How long does an IV take? Tips & Techniques on IV Insertion

Table of Contents

Introduction

Mastering the skill of intravenous (IV) insertion is essential for nurses, and continuous practice coupled with confidence is key to success. While it may be considered a basic nursing skill, it can be challenging to master without sufficient experience. Successful practitioners often become adept through consistent practice and hands-on experiences in the field. Here are some valuable tips and techniques for nurses looking to excel in IV insertion:

Practice Regularly: Like any skill, regular practice is crucial. Consider using simulation models, practicing with colleagues, or participating in skills labs to enhance your proficiency.
Build Confidence: Confidence is a vital component of successful IV insertion. Believe in your abilities, and remember that confidence comes with experience. Take each opportunity to insert an IV as a chance to improve.
Control External Factors: Various factors can influence the success of IV insertion, such as patient cooperation, lighting, and the availability of equipment. Attempt to control these factors as much as possible to create a conducive environment for the procedure.
Patient Assessment: Before attempting IV insertion, conduct a thorough assessment of the patient’s veins. Choose the most suitable vein based on factors such as size, visibility, and accessibility. Feel for veins and assess their condition to improve your chances of success.
Proper Positioning: Ensure the patient is comfortably positioned with good lighting. Proper positioning not only facilitates the procedure but also ensures patient safety and comfort.

Use a Tourniquet Effectively: Applying a tourniquet helps in vein visualization and engorgement. However, ensure it is not too tight, as this may cause discomfort and distort the vein.
Warm Compress: If veins are not easily visible, consider using a warm compress to dilate the vessels, making them more accessible for insertion.
Needle Selection: Choose the appropriate size and gauge of the needle based on the patient’s condition and the intended use of the IV line. Smaller veins may require smaller needles.

Mindful Technique: Employ a steady and controlled technique during needle insertion. Avoid abrupt movements, and advance the needle slowly. If encountering resistance, reassess the angle and depth of insertion.
Continuous Learning: Stay updated on the latest techniques, equipment, and best practices in IV insertion. Attend workshops, training sessions, and seek guidance from experienced colleagues to continuously improve your skills.

Techniques for Initiating IV Therapy

Prioritize Preparation and Focus: Success in IV insertion hinges on preparation and skill. Ensure both you and the patient are composed, as a rushed procedure may lead to failure. Address anxiety by explaining the procedure, understanding the patient’s IV therapy history, and ensuring their comfort and warmth to prevent vasoconstriction.
Radiate Confidence: Project confidence in your abilities, reassuring the patient of your expertise. Your self-assurance will inspire confidence in the patient and yourself.
Identify Needle Phobia: Recognize symptoms of needle phobia, such as tachycardia and hypertension before insertion, and bradycardia, blood pressure drop, pallor, diaphoresis, and syncope during insertion. Mitigate needle phobia through a soothing tone, patient education, keeping needles out of sight until the last moment, and using topical anesthetics.
Adhere to Infection Control: Employ gloves during cannula insertion and follow aseptic technique and infection control measures. Wipe the insertion site with a cotton swab or alcohol pad to minimize microorganisms and enhance vein visibility.
Evaluate Vein Condition: Assess the patient’s vein condition before needle insertion. Hydrated individuals typically have firm, supple, and accessible veins. Ensure the chosen vein is suitable and not frail to prevent complications. Take time to assess properly.
Trust Your Touch: If a suitable vein isn’t visible, rely on your fingers more than your eyes. Feeling for veins is crucial, and manipulating a potential vein can distinguish it from a tendon.
Consult with the Patient: Seek input from the patient regarding suitable veins based on their previous IV experiences. Their knowledge can provide valuable insights.
Select Appropriate Cannula Size: Match the needle and cannula gauge to the patient’s size. The gauge, representing the diameter of the lumen, should be chosen accordingly. Smaller gauge numbers indicate larger lumens, while larger gauge numbers indicate smaller lumens. Use an appropriately sized cannula to avoid injuring the vein during insertion.
Take into Account the Purpose: When selecting a cannula, consider the specific type of infusion required. Smaller gauge needles may not be suitable for procedures such as blood transfusions and parenteral feeding. Opt for larger-diameter lumens, as they enable a higher fluid rate, allowing for the administration of more concentrated solutions or medications. The contemporary use of needleless equipment is prevalent, aiming to minimize potential vein injuries both during and after the insertion process.
Begin with the Non-Dominant Hand: Initiate the insertion process on the non-dominant hand whenever possible. This approach allows the patient to retain functionality in their dominant hand for basic activities. In instances where locating a suitable site or vein on the non-dominant hand proves challenging, then proceed with insertion on the dominant hand.

Vein Selection Tips for IV Initiation

Commence with Distal Veins: When selecting vein sites for venipuncture, start with distal veins and progress towards more proximal ones. Initiating the selection process from the lowest veins ensures that potential sites below are not inadvertently overlooked.
Opt for a BP Cuff over a Tourniquet: Instead of a traditional tourniquet, consider using a blood pressure (BP) cuff, especially in patients with low blood pressure. Inflate the BP cuff to an appropriate pressure to induce vein dilation. This technique proves beneficial for older patients or those with challenging veins. In cases of hypovolemia, choose larger veins, as smaller ones may collapse more quickly. Invert the cuff when using it as a tourniquet to maintain a clear view of the site, preventing tubing contamination. The BP cuff provides a wider, more comfortable tourniquet that compresses evenly, and its pressure can be precisely adjusted to facilitate vein dilation.
Proper Tourniquet Application: Apply the tourniquet with sufficient tightness to impede venous flow but without hindering arterial flow. This allows blood to flow into the extremity but creates resistance as it exits, distending the veins. Position the tourniquet snugly, approximately 20 to 25 cm above the needle insertion site. Check for the radial pulse with the tourniquet in place; if palpation is challenging, the tourniquet may be too tight.
Consider Puncturing Without a Tourniquet: If the patient has adequately filled but fragile veins, consider proceeding with insertion without using a tourniquet. The pressure applied by the tourniquet may risk blowing out delicate veins upon puncture.

Enhancing Vein Visibility for IV Initiation

Leverage Gravity: If no veins are initially observed, allow the patient’s arm to dangle down the side of the bed. This position promotes venous filling as gravity slows venous return, distending the veins. Full and distended veins are easier to palpate and present an optimal option for insertion.
Utilize Warm Compress: Apply a warm, moist compress or warm towels to the area before insertion and cleansing. This technique, left in place for 10 to 20 minutes, raises the temperature, facilitating vein dilation and making it more visible on the surface.
Avoid Slapping the Vein: Refrain from slapping the insertion site, as veins possess nerve endings that react to painful stimuli by contracting. This practice can make locating the vein more challenging and unnecessarily increase patient discomfort.
Employ a Gentle Flick or Tap: Instead of slapping, use your thumb and second finger to gently flick the vein. This action releases histamines beneath the skin, leading to vein dilation without causing unnecessary pain.
Palpate the Vein: Place a tourniquet above the insertion site to dilate the veins and gently palpate by pressing up and down with consistent fingers. This method allows you to familiarize yourself with the feeling of a resilient, bouncy vein. Tap the vein gently without slapping to prevent contraction.
Encourage Fist Clenching: Instruct the patient to clench and unclench their fist, aiding in the compression and distension of distal veins for improved venous filling.
Employ the Multiple-Tourniquet Technique: Use two or three latex tourniquets for this technique. Apply one high on the arm for 2 minutes, then place the second mid-arm below the antecubital fossa. This encourages the appearance of collateral veins, and the third tourniquet can be used if needed.
Vein Dilation with Nitroglycerine: Apply nitroglycerine ointment to a small vein site for one to two minutes before final disinfection. Remove the ointment during the final alcohol pad disinfection to assist in vein dilation.
Direct Alcohol Pad Rubbing: When disinfecting the insertion site, rub the alcohol pad in the direction of venous flow. This technique improves vein filling by pushing blood past the valves in the desired direction.
Thorough and Extensive Cleaning: Clean the area vigorously and over a broader surface to ensure secure adherence of tape and dressing to clean, dry skin. Disinfecting a wider area is advisable in case an alternative vein becomes visible during the process.
Employ Vein Locator Technology: In situations where veins are challenging to locate, especially in infants or small children, consider using vein locator tools such as trans illuminator lights or pocket ultrasound machines. These devices illuminate vein pathways, providing a visual guide for catheter insertion. Exercise caution to avoid skin burns, and limit the duration of contact with the equipment.

Insertion of the Intravenous (IV) Catheter

For the upcoming IV initiation tips, careful attention is crucial. This segment of the guide outlines the correct technique for inserting the catheter and offers troubleshooting strategies if the initial attempt is unsuccessful.
Ensure Vein Stability: To assist with needle entry and minimize patient discomfort, pull the skin taut just below the entry site to stabilize the vein. It is essential to wait for the alcohol to dry on the skin before insertion to avoid additional pain for the patient.
Direct Catheter Insertion atop the Vein: Insert the IV catheter directly over the vein rather than from the side. Initiating venipuncture from the side may push the vein sideways, even if anchored by your hand.
Prevent Cannula Kinking: In cases where the vein is hardened or scarred, there is a risk of kinking the cannula. However, it is possible to navigate through the scar to reach a usable portion of the vein using the following technique:
Rotate the Catheter Hub: Overcome mild obstructions, vessel tortuosity, fragility, and frictional resistance by gently rotating the catheter hub. During insertion, employ a slight rotating motion to help the catheter glide over certain areas of the vein.

Orient the Bevel Upwards: Ensure the bevel of the needle is facing upward, as this is the sharpest part of the needle. Inserting the needle in this orientation facilitates smooth gliding.
Angle the Insertion at 15-30 Degrees: Hold the catheter at a 15-30 degree angle over the skin with the bevel facing upward, and inform the patient of the impending needle insertion. This positioning enhances the ease of needle insertion.
Assess for Resistance: While inserting the needle, be attentive to any resistance, particularly associated with pain. If no resistance is perceived, proceed to advance the needle cautiously. However, if resistance is encountered, halt the insertion to prevent potential disruption and injury to the vein.
Observe the Flashback: Once a visible backflow of blood, known as “Flashback,” is observed, remove the tourniquet. Subsequently, fully advance the catheter and withdraw the needle. Secure the catheter appropriately on the patient’s skin and initiate the therapy by opening the infusion line. Experiencing this “Flashback” is a gratifying moment in nursing.
Exercise Caution in Advancement: Recognize when to cease advancing the catheter. Upon hitting the vein and witnessing the “Flashback” of blood, refrain from further advancement and lower the angle of approach. Excessive advancement may lead to unintended puncture through the vein.
Gradual Initiation of IV Fluids: Take a measured approach when starting the IV fluid. Even after successful insertion and securement, initiate the IV infusion slowly, especially when working with delicate veins. Rushing to commence the fluid infusion may lead to vein blowout.
Release the Tourniquet before Advancing: After confirming that the catheter is properly within the vein, release the tourniquet before advancing the catheter further. This precaution prevents potential vein blowout due to an increase in pressure.

Securing the IV Line

Proper Taping Technique: Pay careful attention to how the IV tubing is taped. Inadequate taping across the cannula and the underlying vein can lead to discomfort during infusion. Ensure the tubing is taped away from the cannula site, securing it in a manner that maintains accessibility while Secure in Motion: When the patient’s limbs are in motion, especially in scenarios like inside an ambulance, ensure a secure IV site by immobilizing the arm in extension and preventing flexion at the elbow.

Flow-Conscious Taping: When taping down the tubing, align it with the natural movements of the body. Run the tubing laterally along the limb, following the direction of motion. This technique helps prevent coiling or tangling, allowing the tubing to “go with the flow” of the body.
Stress-Tape Strategically: Apply one or two stress tapes to prevent direct pulling from an IV site if the tubing gets snagged. Avoid taping excessive loops or coils that may shorten the tubing length. Refrain from taping on the proximal side of a flexing joint, as it can be easily removed. Additionally, do not wrap the tubing around a digit, as clenching a fist could pull it out or alter catheter flow. A secure double-back of the tubing with a short loop provides effective stability keeping the catheter firmly in place.
Managing Leakage: In the event of a small leak occurring at the point of insertion, the vein may still be usable if the catheter tip can be fully advanced beyond the leakage. Conduct a careful test infusion with a non-irritating fluid to observe for any extravasation before considering further use.
Avoid Probing for Veins: Refrain from the practice of “fishing” or “vein searching,” as it can be painful, especially when inadvertently probing into muscle or tendon. If you do not observe a flashback, avoid moving the needle around in an attempt to locate a vein. This may indicate that you have missed your target, and the needle may have been deflected by rolling or hard veins. Instead of persisting, consider pulling back the needle and inserting in a different direction, as this approach is preferable to restarting the entire procedure.

IV Therapy Tips and Special Considerations

Older and Pediatric Patients: Recognize that older and pediatric patients often have smaller and more fragile veins compared to adults. Opt for smaller gauge needles that facilitate proper venous flow. Choose insertion sites carefully, with the hands being a potentially safer location. Ensure stabilization of the site, especially with pediatric patients who may gesture frequently, and elderly patients who are more prone to falls.

Dark-Skinned Patients: When dealing with patients with dark skin tones, enhance vein visibility by utilizing a blood pressure cuff. Inflating the cuff helps distend the veins, making them more clearly visible. Additionally, the technique of wiping a cotton swab in the direction of the vein proves useful for better visualization, especially in pediatric, elderly, and dark-skinned patients.
Veins with Valves: When encountering veins with prominent valves, which can impede catheter insertion, employ the floating technique. Individuals such as weightlifters and sculptors commonly have noticeable valves, felt as small bumps along the vein’s path. If catheter insertion is challenging due to these valves, use the floating method by attaching a primed extension tubing to the cannula. Gently flush the tubing with normal saline via a syringe while advancing the catheter to help open the valves.
Bifurcating Veins: Identify bifurcating veins, characterized by a noticeable inverted V-shape, which are less prone to rolling during insertion. However, it’s essential to access the vein below the bifurcation for the highest probability of successful cannulation.
Seek Expertise: If multiple attempts to insert the IV catheter prove unsuccessful, it is advisable for the nurse to call in another healthcare provider with more experience, often referred to as the “vein whisperer.” Professionals from NICU, Anesthesia, or vascular surgery departments may be called upon for certain patients. It’s crucial to involve those with the best chances of success before exhausting all available veins.
Use of Restraints: In cases where infants and children may be uncooperative during IV insertion, consider splinting or restraining their limbs. Prior to securing the splint, remember to place the tourniquet to avoid disturbing it during the venipuncture process.
Papoose or Mummy Wrap Restraint: Consider utilizing a “Papoose” or “Mummy” wrap to restrain particularly uncooperative children. While this may be unsettling for the family, it’s important to explain that it is done to increase the chances of success on the first attempt.
Master the Art of Distraction: Recognize the importance of distraction techniques for uncooperative children during procedures. Methods such as blowing bubbles, singing, or counting can be effective in redirecting the child’s attention and cooperation.
Initiating an Intraosseous Line: In emergency situations, when establishing an IV line is challenging, particularly with critically ill children, consider using an intraosseous (IO) line. The IO line is inserted directly into the bone marrow cavity, providing a rapid point of entry for fluids, blood products, and drugs. The bone marrow serves as a non-collapsible vein, allowing fluids infused into the marrow cavity to enter the circulation through a network of venous sinusoids.
Infiltration Detection in Obese or Edematous Patients: When dealing with obese or edematous patients, compare the skin turgor and size of the limb to the opposite extremity. Thoroughly inspect the site for signs of swelling, coolness, blanching, discoloration, and leakage at the needle’s insertion point. If uncertainty persists, apply a tourniquet proximal to the venipuncture site, ensuring it is tight enough to restrict venous flow. If the infusion continues without assistance from a mechanical pump device, infiltration is confirmed.
Assessing for Infiltration: To evaluate for infiltration, occlude the vein proximal to the IV site. If the IV fluid continues to flow, it suggests that the cannula is likely outside the vein. Conversely, if the IV flow stops after occluding the vein, it indicates that the device is still positioned within the vein.
Assessing Patency: Verify the patency of the IV line by lowering the IV fluid container below the IV site and observing the appearance or backflow of blood in the IV tubing. The presence of blood indicates that the IV device is still positioned within the vein.
Dealing with Infiltration: If infiltration occurs, promptly remove the IV device and elevate the affected extremity. Applying a warm or cold compress over the affected area can aid in managing the situation. Consider restarting the IV device in the opposite extremity.

Inserting an IV in Pediatric Patients

Maintain Calmness and Comfort the Child: When initiating an IV on an infant, attempt to soothe them beforehand using a pacifier. If the parent desires to hold the baby, allowing bottle or breastfeeding during the procedure can be reassuring.

Choose the Nondominant Hand: For small children of walking age and infants, prefer hand veins in the nondominant hand.
Utilize an Immobilizer: While the antecubital (AC) is a viable location for children, an immobilizer board may be necessary to keep the IV line patent.
Consider Scalp Veins: In neonates, scalp veins or veins in the feet may be preferable and easier to access.
Advance on Flashback: With preemies and small newborns, consider advancing the catheter instead of the needle after the initial flashback of blood to avoid blowing a vein.
Gentle Approach: When dealing with neonates and newborns, adopt an approach similar to a TB skin test stick almost flush with the skin, as their veins are close to the surface.
Minimize Pain: Use anesthetic creams or sprays for pain relief in children.
Use Distractions: Employ distractions such as singing nursery rhymes, providing pacifiers, or using musical toys for toddlers (ages 1-3).
Honest Communication: With young children aged 4 and up, be honest about the procedure. Assure them that the pain will be brief and that they will not lose a significant amount of blood. Consider offering incentives like stickers or toys for cooperation.
Minimize Tourniquet Use: Avoid using tourniquets if possible. Apply traction with your hands and enlist the help of coworkers, as tourniquet use increases the risk of blowing veins in children.
Facilitate Blood Flow: Have the patient dangle their arm off the side of the bed or let it hang by their side before the procedure to increase blood flow, making veins easier to feel and see.
Know When to Seek Help: Recognize the limits of repeated attempts and seek assistance from someone with more experience if needed. Prioritize the well-being of the child and avoid unnecessary discomfort.

Other Tips for Initiation an IV

Employ Firm Traction: Given that veins tend to roll, especially in older individuals with thin skin, maintaining firm traction is crucial. Holding firm traction at the top and bottom of the insertion site with your non-dominant hand helps prevent chasing the vein, minimizes patient discomfort, and reduces the risk of stabbing through the vein.
Rely on the Sense of Touch: In addition to visual inspection, develop the ability to feel veins. Some of the most suitable veins may not be visible but can be palpated. Practice feeling veins that are visible and distinguish the differences between veins and muscle/flesh. Over time, you may become adept at starting IVs with your eyes focused on the feel of the veins.
Consider Tourniquet Use: Evaluate whether using a tourniquet is appropriate for the situation. In instances where a large vein is palpable and visible, skipping the tourniquet may be advantageous. Tying the tourniquet too tightly can lead to vein blowouts upon puncture. If a vein is blown using a tourniquet, consider attempting the access without it.
Choose the Right Needle Size: While a larger gauge may be preferred for optimal access, using an excessively large needle can result in vein blowouts. Select an appropriately sized needle for the specific situation, balancing the desire for a larger access with the necessity of preserving the vein’s integrity.
Learn from Unsuccessful Attempts: Accept that not every attempt will be successful. Whether due to a flawed technique or challenging veins, unsuccessful attempts are part of the learning process. Release the frustration associated with unsuccessful attempts and approach each new opportunity with confidence. Practice and experience will contribute to improving your skills over time.