Starting IVs

The common rule of thumb is to start low and work your way up, yes. I never start in the hand though, as there are too many nerves to hit, and many medications should not be pushed through hand veins. Hands are usually a last ditch effort for me. I usually start in the low forearm if there is no indication for a more major vein like the antecubital (administration of certain meds such as Phenergan or potassium, PE studies, etc), and work my way up to even shoulders or subclavicular peripheral lines if needed. You don't necessarily have to start low and work up, but if you blow a vein at any point, you shouldn't try to start at a lower point on the same vein. As for what causes veins to blow, there are many factors (increased pressure from a tied tourniquet, baseline high venous pressure, little fragile Gramma veins), and the list goes on and on.

Fantastic answer, PsychNP! I definitely learned some new things from it. Thanks!

PsychNP is right, but in the ideal world of IV's

In the real world of IV's....I have given phenergan through a 24 gauge IV placed in a finger of an adult! They were an IVDA it was an out patient procedure. Back in the old days when phenergan was not such a black box drug. It worked fine.

Where an IV goes depends on why the patient needs it and who is placing the IV.

A new nurse gaining her skills and confidence in IV's under "normal" conditions should put the IV in the best, juciest, straightest, vein, (between the back of the hand and shoulder), that she can find. Where in her gut she feels like "this is a good one".

In a "normal" patient getting some LR and every 6 hours antibiotics, an IV in the hand is fine. If later on it develops that that patient needs a medication that requires a bigger vein they can have another IV placed.

If that patient becomes critically ill they can get another IV, they can get a PICC, get a central line, etc. by surgeons or an IV team.

The rationale behind starting distally and working proximally is that if you blow/damage a proximal vein (further up) then all veins communicating with that vein will run into that same clot/occlusion/injury. Therefore, whatever is being administered through that IV will not reach central circulation, OR could cause further harm if leaking into tissues (depends on what happened to that proximal vein).

You need to avoid the hands and wrist especially the volar wrist for any vesicants or any fluids or medications known to cause tissue damage.That is why it essential that you know what the IV will be used for.You should select the smallest and shortest cannula that will meet the need of the patient.In fact avoid the wrist area just above rhe thumb for about 4 to 5 inches.On autospy they have found it is very common for the nerve to cross over the vein up to 3 times. If infiltration /extravasation occurs here it can lead to permanent damage and chronic pain syndromes.

Brownbook,

I currently work in a busy ED where a majority of my population has destroyed most of their veins with IV drug use, so I hardly live in the ideal world of IVs. I have started IVs in thumbs, wrists, forearms, shoulders, EJs, breasts, and feet, wherever there may be a salvageable vein. However, I would never administer Phenergan (or any other potential vesicant) through an IV such as a 24 in a finger, because I've seen what it can do if it escapes into the peripheral tissues.

While I agree that the new nurse should go for the "juiciest, straightest," squishiest vein, unfortunately, in today's day and age, normal is most people having few to no veins to write home about. The new nurse should always go for the vein that she's almost certain s/he can hit, but s/he should always be aware that s/he may have to end up going where no nurse has gone before in the way of finding a vein.

I also will not administer some of the rougher antibiotics through the hand since they can be very irritating, and I don't like to poke people more than once if possible, so no, I won't just throw one in the hand now and try to find another one later if there are other viable options. Also, in my hospital, the PICC team is not available after 7pm, and we're often so busy with very sick patients that we may not be able to pull a physician from a room with a stroke, STEMI, OD, etc. in order to place a central line, and if we attempted to call a surgeon to place a CL, we'd get laughed at. Most of the time, in the ED, we ARE the IV team.