Clinical Skills - Peripheral IV Insertion (Venipuncture)
by Ellis Parker March 02, 2022 Updated: December 07, 2022 14 min read
Hi. I'm Ellis with Level Up RN. In this video, I'll be demonstrating how to perform a venipuncture or how to start a peripheral IV. I'll be using the steps that are listed on our clinical nursing skills cards. So if you've got this deck, grab the corresponding cards and you can follow along on the steps with me. If you don't have the deck and you want to check one out, head on over to LevelUpRN.com. After the demonstration, I'll be coming back here to show you a couple of cool things about IV needles and catheters and just a couple of tips and tricks that we've learned along the years.
To prepare for the peripheral IV insertion, I've got to go ahead and gather all of my materials. So while you can get, in some facilities, just a kit that comes with all of this together, I've gone ahead and just separated it out for us to go through. So I've got my extension tubing, an antiseptic swab, a normal saline flush, tourniquet, tape, transparent dressing, my IV needles, and a pair of gloves.
So I'm going to go ahead and assess my patient's arm. I like to start with their non-dominant arm because then when they are eating or playing on their phone, they're less likely to bother that site. So we'll go ahead and start with his non-dominant arm. I'm going to put my catheter a couple of inches above the site that I think I'll be using. We do want to start as distally as possible. So I could potentially start with the back of the hand or some of these forearm veins. So I'm going to tie my tourniquet. I'm going to hold both straight up. Then almost as if I'm tying a knot, I'm going to loop one under but then drop it before the knot is tied. I messed that up. Let's try that again. It's hard to do it slowly.
So I want to assess these veins. It's nice to be able to visually inspect them, but really, what you need to be able to do is palpate them. They need to feel kind of spongy and soft, and you want to be able to palpate them. We do not want to choose the dorsal side of the wrist because there are nerves there that if I potentially were to puncture, I could cause damage to my patient. And even though it's a popular site, the antecubital area or this area in your elbow, it's actually not ideal either because it moves so much that we might mess up the insertion site or cut off the flow of the IV itself.
So I'm going to go ahead and choose this site right here. So I'm going to release my tourniquet, get one of my antiseptic swabs, and clean the site. I'm going to start at the center and do concentric circles going out. Then, while that's drying, I'm just going to go ahead and prepare the rest of my materials. I'm going to open my extension tubing, trying not to touch the extension tubing ports so that they remain as sterile as possible. Then, I'm going to take my flush and uncap it, take my extension tubing and attach that just with that push and twist into the Luer Lock, and I'm going to remove the cap off the end of the extension tubing. I can then flush this tubing so that it's ready for connecting to my patient. And then when I put this down, I'm putting this distal end into the container so that it's not sitting on my table or anything and potentially becoming contaminated.
I'm going to open my needle, and I can open my transparent dressing so that that's ready as well. I can then hand hygiene and put on my gloves if I haven't already done hand hygiene. I'm going to reapply that tourniquet, again, a couple inches above my site, not touching the site I've already cleaned, so I can come at it from a different angle even. I want this tourniquet to be tight enough for my veins to become slightly distended but not so tight that it occludes all blood flow. So once I've got my site and tourniquet on, [I can?] obtain my needle. These needles are usually flared. I'm going to place my fingers on that flare, take my non-dominant thumb, hold the skin taut underneath the site of insertion so the skin isn't moving around while I'm trying to puncture it.
I'm going to put my needle at a 30- to 45-degree angle initially. So I'm going to insert into that vein.
Once I know I'm in the vein, or once I think I'm in the vein, I'm going to actually drop the angle of my needle, insert it just a little bit more, like a millimeter or two more, and then push the catheter off the needle, apply pressure with two fingers, and withdraw my needle. I was looking for flashback in my IV needle itself. Now, some of these IV needles will auto-close so that needle is no longer exposed, and some of them do require you to push a button. So for safety reasons, I'm going to immediately push that button, make my needle disappear, and place it in my sharps box if I can.
Now you can see here, I have my two fingers pushed firmly above the insertion site. And doing that is hopefully going to stop this blood flow from happening or at least reduce it. I'm going to release my tourniquet to make sure that I now have free vein access. Get this already prepared extension tubing and attach it, twisting it on. I can pull back slightly if I want to and, oh, that's beautiful. I've got that beautiful blood return. But I want to flush. And while I'm flushing, I'm checking that surrounding tissue, making sure that I don't see any bubbling or that that fluid's going into the tissue and that it is, indeed, going into the vein. I'm going to flush it. It's going into the vein. It's not difficult to flush. I'm not having to push really hard. I'm going to remove that flush. If needed, I can use a swab to clean up any additional blood. And I'm going to put my clear occlusive dressing.
We want a transparent dressing so that we can view that insertion site at all times. The insertion site should never be red or swollen or anything like that. Once I've got that occlusive dressing on, it should be labeled with the date, time, and my initials. And then I can tape this additional J-loop portion down just so that it's not at risk of getting caught on any of his clothing or bedding. That's all we need to do. And I just clean up.
Initiating an IV can be really exciting for students, so I want to make sure that I give you all the information I can to make sure that you are successful with this skill. So I'm going to give you two pieces of advice first that I got schooled on when I first started nursing. Number one, take off the tourniquet. You must remove the tourniquet before you inject anything into the IV site. If I were asked what mistake most of my learners make or what's the most common mistake my learners make when they're starting an IV, it would be that they do not remove the tourniquet. They do the whole skill and it's beautiful and they look at me and the tourniquet's still on the arm. So when I'm working with my IV site, right, I've placed the IV catheter, I'm ready, and I screw this onto the hub and I'm ready to flush my saline lock, stop, pop your tourniquet, and then carry on with what you're doing. If I were to pull back to check for blood return and then push to flush that line without popping the tourniquet off, then because there's pressure above the site, there's nowhere for that to go, and I could potentially blow my line. So after I connect this to the hub, before I actually flush it, just reach up and pop off that tourniquet.
I think that this is just really easy to skip over in my brain because there's a lot of other things going on, and we're just so ready to wrap the skill up and get everything connected. Again, in practice, I've done this. I vividly remember early in practice putting an IV in a patient, leaving the room, coming back like 20 minutes later, and her tourniquet was still on her arm. And I said to her, "Why didn't you call me? Why didn't you tell me?" And she was just like, "I don't know. I just trusted you and thought that that's what it was supposed to be like." And I was like, "Oh, my God. First of all, well, you trusted me," and that had to have been uncomfortable. And when you experience something like that, it really sticks in your brain, and you don't do it again. So I'm hoping that by sharing it with the world, that you don't make the same mistakes I did.
All right. My tip number two, again, from a mistake that I made, is to make sure you applied pressure above the insertion site before you connect to your extension tubing. My example. In my ER internship as a nursing student, I went to go place my very first IV. I was super excited and super nervous. It was with a 15-year-old patient. And again, I put the needle in, pulled the catheter off the needle, discarded my needle, and then I turned to get this equipment, which was my first mistake. Why did I turn around? Couldn't tell you. Why wasn't all my equipment ready? I don't know. Now, I know better. But I turned back around, and [I view?] the hub in my patient's arm is just spraying blood. And of course, it looked like a lot more blood than it was, but to my 15-year-old patient and to my little baby nursing-student heart, it seemed like so much blood.
Luckily, I have a great poker face. I finished what I was doing, attached his extension tubing, flushed it, taped it, all that good stuff, cleaned them up, left the room. My preceptor turns to me and is like, "What did you do that for? Why didn't you put pressure on his arm?" And I genuinely could not remember having learned that for some reason. So I share unto you, after you insert the needle and then remove the needle, before you put the extension tubing on, you should be holding pressure above the insertion site, not on the insertion site but slightly above the insertion site, to reduce the amount of blood that's coming out.
I think what can exacerbate this issue for our students is that it's really hard to mimic that in the lab. I can put blood in my Manikin arms to help facilitate some things, but because they don't actually have blood pressure, blood doesn't always come out, and blood certainly doesn't shoot out, and sometimes it doesn't really do much of anything. And so I think when I'm practicing with Manikins it can be hard to remember, "Oh, a real person has blood pressure and blood flow, and blood would be coming out of this." So I can tell my students all day, "Put pressure above the site," but there's no visual reminder of that because nothing is usually happening if they don't put pressure above the site. So put pressure above the site.
All right. Now I'm going to show you some things. Let's talk about gauges. So I really wanted to show you our beautiful rainbow of gauges because it's a little bit alarming the differences between the sizes. So on my board here, I start with a 24. 24 is my yellow gauge, and you can see that she's a little dainty. She's shorter, she's smaller, and she is going to be for any of my really hard-to-stick patients, my geriatric patients, my pediatric patients, but ideally not a regular-use size because there are certain restrictions in terms of how fast I can run things and what type of things I can run through this size.
So one size bigger is going to be my 22, and you'll notice with what I just said, it starts with 24 and goes to 22. So the smaller the number the larger the gauge. So 22 is blue. Remember that. Oh, God, I fucking hate when I wink. I'm going to start this over.
All right. Let's talk about gauges. So I've got here a beautiful rainbow of different sizes for us to look at. I start with my size 24. So 24 is yellow, and you can see that it's fairly short and definitely really small and skinny. So this going to be used for things like a patient who is pediatric or even geriatric or maybe has very small or fragile veins. However, the small size of this gauge really limits how much, how fast, and even different types of things that I can run through the line. So I don't want to use it just because it's easier to get the smaller sizes in.
The next size is my 22. So you'll notice there that I started with 24; I went to 22. So the smaller the number, the larger the gauge. So 24 is my smallest, and on this board, 14 is my biggest. So I've got 24. Blue is 22 which rhymes. So a 22 is blue, super common to use on med-surg. Again, though, I am restricted. I shouldn't be doing things like blood through a 22. But it's a fairly standard size gauge to use on adult patients and even perhaps my larger pediatric patients.
My pink is a 20. A 20 is really the ideal size, probably, for my med-surg patients or for many of my patients. It's large enough that I could run blood through it, it can handle faster solutions, and it's just a really good size for things like that. The one size bigger, my 18, is again ideal for things like blood or CT contrast. And so for that reason, patients that are perhaps in a trauma situation, an ICU, or especially in my emergency department situation are more likely going to get a 20 or an 18, and that's because the nurses need to be able to facilitate things like blood or large quantities of fluid or IV contrast for things like a CT scan.
And that being said, these sizes are possibly easier to get in something like the antecubital, which is that elbow region. Now, as a med-surg nurse, I don't love sticking the elbow region because it bends. And it can be really, really frustrating because it can become dislodged, it could become kinked. My IV pump beeps every 20 seconds because if the patient moves their arm a certain way, it occludes the IV, and then the line gets mad. It's just a lot. So we try as best as we can to avoid joints including the antecubital. However, if I worked in the emergency department, that might be my ideal situation because I can get a larger-bore needle, like a size 18 in there, and then I would be able to use it for things like contrast or blood administration, which I'm far more likely to utilize in an emergency room setting for something like a trauma patient. So different size gauges are not only for certain patients but are also more useful in certain departments and in situations. So that's my size 18.
Size 16 and 14, as you can see here, are very large, 14 especially. That is a big needle. These are exclusively for things like trauma patients. This would get, again, a very large volume of fluid in very quickly, large volumes of blood in very quickly, and we wouldn't have to worry about the catheter not being able to accommodate that. So these are my different types of gauges. And now, I'm going to demonstrate the different parts of the IV catheter itself.
I went ahead and grabbed my size 14 because it's the largest and I wanted to make sure it was visible to you. Again, not usually the one I would use. Just for this demonstration, it makes for the easiest visual. So my different pieces here are going to be my flash chamber. So when I insert this into my patients, this is where I would see flashback usually right up in this top part. Again, every brand is going to look a little bit different, totally fine, but they will always be clear here so that I can visualize flashback. I also may not always see flashback. That's why it's important when I insert my needle to drop down a little bit and go just a little bit further. At that point, I may then see flashback, but if I'm not feeling or seeing any reason why it would not be in the vein, I would usually go ahead and advance the catheter anyway. I just might not have a lot of flashback or visible flashback. So this is where my flashback would occur.
Most of my needles have some type of safety function. Sometimes they auto-work. This one has a button that I'll click after I'm done using it. And then, my favorite part to show students - because I think this is the most common misconception with IV catheters - is that it's not a needle that remains in your arm. So after I inject the needle, drop it, push a little further, I then push off the catheter, which I've now said a few times, but now I want to show you. This leaves my needle remaining on this portion that I'll set aside here so I don't stab myself with it, and then this is the part that remains in my patient. This is bendy. It's kind of like a straw. So it's hollow and it's just plastic. So that's why I can put it in somewhere like my antecubital because, hypothetically, I could bend, and it would bend with my arm. Of course, sometimes it gets too bent, and then it doesn't work anymore.
But I think it's a really common misconception. In fact, I thought when I first went to nursing school that when they put an IV in you that they were leaving a needle in your arm. And that scared me, and it sounded painful, and I was confused as to how that worked because the only thing I had been exposed to up to that point were shots - right? - like immunizations and things like that, so I didn't really understand how this worked. So, like I said, after I insert it, I'm just going to slide my catheter right off, and then I'll either deploy the safety feature or I'll withdraw it, depending on the brand of the needle, and just this plastic piece remains. If you can't tell, I find IV insertion really interesting and exciting and could probably talk about it all day. But I'm going to wrap it up here.
I have two more quick tips to share with you, given to me by our lovely nurse, Maris, who works on the team with me. So the first thing she mentioned is that to avoid losing the site so I don't have to keep pressing - because especially after I clean, I should not be touching the site that I plan on inserting - I can point at it with my alcohol swab. So let's say, for example, I'm going to use the antecubital, even though I don't generally recommend it, but it'll be for good visual. I'm going to clean my site. Say I found it right here. I'm going to clean. And then, right there, so that this little corner is kind of pointing to where I plan on doing my injection. So I thought that was a cool tip.
And then, the other thing I just want to mention is that I secured the site with a clear dressing, which is always imperative to do, but if I needed to - and there are cases in which this is important, often with someone like a patient that has a memory impairment, dementia, Alzheimer's, sometimes my psychiatric patients or pediatric patients, if I'm worried for some reason that they might interfere with the integrity of the IV or the dressing - then I may need to put something like a cling wrap around it or some type of bandage around it to make sure that they aren't grabbing at it or pulling at it. So I still need that clear dressing because I then would be able to remove the top dressing to look at the clear dressing and visualize that site and look for things like redness and swelling - right? - but then I could wrap it back up if I had to. So there are options for really securing those so that the lines and catheters are not pulled out.
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