If you want a truly comprehensive course on exactly how to start an IV with lots of full-length examples, check out my IV Video Course.
In this post I’d like to compile some of what you can find on my Instagram (@theivguy) and YouTube accounts into a mini-guide on how to insert an IV from start to finish.
Selecting an IV catheter
The size of IV catheter is mostly dictated by the ordered therapy, though the basis of needle selection is to use the SMALLEST catheter for the ordered therapy. Larger IVs have a higher chance of causing mechanical phlebitis. If you need large amounts of fluid or rapid transfusions, a larger bore IV will be necessary. An 18 or 20 gauge will likely be adequate, though larger IVs can be useful in emergency situations. If the therapy is simple IV antibiotics, routine blood transfusions, or a bolus of up to 2L/hour, a 22 gauge will work just fine. I try to stress the importance of using the smallest IV, but if you anticipate the patient needing emergency intervention, a 20 gauge or larger might be best.
Placing a tourniquet
Everyone does this slightly different, so do what works for you. What we’re trying to accomplish with tourniquet application is to restrict venous return while not effecting arterial flow. That means it has to be fairly tight, but not excessive.
Place your tourniquet behind the patient’s arm and hold one end while stretching the other end tight. Grasp that end, then stretch the other side tight and tuck it under the opposite end from the top down, which will keep the tails of your tourniquet out of your prepped site. This is where quality video comes in, as simply reading a description like that probably won’t work for most people.
If the patient is obese or edematous, a double tourniquet or blood pressure cuff inflated just below the patient’s diastolic blood pressure might work best.
Finding a vein
Palpation is the name of the game. Once you have your tourniquet in place, you can start palpating. Most people describe finding a vein as “feeling for a bounce”, which is really just a collapse and rebound in the tissue under the pressure of your finger. Search all areas in the hands, forearms, and AC, and trace each vein proximally and distally. This will give you a good sense of which direction the vein is running. You should also note the depth and thickness of the vein you choose in your mind.
Selecting a vein
Select a vein appropriate for your ordered therapy. If you simply have antibiotics or continuous fluids, choose a location away from areas of flexion so the IV doesn’t become occluded when the patient bends their arm (incessant beeping will drive anyone insane). If you need a larger IV for rapid infusions, the AC may be the most appropriate.
Prepping the site
Once you’ve selected a site, find landmarks on the skin so you can remember where the vein is once you’ve prepped the area. A freckle, mole, scar, tattoo, or patch of hair will all work. You can also place a sterile alcohol pad with the corner pointing to the entry point of the vein before prepping (more examples in the full course). Then release your tourniquet.
The skin prep of choice is chlorhexidine gluconate in alcohol. This solution kills existing bacteria on the skin and actually prevents future growth of bacteria once the site is prepped. Crack the applicator and scrub the site in an up-and-down, side-to-side motion for 30 seconds, then let it air dry or wipe the insertion site with a sterile gauze pad, being careful not to drag bacteria from non-prepped skin into your prepped site.
Prepping your supplies
Flush your IV extension tubing with saline to remove the air, fold over a tab on your transparent dressing to make it easier to open when the time comes, and have tape, gauze, and extra supplies available in case you need to make a second attempt.
Insert the IV
Reapply your tourniquet, uncap your needle, and release the catheter adhesion by twisting the hub of the catheter (rather than pulling it off and on which can cause catheter shear).
Anchor the vein by pulling the skin below and next to your selected site downward, stretching the vein slightly without occluding it.
Insert your needle, bevel up, at 30 degrees or less. Try to insert it as swiftly as you can to the depth you felt the vein to be during palpation. This will lessen pain and cause fewer blown veins, though it can take some practice.
Once you see flash, pause, lower your angle of insertion, then advance the needle another 2-6mm, then thread the catheter.
Remove your tourniquet, perform a tamponade at the end of the catheter if you’re using an open system, and activate your safety.
Hook up your extension tubing with saline flush, draw back to check for blood return, then flush the IV.
Secure the IV
IV securement can be done a million different ways, but this is one way to do it if all you have is tape and a transparent dressing, ie tegaderm (and an alert/oriented patient). I demonstrate a few more methods of securement in the video course using various all-in-one securement devices and combinations of tegaderm and statlocks. First, apply your transparent dressing over the IV starting just below where the IV extension tubing connects to the catheter hub. There should be nothing under the tegaderm (if there’s gauze, the dressing should be changed at least every 48 hours due to the increased chance of infection). Next, place a strip of tape over the extension tubing just under the hub connection, pinching the tape together underneath in order to elevate it off the skin slightly. Loop the tubing upwards and place another strip of tape near the needleless connector in the same fashion, taping across the hub while leaving the insertion site visible for assessment. Taping like this ensures the IV catheter sits at the angle of insertion while decreasing movement and pressure on the skin, preventing skin breakdown.
Make sure to initial, time, and date your dressing, then chart accordingly.
That’s it! Again, if you want more detail and lots more examples, check out The IV Video Course!
If you’re a nursing student and want more detailed nursing skill tutorials beyond IV insertion, check out SimpleNursing’s Nursing School Support resources to help you excel in nursing school!