Why do you choose to start IVs in certain veins

Esme12, ASN, BSN, RN · Oct 9, 2013

Well technically she was wrong....you should always start low and work your way up the arm. Many patients do not like hand IV's for they do hurt and can be cumbersome for the patient.

You choose your IV's by which vein can you stick....and what medicine is going into them. If it is caustic or have to use for blood you choose the best vein that is large.

Sometimes tou just have to stick what's available.

**NICU Guy, BSN, RN** · Oct 9, 2013

Preferably avoid the ante cubical, even though it big (my first choice in EMS). The floor nurses will hate you because every time the patient bends their arm, the IV will occlude and the pump alarm will go off. Ideally, top of hand or forearm is the best place.

IVRUS, BSN, RN · Oct 9, 2013

I agree with Esme,

Start looking distally and then work your way up the forearm. If you start in the Forearm and "blow-it" you can't go back to the hand.

However, hand veins in the elderly may not always be the best option. You see, as we age, we loose SQ tissue, this SQ tissue used to support the metacarpal veins. Once its thinned these veins become very fragile and blow easily when access is attempted.

Also avoid the median antebrachial veins (Those on the underside of the wrist) though these vessels may be soft and quite palpable, the epidermis is very thin there and the nerves of the brachial plexus are plentiful.

Also what is the medication that will be infusing... If it is a vesicant, like Vancomycin, you'll want the smallest gauge IV catheter in the largest vessel of the arm, that isn't near an area of flexion.

Hope that helps.

ChristineN, BSN, RN · Oct 9, 2013

Preferably avoid the ante cubical even though it big (my first choice in EMS). The floor nurses will hate you because every time the patient bends their arm, the IV will occlude and the pump alarm will go off. Ideally, top of hand or forearm is the best place.[/quote']
Actually sometimes you NEED a AC or higher. If you are getting a CT with contrast (especially a PE protocol) the PIV must be a 20 above the forearm. So, while I know it isn't a floor nurse's favorite spot, there are many times when a pt comes in with chest pain or SOB that myself and my ER collogues will make a point of trying to get that AC.

ChristineN, BSN, RN · Oct 9, 2013

I tried to start on IV today and I was preparing to stick the hand veins. However, my nurse told me to start on the forearm.
What do you consider when choosing a vein for IV? Type of solution/continuous vs. intermittent infusion/other factors? Why not start IVs on the hand if the veins are visible/palpable instead of going to forearm or other areas?

If a person has lots of veins, the forearm is a good spot cause it won't hurt as much as a hand, and no risk of occlusion like the AC. However, many pts I see are chronic pts that do not have many easy to find veins so I have to take what I can get. Remember in someone that is a hard stick, any access is good. Sometimes if you are having a really hard time finding a vein in the arm, then I will look in the hand since they can be a bit easier to feel, but I try not to make the hand my first choice.

hodgieRN · Oct 9, 2013

Consider the size of the vein b/c medications can burn and veins can blow. If you have to give IV potassium, the higher up the arm, the less it will burn. Veins become thicker as you move up. Hands will burn more than AC's. Hand IV's can become dislodged easily since pt's obviously use their hands. Forearms will stop the pump from beeping. Never forget that you can use the upper arm. You may find that there's nothing AC or below and find a pipe right on top of the bicep. Plus, you'd be surprised that people do draw blood from the forearm with fluids running through the hand. If it is higher, than there's less of a chance for that mistake. Lastly, different spots hurt more than others. Top of the hand can hurt. So can the inner forearm and the wrist. A pt may tell you that you only get one chance, and your only option is to go for the sure thing in the AC. It all depends.

KelRN215, BSN, RN · Oct 10, 2013

Actually sometimes you NEED a AC or higher. If you are getting a CT with contrast (especially a PE protocol) the PIV must be a 20 above the forearm. So, while I know it isn't a floor nurse's favorite spot, there are many times when a pt comes in with chest pain or SOB that myself and my ER collogues will make a point of trying to get that AC.

This must be facility-specific because I've never heard of such a thing... and that sounds IMPOSSIBLE in pediatrics.

SaoirseRN · Oct 10, 2013

If an IV is going to be staying in for a few days, particularly if it will be infusing fluids and not just for intermittent use, I will often skip the hands and go for a forearm vein, too. Hands get used, sites get irritated because they are always moving, can be positional, catch on things, get wet when hands are washed, and in many people, stop working for one reason or another before they are actually due to be resited.

This may be where your nurse was coming from. Yes, ideally we start as distally as possible, but most of the time I'll pick a good forearm vein (forearms don't move like hands!) and insert the IV as distally as possible.

Alternately, when someone needs a site for a single treatment (iron, IVIG), I will use the hand almost always unless they haven't a good option there.

SaoirseRN · Oct 10, 2013

This must be facility-specific because I've never heard of such a thing... and that sounds IMPOSSIBLE in pediatrics.

Our facility sometimes requests ACF sites for CT scans too.

The facility where we send our angiography patients also requests IVs in the forearm, not the hand unless it is the only access available.

applesxoranges, BSN, RN · Oct 10, 2013

I usually pick opposite dominant hand and in the forearm when there is little risk of them getting a chest CT to r/o PE. Our facility requires an 18 in the AC for the r/o PE chest CTs. Our facility wants the 18s because something about the dye wasn't being injected fast enough sometimes with the 20s or if it was lower than the AC.

You also have to think about the usage too. If it is their right hand and they are using it and getting tangled up in the IV wires, that would be annoying. In the forearm but not the AC you still have some usage. If it is necessary or just for a short time, we use the hands, wrists, or whatever we can find.

classicdame, MSN, EdD · Oct 10, 2013

1. What is the purpose of the IV? Am I giving fluids, medication with high/low viscosity/blood products?

2. Viscous meds, low Ph meds, blood products need bigger catheter and bigger vein

3. Phenergan does not go into the hand. Period.

4. How long do I expect the IV to be used? Bigger veins for longer periods.

5. Will the IV placement interfere with a procedure or patient's ADL's (I hate it when someone places IV in baby's antecubital space as baby keeps arm flexed and IV will not flow).