I decided to put this here so I can easily access it later! Much thanks to the original writer, editor, compiler, uploader and site (source below). It is a foreign nurses' site, so mainly addresses nurses, but IV insertion is largely the onus of the HOs in this country. In any case, the advice is mostly usable, although we lack many of the more advanced equipment in the post and there are always personal or regional preferences and SOPs to consider.
A side note from me, given from other seasoned healthcare practitioners: You can (and should) try your best to minimize your patient's discomfort, but do not feel too bad about the none-too-occasional vein searching and multiple pokes. IV cannulation is 80% skill; 20% luck (and 40% mood)!
Starting from the link below, the contents are not mine.
Source: http://nurseslabs.com/50-intravenous-therapy-iv-tips-tricks/6/
Most complaints that are received from patients and their
significant others even before the start of a shift are swelling and
infiltrated intravenous sites.
Intravenous therapy (or simply IV therapy) is
one of the most basic treatments given to almost every patient admitted to
every hospital, and the skill of intravenous catheter insertion must be
remembered by heart by every nurse therapist. To avoid these complaints and
giving undue pain to your patients, take a look at these tips on how to become
a sharpshooter in every
intravenous
insertion that you make.
1. Stay calm and be prepared. Hitting the
bullseye on one try will depend on the nurse’s preparation and skill. You and
your patient should be composed as a nervous, and rushed procedure will likely
result in failure. Allay anxiety by explaining the procedure to the patient and
determine the patient’s history with IV therapy. Ensure the patient is
comfortable and sufficiently warm to prevent vasoconstriction.
2. Exude confidence. Believe in yourself
and reassure the patient you know what you’re doing. The patient will be
encouraged by your confidence and you too, of course.
3. Assess for needle phobia. Needle phobia is a
response as a result of previous IV insertions. Symptoms include tachycardia
and hypertension before insertion. On insertion bradycardia and a drop in
blood pressure occurs with signs and symptoms of pallor, diaphoresis, and
syncope. Reassure the patient with a comforting tone, educating the patient,
keeping needles out of sight until the last minute before use, and use of
topical anesthetics can help manage needle phobia.
4. Observe Infection control measures. Use
sterile gloves in inserting a cannula into the patient. Intravenous insertion
is an invasive procedure and requires sterile technique and proper infection
control measures. Wipe a cotton swab or alcohol pad on the insertion site
to minimize microorganisms in the area and also to visualize the chosen vein more
clearly.
5. Assess the vein. Before inserting a needle
into a patient’s vein, you have to assess its condition first. A well-hydrated
person has firm, supple, and easy-to-reach veins. Well-hydrated veins are
bouncy, making them the right fit for insertion. Some patients need
intravenous therapy but are dehydrated, so it is a challenge to hit the vein in
one go. To avoid injuring the vein, always assess first that you are aiming for
a vein that is not frail enough to blow up during the insertion. The following
tips can help you with that.
6. Feel rather than look. If you can’t see a
suitable vein, trust your fingers even more than your eyes. It’s also an
excellent opportunity to familiarize yourself with a suitable vein. A
tendon may feel like a vein but palpating it through a range of motion may
prove that it is not.
7. Ask your patient. The patient may know more
which veins are suitable basing on his previous IV history.
8. Use appropriate cannula size. Match the
needle and the gauge of the cannula to the size of the patient. You can hit a
vein that is smaller than your needle, but it would be injured and would blow
up because the needle is bigger than it is.
 |
| Parts of an IV catheter. |
9. Consider the use. Put into consideration the
type of infusion that is needed when you choose your cannula. Needles with
smaller gauges could not accommodate blood transfusion and parenteral feeding.
Needleless equipment is now widely used to minimize injury to the vein during
and after insertion.
 |
| Recommended gauges for different conditions. |
10. Insert at the non-dominant hand first. Consider
inserting on non-dominant hand first so the patient can still perform simple
functions using the dominant hand. However, if you cannot locate an appropriate
site or vein for insertion in the non-dominant hand, proceed with the dominant
hand.
Vein Selection
11. Start with distal veins and work proximally. Start
choosing from the lowest veins first then work upward. Starting at the most
proximal point can potentially lose several sites you could have below it.
 |
| Common sites for vein insertion. |
12. Use a BP cuff rather than a tourniquet. If
the patient has low BP, it would be best to use a BP cuff inflated to
appropriate pressure to make the veins dilate. This technique can also be
useful for older patients and those with veins that are too difficult to
access. For patients with hypovolemia, use a larger vein as small veins
collapse quicker. Inflate the cuff to the lowest pressure first and see if the
veins appear.
13. In using a BP cuff as a tourniquet. When
using one as a tourniquet, invert it, so the tubings are away from the limb
giving you a clear view of the site and removing possibilities of the
tubings contaminating the site. The BP cuff lets your patient have a wider,
more comfortable tourniquet that compresses evenly and efficiently and can be
adjusted to the exact pressure needed to dilate the veins.
14. Puncture without a tourniquet. If the
patient has adequately filled but fragile veins, proceed with the insertion
without using a tourniquet. Pressure from the placement of the tourniquet may
cause the client’s delicate vein blow out upon puncture.
Making it more visible
15. Gravity is your friend. Let the patient’s
arm dangle down on the side of the bed if no veins are observed to promote
venous filling. Gravity slows venous return and distends the veins. Full and
distended veins are easier to palpate and are always an excellent option
for insertion.
16. Use warm compress. Apply warm compress or
warm towels over the area for several minutes before you insert. A warmer
temperature would enable the vein to dilate and make it more visible to the
surface.
17. Do not slap the vein. Some nurses have a bad
habit of slapping the site of insertion so that the vein be more visible.
Though the practice is helpful at times, veins have nerve endings that react to
painful stimuli causing them to contract, therefore, making it harder to
locate the vein. Please don’t make an already painful procedure even more
painful.
18. Flick or tap the vein. Rather than slapping,
use your thumb and second finger to flick the vein; this releases histamines
beneath the skin and causes vein dilation.
19. Feel the vein. Wrap a tourniquet above the
site of insertion to dilate the veins and gently palpate the vein by pressing
it up and down. Use the same fingers in palpation so you would be able to
familiarize the feeling of a bouncy vein. Tap the vein gently; do not slap it
to avoid contraction of the vein.
20. Fist clenching. Instruct the patient to
clench and unclench his or her fist to compress distal veins and distend them;
this helps in venous filling.
21. Use the multiple tourniquet technique. By
using two or three latex tourniquets, apply one high on the arm and leave for 2
minutes, apply the second at mid arm below antecubital fossa. Collateral veins
should appear. Use the third one if needed.
22. Vein dilation using nitroglycerine. To help
dilate a small vein, apply nitroglycerine ointment to the site for one to two
minutes. Remove the ointment as you make your final disinfection of the site
with alcohol.
23. Flow where you want it to go. When
disinfecting the insertion site, rub the alcohol pad in the direction of the
venous flow as to improve the filling of the vein by pushing the blood past the
valves.
 |
| Rub the alcohol pad in the direction of the venous flow |
Cleaning
or Disinfecting IV Sites
24. Clean vigorously and widely. To have the
tape and dressing adhere tightly to clean dry skin. Disinfect a wider area to
in case another vein shows up.
25. Use a vein locator. Veins can be very hard
to find in infants or small children, equipment like transilluminator lights
and pocket ultrasound machines can illuminate vein pathways so you can have a
visual direction of where you should insert your catheter. Be wary of
burning skin and limit the duration of contact.
 |
| Example of a vein locator: Accuvein. |
Insertion of the Catheter
26. Stabilize the vein. Pull the skin taut just
below the entry site to support the vein for needle entry and this also lessens
the pain the patient may feel upon insertion. Make sure that the alcohol has
already dried on the skin before inserting because this may become more painful
for the patient.
27. Insert the IV catheter directly atop the vein. Initiating
it from the side of the vein can push it sideways even if it’s anchored by your
hand.
28. Prevent kinking. Sometimes, if the vein is
hardened or scarred, there is a risk of kinking the cannula. Otherwise, one can
get through the scar to a usable portion of the vein by using the following
technique:
29. Twirl the catheter hub. Mild obstructions,
tortuosity of the vessel, vessel fragility, and frictional resistance can be
overcome by “twirling” the catheter hub. To do this insert the IV with a
slight rotating motion to help glide over some parts of the vein.
30. Bevel up. Make sure the bevel of the needle
faces upwards as this is the sharpest part of the needle. Believe me, the
needle will glide easily if inserted this way.
31. Make the shot at a 15-30 degree angle over the skin. Hold
the catheter in a 15-30 degree angle over the skin with the bevel up and inform
the patient that you are going to insert the needle.
Additional techniques for IV insertion.
32. Feel for any resistance. As you insert the
needle, feel for any resistance from the pain. If no resistance is felt,
advance the needle carefully. If there is resistance felt, discontinue your
insertion because you might disrupt the vein and injure it further.
33. “The Flashback.” Once you can see that
there is a backflow of blood (i.e., “Flashback”) from the veins, remove the
tourniquet and completely advance the catheter and remove the needle
altogether. Secure the catheter to the patient’s skin correctly and open the
infusion line to start the therapy. It’s
one of the best feelings
in nursing!
 |
| Rejoice! |
34. Don’t go all in. Know when to stop advancing
your catheter, once you hit the vein and see a flash of blood back, stop and
lower your angle of approach. Advancing it further may puncture through the
vein.
 |
| An inside look at a vein with an IV catheter. |
35. Don’t rush into starting the IV fluid. Once
inserted and secured, initiate the IV infusion slowly as if you’re working with
fragile veins. Rushing to start the fluid might blow the vein.
36. Release the tourniquet first. Once you have
ensured the catheter is within the vein, untie the tourniquet before advancing
the catheter to prevent it from blowing due to increase in pressure.
Securing the line
37. On taping the IV tubing. Improper
taping of the I.V. tubing across the cannula and the vein beneath it will later
cause pain during infusion. Tape the tubing away from the cannula site. When
taping the catheter should be secured and accessible.
 |
| You can also use this specialized dressings for catheter securement. |
38. Limbs in motion? When the patient’s limbs
are on the move (i.e., inside an ambulance), secure the IV site by locking the
arm in extension and blocking the flexion at the elbow.
39. Go with the flow when taping. Tape down the
tubing while considering the natural movements of the body; thus running all
tubing laterally on the limb in the direction of the motion. You can prevent
the tubing from coiling or tangling by “going with the flow” of the body.
40. Stress tape to prevent accidental yanking. Use
one or two stress tapings to avoid a direct pull from an IV site if the tubing
is snagged. Do not tape down excessive loops or coils which shorten the length
of the tubing. One should not tape on the proximal side of a flexing joint;
it’ll just be removed easily. Do not wrap the tubing around a digit when taping
it because when the patient clenches his fist, it can easily pull out or alter
the flow of the catheter. A double-back of the tubing with a short loop will
secure it well.
 |
| Securing the catheter by adding a stress loop. |
41. If it leaks. If a small leak occurs at the
point and moment of insertion, the vein may still be usable if the catheter tip
can be fully advanced proximal to the leakage. Observe a test infusion of
non-irritating fluid for any extravasation carefully before other use.
42. Do not probe for a vein. Also called
“fishing” or “vein searching”–this is painful especially when the nurse
unintendedly probes into muscle or tendon. If you don’t get a flashback, don’t
not let your needle dig for a vein by moving it around. When this does happen,
this may be a sign that you’ve missed your target, and your needle has been
deflected by a rolling or hard veins. Sometimes, you may only need to pull back
the needle and insert in another direction, doing so is better than starting
the procedure over again.
Special Considerations
43. For older patients and pediatric patients. They
have smaller and fragile veins than normal adults do. Use small gauges
that can still aid proper venous flow. Choose the right site for insertion.
Probably the safest location is in the hands, but be sure to stabilize it
because pediatric patients are fond of gesticulating, and elderly patients are
prone to falls.
 |
| Veins of older patients can be tricky. |
44. For patients who have dark skin tone. You
can use a blood pressure cuff and inflate it to visualize the vein more clearly
due to distention. The trick of wiping a cotton swab in the direction of
the vein also helps to visualize the vein better for pediatric, elderly, and
dark-skinned patients.
45. For veins with valves, use the floating technique. There
are some people with prominent valves in their veins that can hinder insertion.
These valves feel like little bumps along the vein’s track and is common among
weightlifters and sculptors. If you have difficulty inserting the catheter to
this kind of vein, use a floating technique to open the valves. Floating method
is done by attaching a primed extension tubing to the cannula and gently
flushing the tubing with normal saline via a syringe while advancing the
catheter.
46. Bifurcating veins. These veins have a
noticeable inverted V-shape and are less likely to roll during insertion.
However, the vein should be accessed below the bifurcation with the highest
probability of cannulation success.
47. Call the “vein whisperer”. After some
reasonable unsuccessful attempts to insert the IV catheter, it would be best
for the patient that the nurse calls for another healthcare provider to try
inserting the IV. Staff in NICU, Anesthesia, or vascular surgeons are sometimes
needed for some patients. Call on those who may have the best chance before all
veins are used up.
48. On the use of restraints. Infant and
children may need to have their limb splinted or restrained before starting the
IV as they may be uncooperative during the insertion. Do not forget to place
your tourniquet before securing the splint as not to have to delve it
through beginning the venipuncture.
49. Restraining using Papoose or Mummy wrap. It
can be wise to restrain using a “Papoose” or a “Mummy” wrap for some children
whom agitation and potential combativeness cannot yet be safely relieved.
Though unsettling to the family, explain that you want to make the best
possible chances of success in the first effort.
50. Learn the art of distraction. Children can
be uncooperative during procedures and use of distraction methods like letting
the patient blow bubbles, sing or count are sufficient techniques.
Intravenous insertion may be one of the basics
skills a nurse would learn, but it could be one of the most difficult if you
lack the practice and the confidence to do it. Most of the sharpshooters have
gained their skill through continuous practice and plenty of experiences in
this field. A lot of factors may affect the way you insert an intravenous
catheter, but you have to control them and bend them to your convenience. Never
rush on any nursing skills that you still not have, or take a shortcut just to
achieve your goals. Nursing practices must be accurate, precise, and learned
not only by the brain but most especially by the heart.
