Missing a vein when trying to start an I.V. (or drawing blood) can be a very frustrating and embarrassing experience for nurses, phlebotomists, and other healthcare professionals. It can also be a painful and frustrating experience for the patient, too. Nevertheless, missing veins is an unfortunate reality that all nurses and healthcare professionals face, even when you have decades of experience and a high rate of successful sticks.
If you keep missing veins on a patient, here are some tips for what to do and how to increase your chances of getting a successful stick on your first try.
How to Respond When You Miss a Vein
When you try to stick a patient and miss the vein, how should you react? I’d recommend you stay clear of one of these two extremes:
- Blame or scold the patient. It’s easy to place blame on the patient and say something like, “Wow, you’re a hard stick. You don’t have any veins!” We’ve all probably done that at some point, but I’ve found that some patients can take offense when you do that. Therefore, I try to avoid placing blame on the patient.
- Blame yourself and apologize for your “error.” The other extreme is that you are overly apologetic for missing the vein, and put all of the blame on yourself. The truth is that it isn’t always your fault if you miss, and when you start apologizing all the time, it makes it seem as though you made a mistake or are incompetent as a nurse or phlebotomist. And you don’t want to go to that extreme, either.
So how should you react when you miss a vein? I find it is best to stay neutral and professional. Before starting the I.V., I’ll say something like this: “I’m going to try right here, is that okay?” If I miss the stick, I’ll say, “It doesn’t look like this one is going to work, is it okay if I try over here?” Stay professional and polite, and avoid placing blame on yourself or the patient.
Also, it’s always a good policy to ask the patient if it is okay to attempt a stick (or second stick).
Another mistake nurses make is that they will allow a missed vein experience to destroy their confidence, and this can be amplified if the nurse was scolded by a patient or fellow nurse. When I started out in nursing, I didn’t have a lot of experience starting IVs. I remember one time in particular. I had a sweet elderly patient in her 90s. Her son was there, and he was very protective of his mother.
When I walked in to start the IV, he looked at me, held up one finger and said, “You get one stick!” He didn’t say “Hi” or anything. It was just, “You get one stick!” I said, “okay.” It was very intimidating, especially because the patient had no visible veins at all and was dehydrated.
As I prepared my supplies, the patient’s son had my every move under a microscope, and he was watching me like a hawk.
Guess what happened? I missed the vein! It was a horrible feeling. So I went a got another nurse who was much more experienced. She came in, attempted the stick, and she missed on her first try, too.
However, the more experienced nurse had something that I didn’t have at the time: confidence. She knew should could get a stick, so she talked the patient’s son into letting her try one more time. He reluctantly agreed, and the nurse got the stick on her second try.
That taught me the importance of confidence. There are times when you will miss a vein, but you’ve got to be confident that you can get a stick on the patient.
Be Aware of Your Nursing Protocols
That leads me to an important thing that you’ll want to remember: Some facilities have protocols in place for the number of attempts each nurse can have when starting an IV. For example, some hospitals limit nurses to two attempts, and if they aren’t successful on those two attempts, they must get another nurse to try.
Therefore, you’ll want to familiarize yourself with your facility’s protocols.
Evaluate Why You Keep Missing Veins
We all miss veins from time to time. However, if you find that you miss veins often, you might want to step back and evaluate the situation. Here are some common reasons:
- Tourniquet is too tight. Perhaps you keep blowing veins because you are placing the tourniquet too tightly on the arm. If that’s the case, you might need to reduce your pressure. When the vein is under a lot of pressure and you stick it, it can cause the vein to blow, much in the same way that a balloon blows when it is blown up and pricked with a needle. On some patients, you might not even need a tourniquet at all.
- Needle gauge wont fit in vein. If you are using a gauge that is too big for the vein you selected, that will cause you to miss your stick as well.
- You aren’t advancing the needle after blood return. Another big problem that new nurses have is that many will forget to push the IV needle in about 2-3mm more (about the width of a nickel) after they see blood return. If you fail to do that, you will have issues threading the cannula into the vein, and it could cause a failed stick.
- Veins are rolling. If the veins roll, which is common on the hand, tell the patient to make a fist, and pull down on the vein (an inch or two below the insertion point) when you go to stick. That will help steady the vein and prevent the vein from rolling.
Learn Tricks to Find Veins
On the other hand, you might be having trouble finding a vein to stick in the first place. If that’s the case, I’d recommend practicing palpating every vein you can to practice! Use family members or yourself. Apply a tourniquet, and feel with your fingers so that you can get an idea of what those veins feel like, and practice finding them by feeling only. They are very bouncy and squishy, and they feel different than the rest of the surrounding tissue when palpating.
In addition, look at some anatomy charts or find some athletic, fit people with very visible veins, and that will help you know where veins are typically found in the arm. For example, the antecubital fossa area of the arm is often a great place to find larger veins. The forearm and dorsum of the hand are also common areas to start an IV.
The Patient Has No Veins. What Should I Do?
While nurses love to see a patient with juicy, engorged veins, the truth is, many of our patients won’t have the best veins. This is especially true if you work with certain patient populations. Things like dehydration, renal failure, heart failure, older age, or extreme obesity can make it all but impossible to find a decent vein to stick on a patient.
So what should you do if you can’t even find a vein by sight or palpation? Below are a some common tricks of the nursing trade:
- Ask the patient if they have a preferred vein. Some patients know they don’t have the best veins, and they will even say something like, “I’m a hard stick. Nurses never get it on the first try.” Ask the patient if they have a preferred area to stick, or if they have a vein that typically works well.
- Place a tourniquet on the arm, dangle it down, and have the patient pump the fist. This can allow the veins to come closer to the surface and expand. However, you do not want the patient to pump the hand if you are drawing labs, as pumping can alter lab values and ruin the test results.
- Use warming blankets or a warm compress. By placing warm blankets or a warm compress on the patient’s arm or hand, it can allow those veins to warm up, expand, and become much more superficial.
- Use a vein light. There are many types of vein lights available, and these devices will illuminate the veins on the arm, allowing nurses or phlebotomists to locate the veins.
- Use ultrasound. While not all nurses will have this option available, I’ve worked at facilities that would allow ultrasound to come up, ultrasound the patient’s arm to find a vein, and start the IV for us.
- Start the IV in a “non-traditional” location. There are times when I have had patients with nothing to stick in the traditional areas due to extreme recreational drug usage, which destroyed the patient’s veins. In those cases, I had to go in a non-traditional route, such as the foot. I’ve seen some IVs started in the chest or other areas, too. However, you will likely need to get approval from a doctor before starting an IV in a non-traditional area such as the foot, so check your facility’s protocols before attempting it.
- Use a central line. While central lines are a bit more invasive and not always ideal, they can be an option for a patient with no available veins, if allowed.
If you’re struggling with starting IVs or finding veins, I have a whole IV video series that can help you.
Never Give Up
It can be a very discouraging experience to miss a vein. And if a patient says something cruel such as “you don’t know what you are doing,” it can be absolutely devastating and traumatizing to the nurse. Some nurses even get bullied or mocked by their peers if they struggle to start an IV.
However, I just want to encourage nurses, phlebotomists, and other healthcare professionals who are struggling with starting IVs or drawing blood. This is a skill that takes practice. No one is born knowing how to start IVs and find veins. You have to practice, practice, practice.
Therefore, even if you aren’t the best at starting IVs right now, you can become the IV guru on your floor over time. And while there is nothing wrong with getting a more seasoned nurse to help you with an IV after a few failed sticks, you don’t want to be the nurse who constantly asks other nurses to start their IVs for them. There will be times when you’ll need to start an IV on your patient because they need a medication immediately, and no other nurses will be available to help you.
Therefore, you don’t need to give up. Keep practicing your needle stick skills, and you will get better and better. I promise. If you have a bad experience or someone tells you that you’re a horrible nurse, let it roll off of you. Before you know it, you’ll be the person that new nurses come to when they miss the vein!