Twice is enough…

The practice criteria in the INS standard 35 on vascular access site preparation and device placement states:

“No more than 2 attempts at vascular access placement should be made by any 1 nurse, as multiple unsuccessful attempts limit future vascular access, and cause patients unnecessary pain. Patients with difficult vascular access require a careful assessment of VAD needs and collaboration with the healthcare team to discuss appropriate options.”

I cringe when I hear patients say it took the nurse ..(X).. number of tries to get an peripheral IV in place where X=more than 2 insertion attempts. One patient told me it took 16 tries and 4 nurses  and still wasn’t able to get a PIV inserted. Some patients take  pride in the fact that they are “difficult sticks” and expect to be stuck numerous times for a PIV insertion. Others equate the unsuccessful attempts by nurses as: “incompetence or inexperience”.   

 When it comes to unsuccessful attempts to insert an IV catheter, two unsuccessful attempts by a nurse is enough. Yes, there will be times when even the most proficient nurse will  be unsuccessful on the first try. This standard applies to all settings even for patients receiving infusions at home and there’s no other nurses available to try.  


Here are some IV tips I find helpful when peripheral veins are hard to find.

Palpation: Apply the tourniquet. Use your index finger to palpate the veins. Press directly on the vein with your index finger, assessing for vein softness and volume. Then release the pressure slowly without lifting your finger and feel the vein bounce back to your index finger. Repeat as often to ensure you found a suitable vein. Don’t stick without palpating the vein!

Tapping: Apply the tourniquet. Lightly tapping the skin or area where you see veins will help distend the vessel. Avoid “beating” the skin as it might cause venospasms.

Dry heat: Use dry heat to the proposed site. Application of dry heat increases blood flow allowing for good venous dilatation, thus improved vein visualization.  A study showed dry heat is 2.7 times more likely than moist heat to result in successful IV insertion on the first attempt, have significantly lower insertion times, and more comfortable.

Stroking: Stroking the vein toward the hand allow for venous refill.

Open/Close fist: Open and close fist during vein assessment but keep arm relaxed during venipuncture.Keep arm/hand in low (dangling) position.

Skin Anchoring: An important step to the success of venipuncture. Prevent the movement of veins during venipuncture.(especially for “rolling veins”). Pull skin downward below the point of insertion with the thumb of the non-dominant hand or pull skin above the point of insertion with forefingers or pull skin from underneath the extremity.

Insertion: Select the smallest gauge and shortest length catheter. Position catheter tip bevel up. Approach angle to skin at 10 –15 degree. Deeper veins need greater angle. Superficial require lesser angle. If parallel to the skin surface, will drag the skin as you puncture it. Lower angle once blood return is observed and advance the catheter.

Vein Viewer and Ultrasound: There are devices that can help you find veins. The equipment ranges from transillumination to ultrasound. These are expensive equipment and would require training prior to use. There is increasing evidence that the use of ultrasound for venous access is safe and successful.

Take a deep breath: Both you and the patient! Let the patient know when you are ready to stick and tell them to take a deep breath and blow it out slowly. This will distract them from the stick and help the tension in their arm.

Patience: Take the time to do a vein assessment and vein palpation prior to each attempt, don’t stick only because you can see a blue line. Some veins are located deep in the superficial fascia and the extra “fatty deposits” doesn’t help. Veins won’t change position just because you are in a hurry.

Oh, and do document your unsuccessful attempts at PIV insertion – many nurses don’t.

4 thoughts on “Twice is enough…

  1. As a last resort, I use a blood pressure cuff with sphygmomanometer attached. Similar concept of “milking” the arm, I pump the cuff to 60mm/hg 3-4 times, releasing pumping, releasing pumping, then on the last pump, leave the pressure on 60mm/hg, palpate for a pulse, there should be one. Have all equipment needed, do a vein assessment under 2 minutes time. If it takes longer to find a suitable vein, release the pressure and wait for circulation to return, then start again. This technique was given to me by a surgeon, many years ago, before I was about to start a peripheral IV on his mother. He warned me she would be a challenging person to insert a peripheral IV, then proceeded to share this wonderful tip with me. He was correct and I was able to insert her peripheral IV on the first attempt.

  2. I work in Texas and am curious if medical assistants can start ivs and administer medication in an office based setting

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