How To Start IVs In The Hand

[LibraNurse27, BSN, RN]

Hi all, does anyone have tips on starting IVs in the hand? At my new job they like IVs in the hand for certain procedures. In the hospital I worked they didn't like us to put IVs in the hands because of the nerve endings/pain and they usually didn't last long. One PICC nurse would be SO mad if she saw a hand or wrist IV. So, I am confident with forearm and AC IVs as long as it's not a super hard stick, but hands scare me! All I can see is use a lower angle, almost flush to the skin (like 5 degrees?) and stabilize well. Thanks for any advice!

[speedynurse, ADN, BSN, RN, EMT-P]

The best advice I can give is stabilize the vein. Pull the skin down tight so it doesn’t roll. I feel like 9 times out of 10 the difficulty with hand veins is they roll if you don’t stabilize. I did a LOT of ACs in the ER especially when I was in a rush or tired.....which was most of the time. In pre op, they don’t like ACs at all so I start most in the hand, wrist, or forearm.

[macawake, MSN]

When I place an IV catheter in the dorsal metacarpal veins I make sure to immobilize the vein by stretching the skin distal to the vein. The initial entry angle will vary a bit depending on the depth of the vein, but I will usually insert the stylet (bevel up) in a patient’s hand vein at about a 15 (to 20) degree angle. When I see blood return in the hub of the cannula I will advance the stylet slightly and then level off the angle so that it’s level with the patient’s skin and then advance the cannula until it’s all the way in. This works for me and the catheter will end up well within the lumen of the vein, but won’t transect/puncture through the back wall of the vein. (Disclaimer: English as a fourth language, so I hope I got the names for the different parts of the catheter right). 

The metacarpal veins are usually prominent and easy to visualize and aren’t located over a point of flexion but they sure do like to roll. I place the catheter so that the tip doesn’t extend over the wrist joint and so that the hub of the catheter doesn’t extend over the knuckles. 

I think the best thing for you to do, is to ask a coworker who’s skilled at IV insertions to demonstrate/explain in real life as it is a bit tricky to explain well over the internet ? 

Best wishes! 

[SmilingBluEyes]

There are some great Youtube videos. Plus you can ask the IV/PICC specialists in the sub forum here.

Stability is key!  That and a warm pack on the hand, and dangle it low. The veins fill nicely and are easier to see/feel and cannulate.

[LibraNurse27, BSN, RN]

@macawake you speak 4 languages?? wow! Now I'm curious which other languages you speak LOL and thanks everyone for the advice!!

[PsychNurse24, BSN, RN]

I did my preceptorship in same-day surgery at a hospital. We also were always supposed to start an IV in the hand and work up, if necessary.  A nurse there was famous for never missing a stick. He never used a tourniquet or stretched the skin.  He had the patient dangle his arm over the edge of the bed, used a warm pack, used a butterfly, sat back on his heels or kneeled so he was close to the patient’s hand and was very successful.  I could never quite duplicate that, but having the patient dangle his arm and using a warm pack helped me.  Good luck!

[DowntheRiver]

When I do hands, I like to have the patient make a fist and flex their wrist down. To me, this helps stabilize the vein. I'd also sit while doing them, lowering the seat to the lowest position so I could get up and close to them.  My other suggestions are the same as others - heat and dangling the arm for blood flow. 

[speedynurse, ADN, BSN, RN, EMT-P]

15 minutes ago, DowntheRiver said:

When I do hands, I like to have the patient make a fist and flex their wrist down. To me, this helps stabilize the vein. I'd also sit while doing them, lowering the seat to the lowest position so I could get up and close to them.  My other suggestions are the same as others - heat and dangling the arm for blood flow. 

This is very true - I have always had the patient hang their arm over the side of the bed because the vein fills up more.

[LibraNurse27, BSN, RN]

Thank you! I will try the fist and positioning techniques. They don't have hot packs but they do have warm blankets so I will wrap the arm in a warm blanket while I do the pre-op questions and eye drops (eye surgery clinic = )) Thank you so much! I'm nervous because some days I need to do 22 IVs in a row! The job is otherwise low stress so I'd like to keep it, but I know my IV skills need to be up to par. Confidence is key! Thanks again.

[PsychNurse24, BSN, RN]

Don’t worry, if you’re doing 22 IVs in a row you’re going to be a pro in no time at all!!  Will be asking you for tips!

[LibraNurse27, BSN, RN]

2 minutes ago, PsychNurse24 said:

Don’t worry, if you’re doing 22 IVs in a row you’re going to be a pro in no time at all!!  Will be asking you for tips!

LOL! I hope so! I am worried because by the end of my time in the hospital I was doing most of my IVs with the ultrasound (lot of IV drug users in our pt population). I wasn't the best like was good as the IV/PICC team, but they always said that's what they do all day, every day! Hopefully once a week will be enough to get good LOL thanks again!

[JayHanig]

On 2/26/2021 at 11:14 AM, speedynurse said:

 In pre op, they don’t like ACs at all so I start most in the hand, wrist, or forearm.

We didn't much care for IVs in the AC on the floors either.  They have a bad tendency to be highly positional.  Making the trip down the hall to reset the IVAC just because the patient bent his or her arm can get old in a hurry.