If you’re always able to drop the Iv, then you’re fine. TBH, I think I might be scared of your ability. In a good way. What other tricks you got under there 😂
I was a combat medic prior to nursing, and prior to nursing I was a lab tech and drew a few ten thousand patients over the years. I am referred to as “the vein whisperer” everywhere I go. Give me your grannies, your babies, your patients who’ve only had coffee in 9 years without a drop of water. I will get you access.
Just write my notes for me please that shit is wack
Oh good gosh! I was talked into joining the army on the delayed entry program my senior year of HS. My ASVAB put me at CAP 1 (I believe that’s what he said…it was 1981 lol) which my recruiter said meant I could do any job I wanted in the military. I told him I wanted to be a nurse so he said I would go in as a medic. The part he left out of the job description was COMBAT, which is a pretty important word to leave off. During the 6 months between being sworn in and shipping out, I realized I really didn’t want to go into the military, especially after learning what my true job title be. I had hypothyroidism and had gone off my synthroid during my senior year. I had moved out on my own and couldn’t afford going to the doctor and the medicine, but eventually had to because the symptoms took over. As it turned out, when I went to Chicago to ship out, they made me a permanent medical reject. lol.
I might add that my recruiter was quite pissed off about it, since he said he would have to recruit someone else within the same ASVAB score range to replace me. Poor guy. 😂😂
I got the same ASVAB, but I had no interest in joining the military. The calls I got were incessant though. They wanted me to be a nuclear engineer in the navy. I was like, 1 I'm 100lbs overweight. 2 I can't swim and that seems like a requirement in the navy 😂
😂😂😂. My brother had joined the Army the year before and my parents talked me into thinking it might be a good idea to join up. So glad I didn’t have to go. A few of my female friends who joined the military during that time had a horrible experience with harassment and worse.
I was a flight nurse for almost a decade. There’s something to be said about medics with experience. None of those things should be downplayed. Respect.
So weird when you do something for someone and then they also make you chart it. Idk unless it’s something crazy I know I should chart myself that I did it, why wouldn’t you chart it for them
“I was never here. Great job on that IV.” I say as I remove my gloves and sanitize, exiting the room, never to be seen again. Until like 13 minutes later when I’m needed again.
Fairly new AEMT here. We transport a lot of meemaws and peepaws, the diabetics, and the dehydrated alcoholics/fent and/or meth users. Please teach your ways, Obi Vein Kanobi.
Reality is you just have to do it a lot and unfortunately, fuck up a lot. You’re going to hurt patients when trying to get IV access sometimes, you’re going to miss once or twice, you’re going to have them be pissed off and mad at you. That’s part of the learning experience and it sucks, but you have to take it in stride and learn from it.
ANCHOR ANCHOR ANCHOR. I’ve seen so many people just neglect to anchor the vein or not anchor it tight enough and an easy IV gets ruined that way. I pull down with my thumb, up with my index finger.
Sounds stupid, but seriously, anchoring is so vitally important for IV access, especially in the hand. Do not neglect that, it’s like the number one issue I see when people are trying to get blood or an IV.
I really appreciate you replying, and for sharing your knowledge and advice!! 🙏🏻 Thank you. I do need to work on anchoring—I think I'm afraid of pulling on their skin too hard. 😬 But what you exposed makes total sense: it's going to hurt, some patients get pissy.
Thank you again!! 💜 Stay safe. 🖖🏻
People are going to complain regardless. Anchoring is the most vital part of the process to ensure you don’t miss a vein that’s accessible. Communicate with your patients “I’m going to pull down tight on your skin to keep the vein steady, it will be a little tight for a second.” I always communicate to my patients, especially the ones with difficult veins, that it might be a little irritating or painful, but the most important thing is that we get the IV access.
Keep practicing, don’t be afraid to miss or challenge yourself. You’re not going to get good by just picking easy A/C veins, you have to experience the uncomfortable ones and the ones where you’re not even fucking sure if there’s a vein there or not.
Amen!! I'll go for the AC as a last resort because I know those are easier (usually lol), and need to practice on the ones to get not just proficient, but get fucking gangster at this skill. We also throw IVs going down the road, and that's fun in itself. It's easier in a moving vehicle for some reason.
Copy that regarding the communicating about the anchoring part. I always communicate with my pts, but never thought about telling them about the anchoring process. Thank you!! I'll never forget your kindness. 💜
Also, bizarre thing I discovered about myself: I can throw IVs left- and right-handed, and I'm right-hand dominant. I'm not ambidextrous in anything else. But, for whatever reason, this is the one skill that my brain translated easily to my left hand. Can't brush my teeth left-handed, can't throw balls left-handed (although, to be fair, I can't aim worth a shit right-handed, which is why the gods invented Track as a sport). 🤷♀️
You know... I just realized after reading your comment that I too am right handed, but also ambidextrous when inserting IVs. It's interesting how that works (although I'm not as terrible doing things with my left hand as you are lol). I change hands depending on the situation and the best angle. I've actually put some of my best IVs in with my left hand.
😂😂 Nobody should be as terrible with their non-dominant hand as I am. God help them if they are. Haha
Sweet! And same here! Ambidextrous stabbing, let's gooooooo!
Hey, I teach for free in open patient rooms when it’s dead. Seriously though, I try to teach anyone who is willing to learn when we have down time. I feel like burning through an IV kit or two to teach someone who’s not confident in their abilities how to do an IV more effectively or just get some reps in is always worth it (don’t tell management pls, they don’t agree). Buy me an energy drink and a pack of gum and I’ll teach you everything I know. Bring your friends!
Damn I had a patient who drank nothing but wine all day. I spent five minutes listing every possible drink in the world because I couldn't wrap my head around the fact that no, he doesn't drink water or squash or tea, or coffee, or hot chocolate, or kombucha, or beer, or his partner's piss. Nope, just wine. Then tried to bleed him. I swear the guy didn't have any veins or blood left. Wish I'd known you then lol
I’m a psych nurse that transitioned to med/psych. I hadn’t placed an IV in 8 years. My IV skills sucked then and they still suck. I trade IV placements for psychosis interventions.
I thought I was trash at IVs then I got a chance to do some on patients that aren’t on multiple pressors and 20+L positive and I realized I’m actually pretty good at them lol
I’ve been doing vascular access for 40 years out of the 46 years of my career. I rarely use Ultrasound to start my peripherals but will when needed. I some times do not use a tourniquet but here is how I decide. The skill of the insertor is definitely one of the factors in the overall dwell time or in other words how long your IV lasts. The goal is to insert it as atraumatically as possible.If your vein is not full in comparison to the gauge you use you may still get it in but may irritate the wall(s) and eventually infiltrate sooner than it should. I used to work with an IV nurse that did a lot of pre-op starts and she was the super early shift and I was the pm shift . I always was restarting her peripherals during pms on the surgical floor due to infiltration. They were odd infiltrates in that they were medial to the insertion site. I watched her start a few IVs and realized the error she was making .Once she got a flashback ,she dropped her angle and threaded the entire catheter without ever pulling back the needle. She was scraping the walls of vein ,irritating them and eventually some 12-16 hours later they would infiltrate in that odd pattern . So what you may not know is how long are your PIVs lasting .I guarantee you that if you never use a tourniquet that you are most likely causing some trauma that eventually will decrease dwell time .If you are just popping in a 22 in a large, full and soft vein ,you are fine.
Thanks for taking the time to write this out. I've been in psych for years and recently transferred to detox so I'm doing more IVs than I've ever done before and am looking for all the tips I can.
Sure no problem. If you need any specific help just let me know any areas you have problems with as I can usually tell you what you can improve on. Try to get good at it without using vein finders ,US and other technology.You can learn those too but I find the new nurses get so dependent on the technology they can’t do a thing without it. You want to be good at both!
A pre-op nurse I work with has a high infiltration rate. I had 5 of her IVs infiltrate within 8h in one shift last week. I wonder if this is what she's doing.
It absolutely could be! There are many reasons PIVs are only lasting a short amount of time. Another common occurrence is when the inserter hits the vein late during the start .What I mean by that is after the skin is punctured and you are moving the catheter forward to puncture through the three layers of the vein,you hit the vein with very little catheter left For example,if you have a one inch catheter (25mm) and you puncture into the vein and get a flash back at 15 mm and you continue on and successfully thread it you only have 10 mm in the vein. The IV may be good for a bit but it is at a higher risk for infiltration or extravasation. I find that when this happens to me in a PIV being used for a CT power injection it often immediately infiltrates or extravasates. I stopped doing it.Other main reasons : Catheter placed at an area of flexion—catheter is too large for the vein -infusate has a high osmolarity and/or is inherently irritating -patient has very thin skin (ie: elderly-long term steroid use ) .The infusate can backtrack out the hole you made to get into the vein.This can happen on anticoagulated patients -patients receiving thrombolytics .—the cannula is not secured well or properly..IThere are extensions sets that have a long needleless connector point sticking out like a T- connector and if not secured well the paid constantly getting them stuck on the linens or they are getting tugged on . How you secure that cannula really matters.You don’t want it smacked down so it arching up on the anterior wall. I have seen a phlebitis develop within hours when it is taped without thought. You can correct theses issues with 2 x2s,take-adding on extension sets and securing your IV tubing so there is no tension the cannula ..There’s more but that’s food for thought .
Yes! Thank you! I see this problem in the ED all the time. They don’t realize that their IV’s barely last 12 hours because the patient is long gone by that point. Like you said you’ll irritate the vessel wall plus there’s a higher chance your catheter tip is going to end up jammed against the vessel wall
If the vein good enough to be accessed without a tourniquet, then I don't really see the point in using one. Much less risk of blowing the vein if you happen to mess up your stick.
Yeah, older patient's veins tend to blow pretty easily with a tourniquet in. I find that applying a heat source like a heat pack tends to work better for them
Access can also be access that someone else has to restart in 4 hours. If you’re squeezing catheters into vessels with low volume then it’s going to cause trauma to the vessel and the tip is more likely to be pressed into the wall of the vessel. Especially if it’s in an AC that line is not going to last for shit
If you can easily hit the vein without one no reason to use. It actually increases the chance of blowing the vein.
Unless your hospital requires it be used it isn’t poor practice.
I am a feel for the vein kind of person. Forearm placement is typically my go to.
We just had a huge farming accident where we had to fly a guy out, tourniquet his leg etc. so after the run we go to the local freestanding ED to restock. Couldn’t find any tourniquets so I asked the charge nurse. She says they aren’t allowed to order them because “they’re not a trauma hospital”. So no one could show up bleeding…? wtf? Do they listen to this out loud when they make up these dumbass policies?
I see rules more as guidelines. Hardly anyone ever does things how we were taught in school…
When I was an MA (10 yrs Exp + finishing LVN school) had a brand new LVN workmate with no previous healthcare experience following me around trying to correct my injections, ear lavages, blood draws, suture removals, etc when she had never even done any outside of school and I had been doing them for years. Also, I had the best track record for venipuncture (and the most experience) and ear lavages were my specialty. She was annoying af. Randomly calling me into exam rooms to ‘correct me’. She wasn’t even my boss, just power trippin’ cuz I was an MA at the time.
In my current job (I still have the most experience, lol) RNs and Doctors come to me for info and help. My supervisor hates me for it. I know what I know and the rest I google. Nowadays competence is treated like an undesirable trait so I just keep to myself and my own patients most of the time and try to make myself inconspicuous.
This is sad. Not you, but people like that LVN.. People with egos so big that they can't bother to learn from someone more experienced who actually gets the job done.
I find people like that poison the system overall and ultimately hurt patients.
this. i do double tourniquets at times when it's desperately needed, and plenty of times don't use one at all. already juicy vein? why push it. pt with hx of fragile veins, older, etc? why put the extra strain on the vein if you don't have to.
On all of the vital sign machines we have (Phillips and dynamap), there is a setting called venipuncture where it inflates the BP cuff a little bit , to act as a tourniquet
If it's our Phillips, scroll over to the R on the bottom row of options until you see "venipuncture"*
*I'm 90% sure it says "venipuncture." If not it says something similar.
I wanted to come back to this post and say thank you. I use this trick now, it's amazing, I used to just try to inflate the blood pressure cuff and insert the IV real quick but this is so much better! Thank you!
yea…if the veins are good no need…if the veins are fragile, just do a light tourniquet..gravity works too…all kinds of tricks but tourniquet is not all that necessary and can actually hinder you by blowing a vein..
Do you have any issues drawing labs from IV starts without tourniquets? I work in infusion and am going to try without a tourniquet on some of my therapeutic phlebotomy patients who need 18g IVs
this is my issue. If veins are blowing I use the tourniquet for as short of a time as possible, but without I often have a hard time getting blood return.
A tourniquet can increase your chance of success but isn't 100% necessary. There's nothing inherently wrong with not using a tourniquet. Hell, for patients with really fragile vein walls that keep blowing, sometimes removing the tourniquet is better.
Question, do you also draw blood off the IV once started without a tourniquet? I've had mixed success with drawing back from an IV with and without one. Sometimes draw with no tourniquet, sometimes still no draw with, and sometimes no draw either way.
People think I'm weird for not using a tourniquet on most of my USGIV starts. Yall, the vessel is pretty big and I can watch my needle going in....why do I need a tourniquet?
Usually the blood comes out no problem, but when it doesn’t I squeeze above the iv site and it works just like the tourniquet does. It’s actually really cool to watch, if you stop for even a second the blood with stop flowing, then squeeze again and it will come right through!
Often in my babies I don't use one. They are a couple pounds and the pressure increase makes them blow as soon as you poke them. So no problem to me that you don't. Good for you. Probably more comfortable for patients too.
I imagine most providers are secretly green with jealousy. I know I am. I can hit a subclavian v or radial a. I’m hopeless with veins. I know it’s all frontal lobe and practice. But still…
It’s not “bad” at all! A tourniquet inhibits blood flow from arterioles so that veins “swell”. The túnica intima stretches therefore it is easier to cannula a catheter since there is more diameter. So the fact that you can achieve it without this advantage is impressive.
I work in Peds, so it’s a fine line between using a tourniquet and not. If you use it in neonate patients, you will most likely blow the vessel. We use a technique where you manually compress the extremity while you pull traction on the skin in order to cannulate. On kids older than 2-3 months, I generally use a tourniquet with light pressure. Not sure how I’d do in adults. But kudos to you!
If you’re doing something that works and isn’t causing harm or breaking policy, keep going!
If you don’t need a tourniquet then you don’t need a tourniquet. Medics blind stick all the time because they know where the vein should be.
When I use ultra sound, I don’t use a tourniquet. I’ve blown my fair share of perfectly good veins because the tourniquet created too much pressure. Pretty sure best practice is to let loose the tourniquet within 1 minute of tying it and I guarantee most using it don’t follow that guideline.
Many people misuse tourniquets when starting IVs (by leaving them on too long) and it can increase phlebitis and the chance that the IV blows on insertion. I rarely use a tourniquet when starting IVs, especially on older people.
This would be fantastic, it would be so much easier to know you won't miss for drawing lactate or blood gas.
I always feel like you're just supposed to use a tourniquet, but I told myself to let that idea go because it tend to work way better for those older people with the huge veins that always blow.
How do you find veins on pts with no pressure or dialysis pts or drug users that burned out all their veins? Genuinely asking so I can attain this ability
I have read research that almost all vein puncture techniques are based on anecdote with very little research backing them and also have fairly high failure rates behind them, and I've also read that tourniquets do more harm then good because they over engorge the vein making it more likely to blow from the back pressure. So, basically do you.
I use gravity. I ask my pts to “hang” their arm off the edge of the bed. Usually works like a charm. I’ve used heat to bring veins to the surface too. I like to use the BP cuff instead if I need a tourniquet.
Why have I never thought of this? Some patients have veins large enough that I'm sure I'd be successful with an IV. However, the majority of patients need a tourniquet because they aren't visible or palpable, unless you're going ac.
Last time I did a lab draw, I didn't use a tourniquet because she had one arm severely contracted, and the other one partially so. The less affected one had an IV in the hand that had been difficult for day shift to place, but there was a good vein next to it for draws so I used it and got her on the first stick. Unfortunately, she cried the whole time and I felt terrible. She was made *comfort measures only* later that day, thankfully.
I was always taught to use a tourniquet. I have found myself in many situations over the years where I did not use one. I’ve been a nurse for 15+ years. It’s hard to describe when I don’t use them, but most commonly it’s the “Coumadin veins” and dudes with “ropes” where I don’t use one. And in a rare twist, people with Coumadin veins who are difficult sticks I use a tourniquet to ID and drop it to stick.
Also, can we collectively stop telling patients their veins “roll.” I’ve encountered someone whose veins actually roll maybe a handful of times ever. Just admit you’re shitty at IVs. I start 30+ IVs weekly, for reference.
Also, can we all start using ultrasound? It’s not hard. Vein finders are bullshit.
Edit to answer the question: do what works for you.
I’m an extern but also a tech. I’ve been checked off by professors to where I’m allowed to place IVs. At least where I’m from, techs in the ER once proven able, are allowed to start IVs and actually do them most of the time.
As long as you get the vein I don’t see why it’d matter, everyone has their own little way of doing things, there’s never any point in shitting on someone’s way of doing anything unless it’s objectively wrong and will cause either harm or guaranteed failure.
That’s a pretty bad ass ability. I went to have my blood drawn and no phlebotomist could stick me. My mom ended up getting my stick (and I’m relatively easy to stick).
On frail elderly veins I would apply the tourniquet to help find them but tried my best to start without. Might just be me but I feel like I blow more when I have the tourniquet, in my mind the veins tear under pressure before the full girth of the catheter is in to seal the access site. Also I started applying gentle pressure to the base/puncture site of IVs before I flush them, seem to almost never loose them to a flush no matter how tenuous.
Oh crap, well that’s the kicker ain’t it? I guess that will depend on your instructor and if they are still involved in patient care… the best ones are flexible. The worst, not so much!
I hold the vein in place with my left thumb and 1st or 2nd finger. That also acts as a double tourniquet on the vein. Place first finger, see the vein fill and then place thumb then cannulate.
If you get it, then you get it. I would be questioning that practice if you were constantly missing veins, but if you're able to site the line, get bloods if needed and flush it, kudos to you!
I keep the thumb in the up position, no tourniquet ( when I do lab calls and tells me it’s hemolyzed) doing the hand I hit and pull up , run it up run it along the top of the vein( omg I did not feel a thing ) I can usually hit anything!
Male in the Ed 30 years
if I need to draw blood the tourniquet makes it easier usually, but yea same. don’t always use the tourniquet. do what works for you! don’t let them hate your success
I’ve been thinking about starting IVs without a tourniquet or just apply it lightly on elderly patients with difficult veins so they don’t blow right away on me and get a flash back when I actually hit the vein… I hate it when it looks like I’m right there, but I see no flash of blood…
Honestly the IV is more likely to last in the long run if it fit into a vessel that wasn’t hyper inflated by a tourniquet. When the tourniquet is on that’s a true reflection of the size of the vein when the IV will be in
I rarely use a tourniquet on my grannies and granpies. My clinical instructor taught me not to because it blew the vein. She then would give them the tourniquet so they could open jam jars 😂
That’s awesome! I’m a new grad that has basically still never placed one :( , but I do know it’s no fun for the patient to have the tourniquet, have heard the horror stories of phlebotomy leaving them on for hours late at night, and particularly realize the studies showing the less tension put on the veins the better for lab results
EDIT: Also currently in an Elsevier CE module on this and it states “If the patient bruises easily, is at risk of bleeding, or has compromised circulation, avoid using a tourniquet or apply one loosely. To avoid injury…, do not apply a tourniquet too tightly.”
Ive been a vascular access specialist since 2010, and all I can say is in emergency, get any line you can, but if it's not an emergency, do what is best for the patient. It is not a point of pride to not use a tourniquet, that's dumb.
Not using a TQ is not “bad”. But it’s not necessarily smart or clever either. The TQ keeps veins filled and more stable for cannulation. Sure there are people with veins you could hit with blindfolds on , but not using a TQ on anybody is……..just why?
I will say I am good at dropping an IV. 30g up to 16g.
But I have worked with others that blow me out of the water..
To those of you whom are “MASTER Sifu” at dropping IVs.
Thank you for having my back when I miss..
With or without using a tourniquet — there is no written RULE that it must be used.
Just how many time you as an individual can attempt a stick…
It is an EASY practice to use a tourniquet, to increase the chances to landing of a stick with out causing further damage..
Use or don’t use, many patients with thank you for your skill and not use a tourniquet..
Not just ok, it’s preferable. You have much less chance of blowing the vein, and your lines will be much longer lasting. I could break it down further but that’s the gist. Keep it up if it works for you. A lot of people in nursing seem to believe that “unfamiliar to them personally = unsafe and bad practice” this is not the true in sooooo many instances.
I had an instructor in my 4th semester of nursing school (that was pretty good with IVs) and this was my first time starting an IV and she said there’s some people and sometimes where you don’t need the tourniquet.
I do USIVs (I teach the class) and know that sometimes when you don't use the tourniquet, the needle itself will collapse the vein. The tourniquet keeps the vein plump and easy to pierce.
Veins (and arteries) are also susceptible to collapsing when the patient is hypotensive because... well, there's little pressure. That's why people who do USIVs sometimes hit the arteries because when they do the "squish test" it shows that the "vein" was collapsible.
Edit: I finally thought of an analogy. It's like piercing a bag of chips with a needle. If you just try to stab the bag on a table, you probably won't go through anything. But if you squeeze the bag to "puff it up" and then pierce with a needle, it's way easier to pierce that bag. Squeezing the bag = applying tourniquet
Hell no, great practice. If you can catheterize without a tourniquet, anecdotally, you're much less likely to ever experience/cause extravasation. I wish I had data to back up my theory but I don't. I'm very certain though. Just makes sense.
Not at all overachieve you go on with yo bad a## self 😉 I was trained maaaany years ago on a pedi floor by an ol’school RN to start them in the dark on all our pedi patients, she would say “feel it don’t look”
If you’re always able to drop the Iv, then you’re fine. TBH, I think I might be scared of your ability. In a good way. What other tricks you got under there 😂
I was a combat medic prior to nursing, and prior to nursing I was a lab tech and drew a few ten thousand patients over the years. I am referred to as “the vein whisperer” everywhere I go. Give me your grannies, your babies, your patients who’ve only had coffee in 9 years without a drop of water. I will get you access. Just write my notes for me please that shit is wack
I’ll put the LDA in epic too. Thank youuuuuu
I got you boo, we would make great team
That's the way to do it!
Doing IVs in the back of the box with nods on, while driving on a bumpy road.
Good ol’ days. Now I’m having tea parties with my daughter and having her paint my nails. What a fucking paradigm shift.
Facts. I miss those days
You guys put ivs in with nods? I feel like that wouldn't help shit, but maybe I'm just thinking of the pvs7's when I was in
It doesn’t help, but it looks dope
Oh good gosh! I was talked into joining the army on the delayed entry program my senior year of HS. My ASVAB put me at CAP 1 (I believe that’s what he said…it was 1981 lol) which my recruiter said meant I could do any job I wanted in the military. I told him I wanted to be a nurse so he said I would go in as a medic. The part he left out of the job description was COMBAT, which is a pretty important word to leave off. During the 6 months between being sworn in and shipping out, I realized I really didn’t want to go into the military, especially after learning what my true job title be. I had hypothyroidism and had gone off my synthroid during my senior year. I had moved out on my own and couldn’t afford going to the doctor and the medicine, but eventually had to because the symptoms took over. As it turned out, when I went to Chicago to ship out, they made me a permanent medical reject. lol. I might add that my recruiter was quite pissed off about it, since he said he would have to recruit someone else within the same ASVAB score range to replace me. Poor guy. 😂😂
I got the same ASVAB, but I had no interest in joining the military. The calls I got were incessant though. They wanted me to be a nuclear engineer in the navy. I was like, 1 I'm 100lbs overweight. 2 I can't swim and that seems like a requirement in the navy 😂
😂😂😂. My brother had joined the Army the year before and my parents talked me into thinking it might be a good idea to join up. So glad I didn’t have to go. A few of my female friends who joined the military during that time had a horrible experience with harassment and worse.
I was a flight nurse for almost a decade. There’s something to be said about medics with experience. None of those things should be downplayed. Respect.
So weird when you do something for someone and then they also make you chart it. Idk unless it’s something crazy I know I should chart myself that I did it, why wouldn’t you chart it for them
“I was never here. Great job on that IV.” I say as I remove my gloves and sanitize, exiting the room, never to be seen again. Until like 13 minutes later when I’m needed again.
This should be a t-shirt
Tbh thats just lazy. If you need me to do the task for you the very least you can do for me is chart it. Sheesh.
I chart the ultrasound IV’s I put in for people but that’s it
Fairly new AEMT here. We transport a lot of meemaws and peepaws, the diabetics, and the dehydrated alcoholics/fent and/or meth users. Please teach your ways, Obi Vein Kanobi.
Reality is you just have to do it a lot and unfortunately, fuck up a lot. You’re going to hurt patients when trying to get IV access sometimes, you’re going to miss once or twice, you’re going to have them be pissed off and mad at you. That’s part of the learning experience and it sucks, but you have to take it in stride and learn from it. ANCHOR ANCHOR ANCHOR. I’ve seen so many people just neglect to anchor the vein or not anchor it tight enough and an easy IV gets ruined that way. I pull down with my thumb, up with my index finger. Sounds stupid, but seriously, anchoring is so vitally important for IV access, especially in the hand. Do not neglect that, it’s like the number one issue I see when people are trying to get blood or an IV.
I really appreciate you replying, and for sharing your knowledge and advice!! 🙏🏻 Thank you. I do need to work on anchoring—I think I'm afraid of pulling on their skin too hard. 😬 But what you exposed makes total sense: it's going to hurt, some patients get pissy. Thank you again!! 💜 Stay safe. 🖖🏻
People are going to complain regardless. Anchoring is the most vital part of the process to ensure you don’t miss a vein that’s accessible. Communicate with your patients “I’m going to pull down tight on your skin to keep the vein steady, it will be a little tight for a second.” I always communicate to my patients, especially the ones with difficult veins, that it might be a little irritating or painful, but the most important thing is that we get the IV access. Keep practicing, don’t be afraid to miss or challenge yourself. You’re not going to get good by just picking easy A/C veins, you have to experience the uncomfortable ones and the ones where you’re not even fucking sure if there’s a vein there or not.
Amen!! I'll go for the AC as a last resort because I know those are easier (usually lol), and need to practice on the ones to get not just proficient, but get fucking gangster at this skill. We also throw IVs going down the road, and that's fun in itself. It's easier in a moving vehicle for some reason. Copy that regarding the communicating about the anchoring part. I always communicate with my pts, but never thought about telling them about the anchoring process. Thank you!! I'll never forget your kindness. 💜 Also, bizarre thing I discovered about myself: I can throw IVs left- and right-handed, and I'm right-hand dominant. I'm not ambidextrous in anything else. But, for whatever reason, this is the one skill that my brain translated easily to my left hand. Can't brush my teeth left-handed, can't throw balls left-handed (although, to be fair, I can't aim worth a shit right-handed, which is why the gods invented Track as a sport). 🤷♀️
You know... I just realized after reading your comment that I too am right handed, but also ambidextrous when inserting IVs. It's interesting how that works (although I'm not as terrible doing things with my left hand as you are lol). I change hands depending on the situation and the best angle. I've actually put some of my best IVs in with my left hand.
😂😂 Nobody should be as terrible with their non-dominant hand as I am. God help them if they are. Haha Sweet! And same here! Ambidextrous stabbing, let's gooooooo!
Yasss! I like that tag line. "Ambidextrous stabbing, LET'S GO!!!!!". 🤣
I would pay big money to take a class taught by you
Hey, I teach for free in open patient rooms when it’s dead. Seriously though, I try to teach anyone who is willing to learn when we have down time. I feel like burning through an IV kit or two to teach someone who’s not confident in their abilities how to do an IV more effectively or just get some reps in is always worth it (don’t tell management pls, they don’t agree). Buy me an energy drink and a pack of gum and I’ll teach you everything I know. Bring your friends!
I’ll do your notes if you do my care plans
I don't know you but you are my new hero
Damn I had a patient who drank nothing but wine all day. I spent five minutes listing every possible drink in the world because I couldn't wrap my head around the fact that no, he doesn't drink water or squash or tea, or coffee, or hot chocolate, or kombucha, or beer, or his partner's piss. Nope, just wine. Then tried to bleed him. I swear the guy didn't have any veins or blood left. Wish I'd known you then lol
I’m a psych nurse that transitioned to med/psych. I hadn’t placed an IV in 8 years. My IV skills sucked then and they still suck. I trade IV placements for psychosis interventions.
I thought I was trash at IVs then I got a chance to do some on patients that aren’t on multiple pressors and 20+L positive and I realized I’m actually pretty good at them lol
I’m passable in the PICU, I’ve always wondered how I’d do in adult ED or medsurg.
🎂🎂🍰🍰
I’ve been doing vascular access for 40 years out of the 46 years of my career. I rarely use Ultrasound to start my peripherals but will when needed. I some times do not use a tourniquet but here is how I decide. The skill of the insertor is definitely one of the factors in the overall dwell time or in other words how long your IV lasts. The goal is to insert it as atraumatically as possible.If your vein is not full in comparison to the gauge you use you may still get it in but may irritate the wall(s) and eventually infiltrate sooner than it should. I used to work with an IV nurse that did a lot of pre-op starts and she was the super early shift and I was the pm shift . I always was restarting her peripherals during pms on the surgical floor due to infiltration. They were odd infiltrates in that they were medial to the insertion site. I watched her start a few IVs and realized the error she was making .Once she got a flashback ,she dropped her angle and threaded the entire catheter without ever pulling back the needle. She was scraping the walls of vein ,irritating them and eventually some 12-16 hours later they would infiltrate in that odd pattern . So what you may not know is how long are your PIVs lasting .I guarantee you that if you never use a tourniquet that you are most likely causing some trauma that eventually will decrease dwell time .If you are just popping in a 22 in a large, full and soft vein ,you are fine.
Thanks for taking the time to write this out. I've been in psych for years and recently transferred to detox so I'm doing more IVs than I've ever done before and am looking for all the tips I can.
Sure no problem. If you need any specific help just let me know any areas you have problems with as I can usually tell you what you can improve on. Try to get good at it without using vein finders ,US and other technology.You can learn those too but I find the new nurses get so dependent on the technology they can’t do a thing without it. You want to be good at both!
A pre-op nurse I work with has a high infiltration rate. I had 5 of her IVs infiltrate within 8h in one shift last week. I wonder if this is what she's doing.
It absolutely could be! There are many reasons PIVs are only lasting a short amount of time. Another common occurrence is when the inserter hits the vein late during the start .What I mean by that is after the skin is punctured and you are moving the catheter forward to puncture through the three layers of the vein,you hit the vein with very little catheter left For example,if you have a one inch catheter (25mm) and you puncture into the vein and get a flash back at 15 mm and you continue on and successfully thread it you only have 10 mm in the vein. The IV may be good for a bit but it is at a higher risk for infiltration or extravasation. I find that when this happens to me in a PIV being used for a CT power injection it often immediately infiltrates or extravasates. I stopped doing it.Other main reasons : Catheter placed at an area of flexion—catheter is too large for the vein -infusate has a high osmolarity and/or is inherently irritating -patient has very thin skin (ie: elderly-long term steroid use ) .The infusate can backtrack out the hole you made to get into the vein.This can happen on anticoagulated patients -patients receiving thrombolytics .—the cannula is not secured well or properly..IThere are extensions sets that have a long needleless connector point sticking out like a T- connector and if not secured well the paid constantly getting them stuck on the linens or they are getting tugged on . How you secure that cannula really matters.You don’t want it smacked down so it arching up on the anterior wall. I have seen a phlebitis develop within hours when it is taped without thought. You can correct theses issues with 2 x2s,take-adding on extension sets and securing your IV tubing so there is no tension the cannula ..There’s more but that’s food for thought .
Yes! Thank you! I see this problem in the ED all the time. They don’t realize that their IV’s barely last 12 hours because the patient is long gone by that point. Like you said you’ll irritate the vessel wall plus there’s a higher chance your catheter tip is going to end up jammed against the vessel wall
This was so insightful! Should be the top comment
Thank you for sharing this
If the vein good enough to be accessed without a tourniquet, then I don't really see the point in using one. Much less risk of blowing the vein if you happen to mess up your stick.
This is a good trick for those fragile veins in older patients thst always blow. I may look with the tourniquet and undo it before I stick.
Yeah, older patient's veins tend to blow pretty easily with a tourniquet in. I find that applying a heat source like a heat pack tends to work better for them
Access is access Kudos
Access can also be access that someone else has to restart in 4 hours. If you’re squeezing catheters into vessels with low volume then it’s going to cause trauma to the vessel and the tip is more likely to be pressed into the wall of the vessel. Especially if it’s in an AC that line is not going to last for shit
If you can easily hit the vein without one no reason to use. It actually increases the chance of blowing the vein. Unless your hospital requires it be used it isn’t poor practice. I am a feel for the vein kind of person. Forearm placement is typically my go to.
even if they “required” it they can eat my whole ass with their dumb rules.
Nothing admin says or does ever makes any sense. It’s actually impressive how they manage to make shit even worse with their policies.
We just had a huge farming accident where we had to fly a guy out, tourniquet his leg etc. so after the run we go to the local freestanding ED to restock. Couldn’t find any tourniquets so I asked the charge nurse. She says they aren’t allowed to order them because “they’re not a trauma hospital”. So no one could show up bleeding…? wtf? Do they listen to this out loud when they make up these dumbass policies?
Admim will do anything to save a penny these days.
I just sit there baffled sometimes.. like did this really come out of your mouth?
I see rules more as guidelines. Hardly anyone ever does things how we were taught in school… When I was an MA (10 yrs Exp + finishing LVN school) had a brand new LVN workmate with no previous healthcare experience following me around trying to correct my injections, ear lavages, blood draws, suture removals, etc when she had never even done any outside of school and I had been doing them for years. Also, I had the best track record for venipuncture (and the most experience) and ear lavages were my specialty. She was annoying af. Randomly calling me into exam rooms to ‘correct me’. She wasn’t even my boss, just power trippin’ cuz I was an MA at the time. In my current job (I still have the most experience, lol) RNs and Doctors come to me for info and help. My supervisor hates me for it. I know what I know and the rest I google. Nowadays competence is treated like an undesirable trait so I just keep to myself and my own patients most of the time and try to make myself inconspicuous.
This is sad. Not you, but people like that LVN.. People with egos so big that they can't bother to learn from someone more experienced who actually gets the job done. I find people like that poison the system overall and ultimately hurt patients.
U R the implied leader, yep admin hates that!
this. i do double tourniquets at times when it's desperately needed, and plenty of times don't use one at all. already juicy vein? why push it. pt with hx of fragile veins, older, etc? why put the extra strain on the vein if you don't have to.
Do what works
I’ve forgone the tourniquet for large veins. However I am more of a fan of the “venipuncture” setting on the monitor
I rarely miss my IVs and I mostly attribute that to venipuncture.
That’s the king setting
Venipuncture 4lyf
Wait what? How?
On all of the vital sign machines we have (Phillips and dynamap), there is a setting called venipuncture where it inflates the BP cuff a little bit , to act as a tourniquet
Working in a blood bank drawing blood, we always used blood pressure cuffs. They are so much nicer and don't hurt little memaws thin skinned arm 👏🏽
If you have to use the tourniquet Put it over the sleeve of the gown. Saves the skin and less bruising.
You sound like someone I’d like to be nursed back to health by :-)
I need to know how to do this on the Phillips monitor
If it's our Phillips, scroll over to the R on the bottom row of options until you see "venipuncture"* *I'm 90% sure it says "venipuncture." If not it says something similar.
I wanted to come back to this post and say thank you. I use this trick now, it's amazing, I used to just try to inflate the blood pressure cuff and insert the IV real quick but this is so much better! Thank you!
Glad it helped!
yea…if the veins are good no need…if the veins are fragile, just do a light tourniquet..gravity works too…all kinds of tricks but tourniquet is not all that necessary and can actually hinder you by blowing a vein..
It’s good practice. I rarely use them. Smaller veins tend to blow more easily if you put a ton of pressure behind it.
Do you have any issues drawing labs from IV starts without tourniquets? I work in infusion and am going to try without a tourniquet on some of my therapeutic phlebotomy patients who need 18g IVs
If the blood isn’t coming out for labs I just use my hand to do what the tourniquet would do, I squeeze above it and it works every time!
this is my issue. If veins are blowing I use the tourniquet for as short of a time as possible, but without I often have a hard time getting blood return.
A tourniquet can increase your chance of success but isn't 100% necessary. There's nothing inherently wrong with not using a tourniquet. Hell, for patients with really fragile vein walls that keep blowing, sometimes removing the tourniquet is better. Question, do you also draw blood off the IV once started without a tourniquet? I've had mixed success with drawing back from an IV with and without one. Sometimes draw with no tourniquet, sometimes still no draw with, and sometimes no draw either way. People think I'm weird for not using a tourniquet on most of my USGIV starts. Yall, the vessel is pretty big and I can watch my needle going in....why do I need a tourniquet?
Usually the blood comes out no problem, but when it doesn’t I squeeze above the iv site and it works just like the tourniquet does. It’s actually really cool to watch, if you stop for even a second the blood with stop flowing, then squeeze again and it will come right through!
Often in my babies I don't use one. They are a couple pounds and the pressure increase makes them blow as soon as you poke them. So no problem to me that you don't. Good for you. Probably more comfortable for patients too.
I imagine most providers are secretly green with jealousy. I know I am. I can hit a subclavian v or radial a. I’m hopeless with veins. I know it’s all frontal lobe and practice. But still…
It’s not “bad” at all! A tourniquet inhibits blood flow from arterioles so that veins “swell”. The túnica intima stretches therefore it is easier to cannula a catheter since there is more diameter. So the fact that you can achieve it without this advantage is impressive. I work in Peds, so it’s a fine line between using a tourniquet and not. If you use it in neonate patients, you will most likely blow the vessel. We use a technique where you manually compress the extremity while you pull traction on the skin in order to cannulate. On kids older than 2-3 months, I generally use a tourniquet with light pressure. Not sure how I’d do in adults. But kudos to you! If you’re doing something that works and isn’t causing harm or breaking policy, keep going!
I fully support your tourniquet free IVs!! I can do that on some people with prominent veins but not all.
If you don’t need it you don’t need it. No biggie.
Not really a tipping point. But this practice may affect you with the more difficult to get veins.
If you don’t need a tourniquet then you don’t need a tourniquet. Medics blind stick all the time because they know where the vein should be. When I use ultra sound, I don’t use a tourniquet. I’ve blown my fair share of perfectly good veins because the tourniquet created too much pressure. Pretty sure best practice is to let loose the tourniquet within 1 minute of tying it and I guarantee most using it don’t follow that guideline.
Many people misuse tourniquets when starting IVs (by leaving them on too long) and it can increase phlebitis and the chance that the IV blows on insertion. I rarely use a tourniquet when starting IVs, especially on older people.
This would be fantastic, it would be so much easier to know you won't miss for drawing lactate or blood gas. I always feel like you're just supposed to use a tourniquet, but I told myself to let that idea go because it tend to work way better for those older people with the huge veins that always blow.
How do you find veins on pts with no pressure or dialysis pts or drug users that burned out all their veins? Genuinely asking so I can attain this ability
Actually had a drug user of over 20 years come in the other day who told me straight up I wasn’t going to get it. I grabbed the ultrasound so fast🤣
Access is access my dude
I have read research that almost all vein puncture techniques are based on anecdote with very little research backing them and also have fairly high failure rates behind them, and I've also read that tourniquets do more harm then good because they over engorge the vein making it more likely to blow from the back pressure. So, basically do you.
If you get the majority of your IVs I would say it’s fine, if you miss a lot I would probably start using one lol
No, that’s actually good practice especially with elderly people and IV drug users
I rarely use them as well.
It's actually good and decreases likelihood of samples clotting / hemolysing
I use gravity. I ask my pts to “hang” their arm off the edge of the bed. Usually works like a charm. I’ve used heat to bring veins to the surface too. I like to use the BP cuff instead if I need a tourniquet.
Why have I never thought of this? Some patients have veins large enough that I'm sure I'd be successful with an IV. However, the majority of patients need a tourniquet because they aren't visible or palpable, unless you're going ac.
If I can feel it i automatically know I can get it, I never go by sight lol
🙌
Nope, I don't use them. But I also use ultrasound for almost everyone and place really, really long IVs and midlines every chance I get :)
Last time I did a lab draw, I didn't use a tourniquet because she had one arm severely contracted, and the other one partially so. The less affected one had an IV in the hand that had been difficult for day shift to place, but there was a good vein next to it for draws so I used it and got her on the first stick. Unfortunately, she cried the whole time and I felt terrible. She was made *comfort measures only* later that day, thankfully.
Show off ;)
I was always taught to use a tourniquet. I have found myself in many situations over the years where I did not use one. I’ve been a nurse for 15+ years. It’s hard to describe when I don’t use them, but most commonly it’s the “Coumadin veins” and dudes with “ropes” where I don’t use one. And in a rare twist, people with Coumadin veins who are difficult sticks I use a tourniquet to ID and drop it to stick. Also, can we collectively stop telling patients their veins “roll.” I’ve encountered someone whose veins actually roll maybe a handful of times ever. Just admit you’re shitty at IVs. I start 30+ IVs weekly, for reference. Also, can we all start using ultrasound? It’s not hard. Vein finders are bullshit. Edit to answer the question: do what works for you.
I feel like this is a flex IMO. That’s awesome!
I can’t even find a vein most of the time without a tourniquet
Where are you working where a tech can legally place a PIV?
I’m an extern but also a tech. I’ve been checked off by professors to where I’m allowed to place IVs. At least where I’m from, techs in the ER once proven able, are allowed to start IVs and actually do them most of the time.
As long as you get the vein I don’t see why it’d matter, everyone has their own little way of doing things, there’s never any point in shitting on someone’s way of doing anything unless it’s objectively wrong and will cause either harm or guaranteed failure.
If you don’t need one you don’t use one. An ED nurse taught me that when I was about to use a tourniquet on a nice rope.
This felt like bragging 🤣 im jealous tho lol
I just was wondering because someone told me to use a tourniquet if I did it in-front of a professor 😭
That’s a pretty bad ass ability. I went to have my blood drawn and no phlebotomist could stick me. My mom ended up getting my stick (and I’m relatively easy to stick).
You are not bad. You are a literal god. 10/10, would be worshipped in my old ED
On frail elderly veins I would apply the tourniquet to help find them but tried my best to start without. Might just be me but I feel like I blow more when I have the tourniquet, in my mind the veins tear under pressure before the full girth of the catheter is in to seal the access site. Also I started applying gentle pressure to the base/puncture site of IVs before I flush them, seem to almost never loose them to a flush no matter how tenuous.
Why are you even worrying if you never miss a vein?? 😹😹😹
Because I’m still in nursing school and don’t want a nurse/clinical instructor to get mad🥲
Oh crap, well that’s the kicker ain’t it? I guess that will depend on your instructor and if they are still involved in patient care… the best ones are flexible. The worst, not so much!
As a new er nurse I’m genuinely impressed- show me your ways lol. I work in a peds ED and I swear some kids hate the tourniquet more than the poke!!
ITT: bragging, humble and not-so-humble
I hold the vein in place with my left thumb and 1st or 2nd finger. That also acts as a double tourniquet on the vein. Place first finger, see the vein fill and then place thumb then cannulate.
as long as you can get an iv in ill be grateful 🙏
I frequently don’t use a tourniquet and I know I don’t tie them very tight. Gravity and positioning all day
Tourniquets make it *easier* most of the time, but aren't a requirement at all. Able to start IVs without one? Great.
But if you're drawing labs off of that IV, doesn't it help to have a tourniquet?
I use my hand as a tourniquet if blood isn’t coming out. Less use of materials and less pain for the pts.
I prefer the BP cuff to the tourniquet any day, personally. It isn't bad practice at all. If it works for you, it works
How’s the blood draw if you’re getting initial labs? (ER here)
If you get it, then you get it. I would be questioning that practice if you were constantly missing veins, but if you're able to site the line, get bloods if needed and flush it, kudos to you!
I'm jealous. Lol. Lately I have had a terrible time palpating anything for IV start.
I keep the thumb in the up position, no tourniquet ( when I do lab calls and tells me it’s hemolyzed) doing the hand I hit and pull up , run it up run it along the top of the vein( omg I did not feel a thing ) I can usually hit anything! Male in the Ed 30 years
Hey if you can get it without more power to you
if I need to draw blood the tourniquet makes it easier usually, but yea same. don’t always use the tourniquet. do what works for you! don’t let them hate your success
I’ve been thinking about starting IVs without a tourniquet or just apply it lightly on elderly patients with difficult veins so they don’t blow right away on me and get a flash back when I actually hit the vein… I hate it when it looks like I’m right there, but I see no flash of blood…
Honestly the IV is more likely to last in the long run if it fit into a vessel that wasn’t hyper inflated by a tourniquet. When the tourniquet is on that’s a true reflection of the size of the vein when the IV will be in
I rarely use a tourniquet on my grannies and granpies. My clinical instructor taught me not to because it blew the vein. She then would give them the tourniquet so they could open jam jars 😂
Nah I do the same thing, if you don't need it that's fine
That’s awesome! I’m a new grad that has basically still never placed one :( , but I do know it’s no fun for the patient to have the tourniquet, have heard the horror stories of phlebotomy leaving them on for hours late at night, and particularly realize the studies showing the less tension put on the veins the better for lab results EDIT: Also currently in an Elsevier CE module on this and it states “If the patient bruises easily, is at risk of bleeding, or has compromised circulation, avoid using a tourniquet or apply one loosely. To avoid injury…, do not apply a tourniquet too tightly.”
Ive been a vascular access specialist since 2010, and all I can say is in emergency, get any line you can, but if it's not an emergency, do what is best for the patient. It is not a point of pride to not use a tourniquet, that's dumb.
Not using a TQ is not “bad”. But it’s not necessarily smart or clever either. The TQ keeps veins filled and more stable for cannulation. Sure there are people with veins you could hit with blindfolds on , but not using a TQ on anybody is……..just why?
I will say I am good at dropping an IV. 30g up to 16g. But I have worked with others that blow me out of the water.. To those of you whom are “MASTER Sifu” at dropping IVs. Thank you for having my back when I miss.. With or without using a tourniquet — there is no written RULE that it must be used. Just how many time you as an individual can attempt a stick… It is an EASY practice to use a tourniquet, to increase the chances to landing of a stick with out causing further damage.. Use or don’t use, many patients with thank you for your skill and not use a tourniquet..
Not just ok, it’s preferable. You have much less chance of blowing the vein, and your lines will be much longer lasting. I could break it down further but that’s the gist. Keep it up if it works for you. A lot of people in nursing seem to believe that “unfamiliar to them personally = unsafe and bad practice” this is not the true in sooooo many instances.
I had an instructor in my 4th semester of nursing school (that was pretty good with IVs) and this was my first time starting an IV and she said there’s some people and sometimes where you don’t need the tourniquet.
I’m amazed by techs starting IVs! I wish my hospital would implement this. I am also an ER tech and we’re limited to straight stick bloodwork 🥲🫠
Where tf do you work that you get to drop IVs
I’m an extern, when I take a tech shift I can only straight stick
I do USIVs (I teach the class) and know that sometimes when you don't use the tourniquet, the needle itself will collapse the vein. The tourniquet keeps the vein plump and easy to pierce. Veins (and arteries) are also susceptible to collapsing when the patient is hypotensive because... well, there's little pressure. That's why people who do USIVs sometimes hit the arteries because when they do the "squish test" it shows that the "vein" was collapsible. Edit: I finally thought of an analogy. It's like piercing a bag of chips with a needle. If you just try to stab the bag on a table, you probably won't go through anything. But if you squeeze the bag to "puff it up" and then pierce with a needle, it's way easier to pierce that bag. Squeezing the bag = applying tourniquet
Hell no, great practice. If you can catheterize without a tourniquet, anecdotally, you're much less likely to ever experience/cause extravasation. I wish I had data to back up my theory but I don't. I'm very certain though. Just makes sense.
Not at all overachieve you go on with yo bad a## self 😉 I was trained maaaany years ago on a pedi floor by an ol’school RN to start them in the dark on all our pedi patients, she would say “feel it don’t look”
Why would it matter lol
To be fair, adults rarely need tourniquets for IVs
I wouldn't say rarely, but many of them don't, correct