Is this true?

  1. Hello, I just saw this on another post and I am wondering if this is true? If so does anyone know where I can find an article or something to show our educator at the hospital? Every time I get an IV that is where they start it, and I have started several in this space as well. Thank you for any help!

    "7. Do not try to keep an IV in place if it hurting you, or is red or swollen so you will not have to be poked again. Do not let anyone poke you for an IV or blood draw in your wrist or 4-5 inches along the wrist on the thumb side (the radial nerve crosses over the vein in that area up to 3 times so it easy to hit and damage that nerve). Many people do not know this and do not realize that as of 2006 it is no longer acceptable to use this area unless it is a true emergency."
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  2. 16 Comments

  3. by   Rose_Queen
  4. by   MunoRN
    It's a stretch to say it's "no longer acceptable", that would suggest wide acceptance of some recommendations that at least so far are not well established. The Infusion Nursing Society does recommend that the hand and wrist should not be used, the AC should not be used, and that the 4-5 inches of the arm proximal to the wrist should not be used for IV sites, which only leaves a few inches above and below the AC as what it considers to be appropriate sites. While that's their recommendation, it hasn't come close to being accepted as the standard in practice.
  5. by   ccakes
    Wow MunoRN. I didn't know this. That doesn't leave much else places for an IV to go!!!
  6. by   IVRUS
    Quote from MunoRN
    It's a stretch to say it's "no longer acceptable", that would suggest wide acceptance of some recommendations that at least so far are not well established. The Infusion Nursing Society does recommend that the hand and wrist should not be used, the AC should not be used, and that the 4-5 inches of the arm proximal to the wrist should not be used for IV sites, which only leaves a few inches above and below the AC as what it considers to be appropriate sites. While that's their recommendation, it hasn't come close to being accepted as the standard in practice.
    Muno, Muno, Muno..... Why you have such an aversion to INS standards of practice, I'll never know!!! However, while INS Standards of Practice aren't mandatory, and aren't laws per se', they SHOULD be used to measure clinical practice both in and out of a court of law setting.
  7. by   RNinIN
    Quote from IVRUS
    Muno, Muno, Muno..... Why you have such an aversion to INS standards of practice, I'll never know!!! However, while INS Standards of Practice aren't mandatory, and aren't laws per se', they SHOULD be used to measure clinical practice both in and out of a court of law setting.
    The couple of inches left that are acceptable to INS are not always attainable. Muno never stated an aversion, just the facts and the realities
    Last edit by RNinIN on Nov 10, '15
  8. by   IVRUS
    Quote from RNinIN
    The couple of inches left that are acceptable to INS are not always attainable. Muno, never stated an aversion, just the facts and the realities
    ???????????????
  9. by   CountryMomma
    I'll be sure to inform the ED that the AC is off limits, despite the pt's obvious need for a few liters of blood/fluid expander. I'm sure placing an 18ga in the 3" of inner medial forearm they approve will be a snap in an unresponsive, obese DKA pt.

    I'm not a big fan of ACs in pts that aren't at risk of needing blood/bolus b/c they tend to occluded and just generally peev my pts off, but if that's what's available, its what I use.

    We'll completely overlook the requirement for at least a 20ga AC for power jet contrast injections, yes?
  10. by   IVRUS
    Quote from CountryMomma
    I'll be sure to inform the ED that the AC is off limits, despite the pt's obvious need for a few liters of blood/fluid expander. I'm sure placing an 18ga in the 3" of inner medial forearm they approve will be a snap in an unresponsive, obese DKA pt.

    I'm not a big fan of ACs in pts that aren't at risk of needing blood/bolus b/c they tend to occluded and just generally peev my pts off, but if that's what's available, its what I use.

    We'll completely overlook the requirement for at least a 20ga AC for power jet contrast injections, yes?
    Emergency nursing has a completely different set of objectives... However, that is why once a line has been placed in the ER, or even in a non-traditional setting like a MVA site, the IV catheter should be REPLACED within the first 24 hours after placement. What good is it to scrub really well at the site, and be especially pristine in your steps, if your pt is dead?
    And, yes, place a 20g for the CT scan if the patient does not have a power injectable Central line in.
  11. by   Asystole RN
    Quote from MunoRN
    It's a stretch to say it's "no longer acceptable", that would suggest wide acceptance of some recommendations that at least so far are not well established. The Infusion Nursing Society does recommend that the hand and wrist should not be used, the AC should not be used, and that the 4-5 inches of the arm proximal to the wrist should not be used for IV sites, which only leaves a few inches above and below the AC as what it considers to be appropriate sites. While that's their recommendation, it hasn't come close to being accepted as the standard in practice.
    I will post what the actual standard of practice is and no it is not a recommendation but published in the INS Standards of Practice, hence the name Standards of Practice. Granted, this is the standards set forth by a single organization but that organization is cited by most others in the formation their own standards.

    When the nurse goes to court or the board over something IV related I can about promise that the INS Standards of Practice will be referred to. I know this from personal, professional experience with both.


    33. SITE SELECTION

    Standard

    33.1 Site selection for all vascular access devices (VADs)
    shall be established in organizational policies, procedures,
    and/or practice guidelines.

    33.2 The vasculature shall accommodate the gauge and
    length of the catheter required for the prescribed therapy.

    33.3 Site selection for vascular access shall include assessment
    of the patient’s condition; age; diagnosis; comorbidities;
    condition of the vasculature at the insertion site and
    proximal to the intended insertion site; condition of skin at
    intended insertion site; history of previous venipunctures
    and access devices; type and duration of infusion therapy;
    and patient preference.

    33.4 Prior to insertion of a peripherally inserted central
    catheter (PICC), anatomical measurements shall be taken
    to determine the length of the catheter required to ensure
    full advancement of the catheter to the lower third of the
    superior vena cava and the junction of the superior vena
    cava and right atrium.

    33.5 Placement of central vascular access devices
    (CVADs) by nurses shall be established in organizational
    policies, procedures, and/or practice guidelines and in
    accordance with rules and regulations promulgated by the
    state’s Board of Nursing.


    Practice Criteria

    I. Peripheral Venous Access via Short
    Peripheral Catheters

    A. For adult patients, veins that should be considered
    for peripheral cannulation are those found on
    the dorsal and ventral surfaces of the upper extremities,
    including the metacarpal, cephalic, basilic, and
    median veins. Avoid the lateral surface of the wrist
    for approximately 4-5 inches because of the potential
    risk for nerve damage. For pediatric patients,
    similar veins to consider are in the hand, forearm,
    antecubital area, and upper arm below the axilla, as
    well as the veins of the scalp, foot, and fingers in
    infants and toddlers. For adult and pediatric
    patients: avoid the ventral surface of the wrist due to
    the pain on insertion and possible damage to the
    radial nerve.1-5 (V)

    B. Site selection should be initiated routinely in the distal
    areas of the upper extremities; subsequent cannulation
    should be made proximal to the previously
    cannulated site.3 (V)

    C. Site selection should be initiated routinely in the
    nondominant arm. VAD sites should avoid areas of
    flexion; areas of pain on palpation; veins that are
    compromised (eg, bruised, infiltrated, phlebitic, sclerosed,
    or corded); location of valves; and areas of
    planned procedures. In infants and children, avoid
    the hand or fingers, or the thumb/finger used for
    sucking.2,3,6,7 (V)

    D. Veins of the lower extremities should not be used
    routinely in the adult population due to risk of
    tissue damage, thrombophlebitis, and ulceration.2
    (I A/P)

    E. Veins in an upper extremity should be avoided on
    the side of breast surgery with axillary node dissection,
    after radiation therapy to that side, or with lymphedema,
    or the affected extremity from a cerebrovascular
    accident. For patients with chronic kidney
    disease stage 4 or 5, avoid forearm and upperarm
    veins “suitable for placement of vascular
    access.” A collaborative discussion with the patient
    and the licensed independent practitioner (LIP)
    should take place related to the benefits and risks of
    using a vein in an affected extremity.3,6,8-12 (V)

    F. Veins in the right arm of infants and children
    should be avoided after procedures treating congenital
    cardiac defects that may have decreased blood
    flow to the subclavian artery.13 (V)
    G. Cannulation of hemodialysis fistulas and grafts
    for infusion therapy requires the order of a
    nephrologist or LIP.3 (V)

    H. The nurse should consider using visualization
    technologies that aid in vein identification and
    selection.3,14(V)
    Last edit by Asystole RN on Nov 11, '15
  12. by   Asystole RN
    Quote from CountryMomma
    I'll be sure to inform the ED that the AC is off limits, despite the pt's obvious need for a few liters of blood/fluid expander. I'm sure placing an 18ga in the 3" of inner medial forearm they approve will be a snap in an unresponsive, obese DKA pt.

    I'm not a big fan of ACs in pts that aren't at risk of needing blood/bolus b/c they tend to occluded and just generally peev my pts off, but if that's what's available, its what I use.

    We'll completely overlook the requirement for at least a 20ga AC for power jet contrast injections, yes?
    Avoiding areas of flexion sounds reasonable to me.

    What everyone is getting confused about is the Standards v. Practice Criteria. The standard is the Standard, the practice criteria is basically a guide of how to implement the Standard.

    In this situation the standard is to assess for the best placement depending upon a multitude of factors. To guide you in what is appropriate...it is best to avoid putting a catheter in a known troubled location. The standard doesn't say no, it says to assess the situation.

    Reasonable, no?
    Last edit by Asystole RN on Nov 11, '15
  13. by   MikeyT-c-IV
    There is a ton of evidence, now, that tells us which sites are appropriate and which sites are not. I don't care. Get your access and initiate whatever care is necessary. But PLEASE call me in the morning to access the most appropriate site / device for care.
  14. by   jdub6
    Quote from IVRUS
    Muno, Muno, Muno..... Why you have such an aversion to INS standards of practice, I'll never know!!! However, while INS Standards of Practice aren't mandatory, and aren't laws per se', they SHOULD be used to measure clinical practice both in and out of a court of law setting.
    So, with that said-and this is a serious question-where do you place your PIVs then? I'm assuming as an IV therapist you see plenty of pts with less than ideal veins. So take those same pts and now assume you're not the IV nurse who is trained and authorized to use ultrasound and place PICCs and other tricks. You're now a floor or ED nurse getting an admission needing peripheral access ASAP. Can you list your go-to spots that you look at?

    And if the only available sites are in places like the AC or that "interns vein" of the wrist, would you use them? Say you can't get anything in your ideal spots but can get a perfectly respectable 18 or 20 in the "bad" spots, what would you do as a floor nurse? Place the PIV and start the blood/ fluid/ antibiotic or tell the MD you can't and ask for a PICC-or place it and tell the MD that even though you have a PIV that's working you want a PICC due to the site you had to place the peripheral?

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