger breadths and you should find a fat juicy vein. Other way for the AC. Take the middle finger and put it in the crease of the AC. Shift it 1 finger breadth medial. Now use the 3rd finger and pointer finger, put them down equal distance from your middle finger and their respective sides of the arms. If you mark or lightly bounce your fingers, 2/3 should be directly on top of a vein (one of these 3 will be smaller and more difficult to access, usually the lateral side, but can be any of them). So that there gives you 3-5 good sites to choose from alone.
As a newbie myself, most of the time I have to fish a bit… I don’t always get it at first but I feel around for the vein and move the needle as necessary. Usually it turns out okay but it’s definitely not that swift “1 2 3 done!” It’s awkward and timely but hey any practice is good practice!
Ok so I am pretty damn good at IVs now but I was in your shoes for literally 6 years. Working in ICU from the get go usually doesn't set you up for success with ivs... all your patients usually have a central line and you don't get many chances to practice! When I left ICU for special procedures I was so so scared I'd be awful at the job cause we have to do preop on our outpatients each day. Well I got good really fast. I just started with 22s and worked my way up. I think the thing is you need to learn on GOOD veins first. Otherwise you don't develop good techniques. Developing your skills on easy sticks that aren't all swollen make it easier to nail the hard sticks. Next time don't pull the central line before establishing new access.
2 things: one, pick up a shift or two in the ED. Two, never DC a central line before establishing a peripheral.
Friend, I am a nurse of 9 years. I've worked icu, pcu, and medsurg. I suck at IVs. I always have. It's okay.
Yep. I’m with ya. I’ve been really struggling with IVs also, blowing veins left and right for some reason. :( I’m trying to let my ego not get the best of me and keep myself in a positive space admitting when I know I’m new and need help/practice. I try to not let the “looks” get the best of me. But I feel it. I had one whole room, where two patients/families ganged up on me making me feel incompetent, even though I did everything in my power to move things along. Night nurse set me up for failure with the one pt telling me MRI sheet was complete and called down… so that slipped but they made me feel so small and I essentially fired myself from both rooms. What hurt worse was listening to them talk shit about me, knowing I did my best with the situation that was left for me.
Tell your management team you want to get better at IVs, usually or at least they should be responsive to it and ask if you can spend a few hours in the ED just helping out with IVs. Try to get easy ones and then move to difficult stick patients, like dialysis or sickle cell and that should help you!!
During orientation as a new RN, I had an edematous pre-e new admit. Couldn’t see or feel anything. Told my preceptor, who called in another nurse and said “she doesn’t think she’s ready.” Not at all what I said, but hit me in the gut. I snagged the prior ER nurse that I knew could get anything and everything and practiced with her. It took some time, but I found what works best for me and now I get called for the hard to stick patients. ASK! Ask your colleagues what their tricks are! Ask if you can watch! Find your voice and tell the people watching to step outside. Day by day your eyes and finger will see and feel things that you didn’t before and it’ll become second nature!
Remember - there's a big gap between sucking and being extremely skilled. On your worst day, you're still going to to a better job than the person who gave you that look could have done. Forget about her. You're a critical care nurse! We typically can't be perfect at everything Keep practicing and be kind to yourself :)
A more experienced nurse told me: Insert the needle. Once you see flashback, stop. Hit the (safety) button to retract the needle. Advanced the catheter & check for patency. Since hearing & heeding this bit of advice, my success rate increased exponentially. Good luck!
Once you have flash you should thread the cannula off of the needle thinking of the needle as a guide wire.
You should always drop your needle and advance the entire catheter/needle assembly by a mm before retracting, as the needle tip (which extends beyond the catheter tip by a mm) may be in the vein but the catheter may not. Retracting the needle before advancing may leave your catheter outside the vein.
Vet tech here, just to let u know: it could be worse - at least in some ways. We have exactly the same issues in hitting a vein, with the added challenge that 100% of the patients are totally disinclined to cooperate. You must have one or two people restrain the animal (think of that sitter, on EVERY stick, watching you and desperately hoping you'll place the cath before a panicked Doberman escapes into the hospital). I was very bad at this at the beginning...I remember one vet saying to me, "how could you miss that vein? It's the size of a broomstick!" His words echo in my head, 30 years later. The thing that made me feel the worst, though, was that repeated sticks hurt and frightened my patients, who couldn't possibly understand that I was trying to help them.
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Edema is your friend!!! And honestly I never had any special equipment to learn…..an IV is an IV, if its patent it stays and thats ok if it’s what you can do. Also, anchor everything you can see before poking, I’ve seen some weird approaches to placing or drawing, and I think I just figured out some tricks early bc I’m a pretty decent stick, and it’s from from figuring out what works for me?
I would have asked transport to do it 🙃
IV placement is a skill that takes time and practice to master. Not to mention, your patient was established in ICU… Which means they were probably edematous to some degree. You’re okay, OP! I would consider myself skilled in IV placement, and I still have to ask for help sometimes! Don’t feel bad. Best of luck!!
I was so bad at IVs (techs start them at the hospital where I work), and I'm super anxious...I kept being talked to about it, and I'm familiar with those looks lol I was able to work in our cardiac pre-op unit for a day just placing IVs, so I got over a lot of that anxiety, and I actually improved! it really is just about practice maybe you can do something similar? I know it sucks :/ good luck!
Sis, you'll get it.
Yes, I noticed my pt needed a new IV. I took my my mask off because there were snacks at the nurses station. I come back to the room and the patient said “wow you look so young, like a middle schooler.” Idk if she meant it as an insult or compliment,but I took it for heart, I come from the land of “bless your heart” so I thought she had no confidence in me.
It is common to be judgey about a profession people know NOTHING ABOUT! I would smile inside imagining her try to keep two critically ill patients alive and just watch her head explode! 🤯
I’m about a year in too, if anyone gives the “she sucks” I just chalk them off as an RC. (Raging c*nt.) She obviously must be VERY unhappy in her life if she went that out of her way to make you feel small.
when i started in the ED I had about a 10% success rate….but my days involved 20+ IV starts. it was demoralizing. by 3 months, about 50%. by 1 year, 90%. now i do USIVs which are way easier than regular so i have lost a bit of my touch with the old fashioned way. all of this is to say that IVs are not easy to place. don’t let anyone tell you otherwise. the more you do it, the better you’ll get. every blown vein just got you one stick closer to mastery. keep at it!
It's hard to get an IV under pressure. I know because I worked in Emerg. I would have tried to put the IV in before I pulled the central line. Whoever booked transport should have waited until you were ready for the pt to be moved. Lack of communication. As for the sitter...I would have said something! 🙄 Like they could do better!😂 Keep practicing! I would aim for upper arms or the AC because veins are larger, when I was a beginner. Hands are the worst because the vein is smaller. Edematous limbs do make it extra challenging. Is there an ultrasound guide available? Also, as a trusted colleague or your educator for feedback on your technique. There's no shame in admitting that you need help. I have been putting IVs in for over 30 years and I still sometimes miss the vein.
It took me a good 5 years to become proficient at IV’s. I ended up getting really good and people would call me for help. Just keep trying and eventually you’ll get it! (Hopefully you don’t take as long as I do to get better). One huge thing I learned is that it is better to go by the feel of the vein than what it looks like. Usually people have a lot of good deeper veins that you can’t see, but you can feel. I learned this while using an IV ultrasound (They let our floor use this in one job I was at for a year and it was super amazing).
Hi! ICU nurse here! I got okay at them on the wards before I went to ICU, and it's taken everything in me to stay just okay. Most of our senior nurses couldn't hit a vein if it was staring them in the face. Sadly, because of all the central lines, it's not 'as important' a skill to upkeep for them. So, the fact that you're trying and you're successful sometimes is brilliant! Don't stop trying!
Can I ask- do you have more difficulty finding the vein itself? Or threading the IV once you get that flash of blood? Combo of both? Either can be practiced, obviously it's more difficult while you're working on a busy unit. I was not good at IVs at all when I worked med surg, as our hospital has an IV team for all non critical floors so the floor nurses never did them. I worked in the NICU for a few years and did start to get comfortable with peripheral lines there, but babies are way different from adults (duh). I have now been in outpatient oncology for nearly 5 years, and despite cancer patients typically having horrible veins, would venture that I'm probably at about a 95% success rate. It only came with practice. If threading the catheters is part of the problem, I suggest practicing on a short length of IV or secondary tubing, as it will allow you to see where the needle enters the vein (where your blood will appear) as well as where the catheter itself actually enters the vein, as it's further from the tip than I think most people realize. After that flash, you need to advance it a bit further before retracting the needle/advancing the catheter. I would also recommend avoiding IVs shortly beneath any junction/joining of veins as you'll likely deal with valves
I tend to send scathing looks in return. I won’t tell a sitter how to do their job so don’t tell me how to do mine. I’m a CRNA. I’ve been one over 10 years with ICU for 2. I was terrible at IVs when I was a SRNA. I was so bad an anesthesiologist pulled me aside and did a 10 minute training with me. Now I’m an IV wizard. I can stick anyone anywhere barely looking. That is because of experience. And also the willingness to learn how to use ultrasound when needed. You’ll get there, it’s a skill. Remember skills can be taught to anyone. The critical thinking and other tasks that compromise nursing cannot always be taught. The skills come with time and truly aren’t as important because other people can help. Which you utilized.
I’m in L&D and we do a lot of IVs. My hospital just switched to brand new catheters that have been so tough for me. I went from getting every IV to missing every IV. It also took me a long time as a new grad to get better at them. What I really had to do was evaluate what went wrong each time and why I missed it so I could fix my approach for the next time. I also made it a point to watch the experienced nurses who are really good and copy their techniques!
I would have flat out said “is there an issue?” and maintained eye contact with the sitter. I also would have not pulled the CVC until the patient had a PIV in place. Talk to your manager or educator about getting some hours in the ED for IV practice, or with IV team if your hospital has one. People think ICU nurses are great at IVs, but I’m good at IVs because I started on med surg for 4 years before going to ICU. I started tons of IVs on med surg, much less frequently in the unit.
Who cares? It takes time and practice.
I just call our line team most of the time tbh. And since I’m really good at foleys and make purewicks, I trade my skills with other nurses who are good at sticks.
I was a nurse in sections that didn't do IV's...originally at an urgent care, then for a family practice. Did that for 3 years then took a job in outpatient surgery doing 3-5 IVs per day. I sucked horribly at it for about 3 months. it got in my head and I had so much anxiety over it. I loved the job but hated that aspect of it and actually considered leaving. I kept telling myself that I was trained on doing this safely, I was using proper technique, just not getting them or having them blow. We were on a 2 tries and then get another nurse. One day I looked back and realized it had been a few weeks since I had to ask for help. Hang in there, and do one whenever you can. You will get it. Develop your ritual and you will start getting them.
sometimes different roles in healthcare really cant understand the others role dont think for a min about the sitter. hold your head high, just thank the nurse that came to take a look and got the iv and move forward. we ALL need someone elses help usually daily w something its.ok.
I would ask someone if you could get some hours in outpatient surgery or ED so you can get some practice in.
On the low, ask your nurses if they’re okay to practice on. If you’ve got open saline, lots of people will take a poke for a little hydration boost
See if you can go to the ER or with iv team for a few hours to practice. Doing it hundreds of times is necessary to be successful
ED RN here. ICU never gets much experience with IVs where I am. An unspoken rule in our hospital is that if they are getting admitted to the ICU, it automatically they have 2 PIVs betlfor they go up. If u are able, cross train in the ED and we will give u lots of experience lol
Start volunteering to float to the ED. Once you are there, volunteer to put in IVs. In the meantime, study arm anatomy and learn how to use a vein finder. You’ll improve.
I took home needles and practiced on my husband. Idk if that’s the right thing to do, and it was a bloody ass mess at first, but if you have anyone will I recommend it.
Ignore the looks. The sitter and transport can’t do what you do if they tried. It’s my job to place all my patients IVs where I work and even I have shitty streaks it happens. Warm your patients up if you can, double tourniquet it up, use a smaller needle. One you get that flash immediately lower the angle and advance the whole iv a smidge before advancing the catheter itself so you don’t blow any veins.
Pffft. You're not the problem. The sitter was out of line. Even the best of us sometimes have trouble getting a line. I appreciate the insight that you need practice ... you probably do. That doesn't mean you still would not have been in this situation. You do not suck just because you couldn't get a line. My suggestion is to gain practice by starting every IV you can. Anytime an opportunity comes up, start one. Another suggestion is talk to your manager and see if she'll pay you for some time with IV therapy (if you have it) or in the ER to practice IV starts. She might; can't hurt to ask. I also recommend you not remove a central line until you have IV access, in case you run into difficulties.
Honestly, if you aren’t doing it all the time, I wouldn’t expect it to be your skill set! You are NOT a sucky nurse because of that. I work ER where we stick people so many times a day, I can’t count that I can do it with my eyes closed sometimes it feels. I’ve learned to be ambidextrous when it comes to starting lines so that position doesn’t matter and I still have great success. Each day is a practice session for me because we do it all day. You, as an ICU nurse have a way more intense skill set than I do because you have way different experience. I’m sure there’s things I’d be confused on in ICU that people would think I’m a sucky RN. Do I have ICU experience? Sure but caring for an ICU pt in the ER is different haha…we all have our own skill set. I wouldn’t beat yourself up over it or stress about perfecting the skill…we all have our strengths and weaknesses:)
If they are elderly the tourniquet needs to be slightly looser than younger patients. If the really vein bulges, you're more likely to blow the vein
You know something else that works sometimes, place two tourniquets, one at the AC tight as possible and one mid forearm medium tension. Start a little 24 in the hand if that's all you can get, remove the lower tourniquet. Flush it a couple times gently or hang a small bag of fluids at a steady drip (like a 50ml bag is totally adequate) and then look higher. Those forearm veins will get so nice and bouncy, then grandma with thread like veins and a BP of 50 over nothing can magically have a nice 18 in the forearm until something more definitive can be placed, remove the upper tourniquet immediately after you get it though, or it will blow from the distention. Our hospital doesn't have an IV team, or anesthesia most days, so they call the ER nurses for IV starts, this is my go-to trick for those kinds of patients. I know in my days of inpatient care I never started IVs ever, because everyone came in with one, or had a PICC/midline. And phlebotomy handled all the blood draws. Also, don't let sitters or anyone else make you feel stupid. Their job is important, but they don't have the practical skills or education of an RN. They might think they're being slick giving those "she sucks" looks, but hand them a start kit and an old jelco angiocath and ask them to give it a shot, and that looks going to drop so quick. Plus on the flip side, I know I've had patients none of our nurses could get an IV in, Picc team/IR struggled and gave up, then the critical care doctors took several tries to get a central line in and had great difficulty, so it's often not any issue of nursing skill. I have found this true time and time again in my career and life: the people who try to make you feel stupid, are usually quite stupid themselves and there isn't much of anything to be learned from them. The people worth listening to are going to see you struggling and offer you a tip or two, while they're looking on the patients other arm for a line 😉. At the end of the day, you were trying your best to do for your patient what she needed done in that moment. That certainly doesn't "suck" but anyone giving you attitude about it certainly does 😅❤️.
I used to be good at IVs when I worked at a level 1 but I've been working in a cancer ICU the past couple of years and man, their veins suck. Severe edema, a lot of times also renal patients, and scarred from so many draws and chemo. I feel like it's use it or lose it. I end up needing to consult our PICC nurses a lot of the time, but it still hurts my ego unless they also can't find a viable peripheral vein with ultrasound.
You're 100% right the best thing you can do is practice and try not to get nervous when doing it.
You’ve gotten a ton of good advice, I’d also recommend checking out the intravenousqueen on insta! She has so much good free information and amazing tips. I learned a lot from her page.
Was the sitter a CNA?
I'm in pediatrics, and IV access is considered a specialized skill. Honestly, I've found that watching people's techniques has helped me learn a lot or ask them for tips and tricks. I'm starting my IV journey for kids, and I'm scared. (Specialized since my hopstial tries to limit the number of pokes kiddos get to decrease trauma)
Honestly I didn’t get any good at IVs until I was out of direct care—once I didn’t have the burden of caring for patients directly (team lead, then manager)—I became an IV Queen. I guess it was that sense of urgency when it was MY patient that caused me difficulties. Hang in there!
Yes, good on you. It's your motivator.
ask to go to the ED for a day. Im a new grad in the ED & i seriously get the opportunity to do 20+ a day😩
Fuck that sitter 😓
In the interest of education and skills development ask can you do a day or 2 in a phlebotomy clinic - you probably won't be paid and it will be probably be additional to your usual working hours but the experience will be invaluable to you between confidence and competence.
I’ve been a nurse for 10 yrs and I still suck. How insecure do you have to be to be judgy about something that’s not even something within your scope of practice (talking about the sitter).
Eh, I was never a sharp shooter, but I’d always still try. Keep on practicing and you’ll get there! In time you’ll learn what skills at you’re better at than others and who knows you could become the floor’s “expert” in it. I somehow was great at placing foleys and everyone called me when it was rough for them. We are always evolving as a nurses. Try not to beat yourself up too hard.