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    On the road to successful I.V. startsOriginal manuscript by DORIS A. MILLAM, RN, CRNI, MSI.V. Therapy Consultant and EducatorI.V. Therapy Resources, Glenview, Ill.1992

    Revised manuscript by LYNN C. HADAWAY, RN,C, CRNI, MEdLynn Hadaway Associates, Inc., Milner, Ga.2003

    A supplement to Nursing2003

    Volume 33, Supplement 1

    May 2003

    Supported by an unrestricted educational grant from BD Medical Systems, Infusion Therapy



    C E

    Expert clinicians share tips and insights based on 35 yearsexperience performing and teaching venipuncture techniques.

    Performing venipuncture and starting intravenous (I.V.) infusionsare among the most challenging clinical skills youll ever have tomaster. Yet few nursing schools offer enough hands-on learning,and hospitals typically provide only limited opportunities forsupervised practice.

    If you work in a busy hospital, you can understand why. For anexperienced practitioner, its quicker and easier to performvenipuncture than to coach a less-experienced nurse through theprocedure and provide feedback. So the less-experienced nursenever develops the skills to perform venipuncture confidentlyunder all kinds of conditionswhich can cause frustration and

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    needless pain for patients. If all this sounds familiar, this special guide will

    help you increase your knowledge and critical think-ing. Use it along with other opportunities to learn.Courses via the Internet, traditional classroom instruc-tion, laboratory practice sessions using anatomic train-ing arms, and working with clinical preceptors canhelp build your confidence. To become truly profi-cient, however, you must perform many procedureson real patients.

    The learning process will also involve practicing onall types of arm sites. Veins that are easily seen andpalpated wont always be available, so you must learnto cannulate more difficult sites too. In the followingpages, well show you how.

    Your employer must determine that youre compe-tent to perform these procedures before you workindependently. This process usually involves workingunder the supervision of a clinical preceptor or a moreexperienced colleague who likes to teach others.Check the processes outlined in the policies whereyou work to determine how you must demonstratecompetency and what procedures must be included.This may be limited to venipuncture but it couldinclude medication administration, use of electronicinfusion pumps, and blood administration. Begin byworking with patients who are well hydrated withoutchronic diseases or a history of many courses of infu-sion therapy.

    As you work to improve your skills, youre boundto have a few failures. If you make two unsuccessfulvenipuncture attempts, dont persist on a patient. Callin the I.V. team (if available), a nurse whos moreskilled at venipuncture, or an anesthesia provider forhelp.

    Dont let a few setbacks discourage you. With prac-tice, you can refine your venipuncture skills. Thencontinue using them to keep them current.

    SELECTING A VEINWhen choosing an appropriate vein for venipuncture,youll consider many factors, including: the patients medical history his age, size, general condition, and level of physicalactivity the condition of his veins the type of I.V. fluid or medication to be infused the expected duration of I.V. therapy your skill at venipuncture.

    If therapy is likely to continue beyond a week, con-tact the I.V. team or vascular access resource group toassess the patient for a midline catheter or peripherallyinserted central catheter (PICC). Consider the charac-teristics of the therapy, such as the osmolarity and pH,and the length of time therapy will be required. Shortperipheral catheters are indicated when the therapy

    lasts 5 to 7 days, when the fluids and medicationshave a pH between 5 and 9, and when the osmolarityis less than 500 mOsm/liter.

    If therapy is expected to last less than a week, youllwant to start with the most distal location availableand move up as necessary. Use of hand veins, how-ever, requires a careful assessment of the therapy andother factors. You should also rotate from one extremi-ty to the other. By thinking out cannula placementahead of time, you can head off problems during ther-apy.

    To learn more about the veins most commonly usedfor I.V. starts, see Mapping Out a Plan.

    Exploring the optionsFor most adults, veins in the hand may be your firstchoice. Starting with the patients hand, preferably thenondominant one, leaves more proximal sites avail-able for subsequent venipunctures. But you shouldntuse hand veins in elderly patients whove lost subcuta-neous tissue surrounding the veins or in patientswholl be getting in and out of bed frequently or per-forming other activities with their hands. Infusion ofvesicant medications into hand veins is also con-traindicated. Vesicant medications cause tissue necro-sis, which could result in loss of hand function fromdamage to tendons and ligaments. Sites in the handrequire support on a handboard to reduce vein irrita-tion, but this can limit patient mobility.

    Veins in the fingers and thumb may be easily visiblewhen a tourniquet is placed; however, they are proneto complications and cant support a catheter for longperiods. They have a smaller diameter, which allowslittle or no blood flow around the catheter. Themotion of the finger can lead to phlebitis, infiltration,and subsequent tissue damage. If these veins are theonly sites you find, ask another nurse to assess yourpatient.

    Most adults have many venipuncture sites on bothsides of the forearm. Using these veins is usually agood option for short-term I.V. therapy because handand arm mobility arent restricted. This is especiallytrue for patients in home care or those who are usingcrutches or a walker.

    A patients weight can also be a factor in your choiceof forearm veins. In an obese patient, for example, youmay not be able to see veins in the forearm. You maybe able to palpate a healthy vein by knowing the typi-cal locations.

    Veins in the antecubital fossa and above shouldntbe used routinely for insertion of peripheral catheters.These sites may limit the patients range of motion,interfere with blood sampling, and prevent the use ofthese veins for midline and PICC insertions.

    Starting at a distal site and making subsequentvenipunctures proximal to the previous sites is crucial.

  • The large upper cephalic vein lies above the antecubitalspace and is often difficult to visualize and stabilize. Itcan accommodate 22- to 16-gauge catheters, but itshould be reserved for a midline catheter orperipherally inserted central catheter.

    The accessory cephalic vein branchingoff the cephalic vein is located on thetop of the forearm. Medium- to large-sized, its easy to stabilize and canaccommodate 22- to 18-gaugecatheters. However, the catheter tipshouldnt be placed in the bend ofthe arm.

    The median vein of the forearmoriginates in the palm of the hand,extends along the underside of thearm, and empties into the basilicvein or median cubital vein. Thisvessel is medium-sized and easyto stabilize and can accommo-date 24- to 20-gauge catheters.

    The median cubital vein lies inthe antecubital fossa. This site isgenerally used to draw bloodand to place a midline or periph-erally inserted central catheter. Ashort peripheral catheter in thissite limits mobility, and I.V. com-plications, especially infiltration,are difficult to detect in this area.An I.V.-related complication heremeans that the veins below thissite cant be used.

    The basilic vein lies along the medial (little fin-ger) side of the arm. Large and easy to see, itrolls and is difficult to stabilize. Often ignoredbecause its location makes it difficult to workwith, it can accommodate 22- to 16-gaugecatheters. Increase your success with this vein byplacing the patients arm across his chest andstanding on the opposite side of the bed to per-form the venipuncture.

    The cephalic vein, lying along the lateral (thumb) sideof the arm, is large and easy to access. Accommodating22- to 16-gauge catheters, its an excellent choice for

    infusing chemically irritating solutions and blood prod-ucts. Because the radial nerve is close to this vein,

    venipuncture can be done several centimetersproximal to the wrist, but not in the wrist.

    The metacarpal anddorsal veins on top ofthe hand are good sitesto begin I.V. therapy insome patients. Easily visual-ized, they can accommodate24- to 20-gauge catheters.Dont use this site for vesicantmedications.

    MAPPING OUT A PLANBecome familiar with the veins most commonly used for I.V. line starts.


  • When a complication develops at a proximal site, youwont be able to use veins distal to this site because thefluids and medication will infuse into the damagedsite, compounding the problem.

    Avoid these sitesVeins in all aspects of the wrist shouldnt be used forvenipuncture because of their close proximity tonerves. Besides the risk of causing pain, preventingmovement at these sites may be impossible, increasingthe risk of complications.

    Although used in infants, veins of the legs, feet, andankles shouldnt be used in adults. The superficial

    veins of the lower extremity have many connectionswith the deep veins. Catheter complications can leadto thrombophlebitis, deep vein thrombosis, andembolism. If required during an emergent situation,the dorsum of the foot and the saphenous vein of theankle are sites of choice. You can stabilize a foot veinby asking the patient to point the foot toward the endof the bed, then use the same stretching techniqueyoud use to stabilize a hand vein. Catheters in thelower extremity should be moved as soon as thepatient is stable.

    Other sites to avoid include: veins below a previous I.V. infi