Selecting THE vein

Ideal vein selection reduces complications of infection, improved patient outcomes, positive patient experiences, and improves the efficiency of therapy of IV drugs and fluids.

Nursing Points

General

Prior to selecting a vein, consider the patient’s:
1. Current medical condition
  1. Edema
  2. Trauma
2. Previous medical history
3. Age
4. Physical attributes
  1. Height/Weight/BMI
  2. Body Hair
  3. Skin fragility
  4. Previous IV drug use
5. Anticipated needs
  1. Blood products
  2. Viscosity of fluids or drugs to be given

Assessment

Upper Extremities
1. Hands
  1. Dorsum (tops) of hands
    1. This location can be painful
    2. Avoid allowing the lumen of the catheter to end at the wrist
2. Forearms & Arms
  1. Cephalic veins (radial side)
  2. Basilic veins (ulnar side)
  3. Antecubital fossa (elbow)
    1. Usually a good site for emergency placement
    2. Can be deep
    3. Consider the compliance of the patient
      1. Frequent bending of the elbow can cause occlusion
  4. Bicep (cephalic vein)
    1. Good location for fit or lean patients
3. Shoulder
  1. Continuation of the cephalic vein
  2. Option for patients with severe peripheral edema
Lower Extremities
1. Feet
  1. Use with caution
    1. Consider the patient’s condition, facility policy, the difficulty of placement and compliance of the patient
  2. Dorsal venous plexus
    1. Any vein selection in the plexus
2. Lower legs
  1. Saphenous (inner side of leg)

Therapeutic Management

Ideal Vein Selection
1. Straight
2. Non-branching
3. Distal
Palpation
1. Use a tourniquet proximal to the ideal location
  1. Do not place tourniquet longer than 1-2 minutes during an assessment
2. Veins should feel spongy
3. Veins should not pulsate
4. Veins that feel hard are not ideal
  1. May be thrombosed
  2. May not cannulate well
Pro-Tips
1. Do not place in extremities of
  1. Previous mastectomy/lymphadenectomy
  2. AV fistula
  3. Compromised skin integrity
  4. Signs of infection
  5. DVT
2. Place in extremity that is non-dominant.

Nursing Concepts

Patient Education

Ask patient which hand or extremity is the dominant – place in other side
Educate patient not to move during insertion

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Transcript

All right guys. In this lesson we’re going to talk about vein selection. We always want to pick the best vein whenever possible and why do we do this? Well, the first one is always going to lead to more positive patient outcomes and this also means that using your critical thinking skills to figure out what’s needed for your patient, so is your patient going to need blood or contrast or are they going to need an intermittent infusion? This helps you to select the right location for it. Also, some situations tend to lead themselves to being better selection locations than others, so the first thing you want to do anytime you’re selecting a vein is you want to consider everything about your patient. You want to look at things like physical attributes. You want to see is the patient lean or are they baratric patients? Because that will change your vein selection up a little bit.
The other thing you want to look at is any past medical history. Does a patient have a higher likelihood of having maybe atherosclerotic veins where they’re a little bit tougher? Are they going to be at risk for other things like um, kidney disease where they have an AB fistula and maybe it can't go on one side.
These are the things you need to think about. The other things you need to think about are the current medical problems with the patient. Burn patients are really good examples of patients that you have to think about their anticipated needs because they’re going to need fluid resuscitation. So they’re going to need lots of fluids over a really short period of time. So putting a 22 in the hand is not going to be best for them. So you have to think about these things. Other things that you want to think about are, are they currently trauma patients?
Do they have a lot of significant edema? Because that’s going to change the location of the IV. So now let’s talk about locations. First, we’ll talk about the upper extremities. So the first location is the hand. There’s a lot of great veins in the hand, but there are certain things that you have to remember. Only certain gauges can go in the hands. And they’re also extremely painful. Try to avoid them if you can, but a lot of the times if you’re like in the emergency department and its the only option you have, then its the only option you have. One thing to remember when you do start IVs in the hands, you never want the lumen or the end of the catheter to end in the wrist. A lot of times there’s a lot of bending in the wrist and thats going to occlude the catheter and it is going to give you problems all day or night and it may actually compromise the integrity of the catheter.
Now we’re going to move onto the forearms and the arms. There are two prime locations that we look for. We look for the cephalic vein. The cephalic vein is going to be your friend and almost all of your locations because the cephalic vein actually begins here at the wrist and goes all the way up to the shoulder. So you’ll follow that and we’ll talk about it more in a second, but the cephalic vein is going to be a big, its most of the time its a big garden hose and its your first location, especially if your patients are fit and if they dont have any real complications. The next veins you want to consider are the basilic veins. They actually run on the underside of the arm. Thats another good location. It’s also a hidden secret. So I actually had one patient one time who unfortunately was a previous IV drug user, and she knew that the only thing that she could hit was the basilic vein on this side.
And sure enough, I didn’t have to stick her more than twice because I actually got it there. So that’s one thing to keep in mind. Now, the next vein that were going to talk about is the elbow, which we call the AC, which is the antecubital fossa, which actually starts here. Remember that cephalic vein goes here and it ends up right here. So that’s another good location. Its really frequently used in the emergency department because it's usually a big vein. It's usually readily accessible. There’s not a lot of trauma or problems that happen here and a lot of patients are easily cannulated there. One thing you want to keep in mind is if your patient is younger or if they have a tendency, a tendency to be noncompliant, wiggle or move their arms and that’s also going to include that vein and its going to cause a lot of problems for you. So just remind your patients, Hey keep you still, dont bend your elbow cause if not, you’re going to have your alarms going off all night. The next vein we’re going to talk about is a continuation of that. So cephalic, which goes up the bicep and end of the shoulder. In bariatric patients, I’ve often put them in the shoulders. So that's one thing that you consider, but its usually a higher and if it blows, you’re not going to have a good opportunity to be able to put another catheter in somewhere else down here. Now lets move on to the lower extremities. Now Im going to caution you. Best practice is that you do not put IVs in feet. However, I will say that in a practical application, sometimes it is your only option and if your patients option is to get an IV in the foot or they’re going to have some irreparable harm, Im always going to put the IV in the foot because my patients safety is my first concern.
So just use it in caution, especially with your diabetic patients or patients that have some sort of neuropathy in their feet where they can't feel because that puts them at a higher likelihood of having some sort of risk. The other thing that you want to consider with the feet is that they are also painful, so tops of hands and tops of feet. Theres something called the dorsal venous plexus which runs on the top of the foot and there's a lot of Wigley veins, so sometimes theyre a little bit more complicated. The next man I want to talk about is the greater saphenous vein. It's actually a continuation of that dorsal venous plexus that runs from the foot up into the lower leg. It's actually on the tibia side. It's usually a great vein, but just like with your diabetic neuropathic patients, sometimes they lose some of that sensation. So just be aware that when youre using lower extremities, sometimes they come with a little bit of risk.
So lets talk about the dos and don’ts of vein selection. You do want to do these three things. First you want to pick a vein that;s straight, thats going to give you fewer complications. The other thing you want to do is pick a vein that is non-branching. If you pick a vein that's not branching, youre going to have less likelihood of hitting valves and it's going to be easier to sit. And the third thing is you want to pick a vein thats most distal. Remember starting up here in the shoulder, even in a bariatric patient may not lend itself to be a better option. So the lower you can start, the better. So what do we not want to do? Well, the first thing that we dont want to do is we want to put, we dont want to put a peripheral IV on the side that has an incomplete or radical mastectomy. To me, that puts them at higher risk for complications. The other thing is you never want to put it in the same side thats had an AB fistula. You’d never want to put it on the side that has a DVT and you never want to put it in a location that looks infected. You’re just setting yourself up for complications. I hope that these tips have been really helpful and helping you select the right vein for your patient.
Now, as we always say, go out and be your best selves today. And as always, happy nursing.

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Outline

Overview

Nursing Points

General

Assessment

Therapeutic Management

Nursing Concepts

Patient Education

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