Cheat Sheet to Starting an IV

Cheat Sheet to Starting an IV

The insertion of intravenous (IV) lines is equal parts delicate, frustrating, and essential. For patients, this process can be painful and scary; they expect nurses and other healthcare professionals to perform it successfully each time, which is not always the case. Even if you have many years of patient care under your belt, missing veins is still a reality. We hope to help with this cheat sheet.

Mindset

Be prepared. The success of the procedure will depend on the quality of your preparation. Brief the patient beforehand to ensure that they, too, are ready. Have all the tools you need ready, including infection control equipment (gloves, alcohol pads, etc.).

Stay calm & confident. Compose yourself. A patient will be able to tell if you’re nervous and will think you don’t know what you’re doing.

Evaluate the patient for needle phobia. Some patients have had very poor past experiences when it comes to needle insertion; if you suspect your patient has needle phobia, be extra cautious and intentional. Keep needles out of sight before insertion, educate the patient, and determine if you’ll need local anesthetics.

The Cannula

Know your cannula size. It is very important to be able to match needle and cannula gauge appropriately to a patient. The gauge refers to the diameter of the lumen and is inversely proportional to the gauge number: the smaller the gauge number, the larger the diameter (and vice versa).

What for? Consider your infusion type. For instance, smaller gauges will not be able to handle blood transfusions or parenteral feeding. Adjust accordingly.

Vein Selection

Select a vein mindfully. The vein of a well-hydrated patient is said to be “bouncy.” This means a vein that is firm and supple, and easy easy-to-access. Of course, not all patients are well-hydrated, so be careful and don’t panic. When in doubt, trust the feel of the vein, and not your eyes. Some tendons have similar visual characteristics with veins; palpation, however, will prove the difference between the two. You could even just try asking a patient which vein is best, based on their previous IV history.
Distal to proximal. Start distally and work proximally. Why? If you were to miss a more proximal vein, you run the risk of losing other sites below it.

Visibility Hacks

Using multiple tourniquets can help you find veins.

Gravity. Use the power of gravity to help you make a vein more visible (that is, slow venous return). You want to fill a vein—a more distended vein is easier to palpate and thus easier to access. Ask a patient to have their arm dangle on the side of the bed, for example.
Apply warm compress. Higher temperatures enable veins to become more distended. Warm up a vein between 10-20 minutes before insertion with a warm towel or compress. Don’t forget to sanitize the insertion site!
Flick or tap. With your thumb and second finger, flick the insertion site to allow histamines to release and dilate a vein. Do not slap; remember that veins have nerve endings that will respond to painful stimuli. Minimize pain, considering needle insertion isn’t exactly a walk in the park.
Ask your patient to clench their fists. Have your patient clench and unclench their fists to help fill, distend and compress distal veins.
Use a vein locator. Although feelings are mixed about vein locators, they can be especially helpful when your patient is a child or infant. Transilluminator lights and pocket ultrasounds might help you better visualize vein pathways and guide your vein selection.
Try nitroglycerine. Nitroglycerine ointments can help dilate smaller veins. Leave for 1-2 minutes and disinfect the site afterward.
The tri-tourniquet approach. To make collateral veins appear, you can try using two to three latex tourniquets. Apply the first high on the arm. The second should be mid-arm, below the antecubital fossa. Use the third as a back-up.

Insertion

Tourniquet techniques. You’ll be able to determine that your tourniquet is sufficiently tight if the radial pulse can be palpated. The tourniquet should be applied 20-25 cm above the insertion site. However, if a patient has low blood pressure, you may want to use a sphygmomanometer cuff in lieu of a latex tourniquet. This will allow you to adjust to an appropriate amount of pressure by inflating or deflating the cuff. Finally, some patients might not need a tourniquet if their veins are sufficiently filled but also fragile. You don’t want a delicate vein blowing up because of a tourniquet.
Stabilize the vein. Hold the skin taut below the insertion site. This makes needle insertion conducive and reduces pain. Make sure that the alcohol you used to disinfect the site has dried; otherwise, the process of insertion may sting.
Above, not beside. Insert the IV catheter right on top of the vein; if you insert beside the vein, this may push it sideways.
Rotate the catheter hub. A cannula may kink in the presence of a hardened or scarred vein, obstructions, vessel fragility, and friction. Twirling the catheter hub prevents kinking. Rotate the IV as you’re inserting it to help it glide.

Keep the bevel up! A needle glides most easily if the needle bevel is facing upwards. (The bevel is the sharpest part of the needle.)
Always at an angle. The catheter should be at an angle between 15-30 degrees over the skin as you make your shot.

•••

Needle insertion is an important clinical skill that you must learn to master or to manage. It’s a procedure that you are sure to encounter in the course of your career. If you’re doubting your abilities, ask your fellow nurses for guidance or practice on willing friends & family (we’re serious!). Remember that there are always ways to improve. Good luck, and we hope this cheat sheet helps.

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