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A P of Peripheral Veins http//emprocedures.co
m/peripheralIV/introduction.htm

• Successful cannulation of a peripheral vein
  requires proper site selection, as well as
  knowledge of the gross anatomy of a vein.

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Anatomy of a Vein

•   Anatomy of a Vein Potential IV Sites
• Anatomy of a Vein Veins are thin
  walled-structures that lack the thick,
  circumferential smooth muscular layer that is
  present in arteries. As such, peripheral veins
  may collapse and may be difficult to cannulate
  (or even locate) in patients with hypovolemia,
  low blood pressure, . Common causes of
  hypovolemia?
• Venous return to the heart is dependent upon
  contraction of regional skeletal muscle (e.g. the
  gastrocnemius and soleus in the lower leg.)
  Additionally, many veins contain valves that
  prevent retrograde flow of blood. ( Moore, KL) If
  the intravenous catheter abuts one of these
  valves, flow of intravenous solution may be
  occluded. (Similiarly, valves can interfere with
  phlebotomy.) Client is valvey

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Artery vs. Vein
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• General Concepts
• The identification of the optimal site involves
  both visual and tactile exploration. The vein may
  be visible as a blue-green subcutaneous
  structure. It may pop out as it engorges with
  blood or merely be palpable as a springy canal
  coursing between the soft tissues. Given the wide
  variation in anatomic location of superificial
  veins, purely "blind" attempts, without visual or
  palpable landmarks, are highly unlikely to be
  successful and should be discouraged except in
  emergent situations.
• Ideally target a good sized vein with a straight
  segment at least the length of the catheter. For
  elective placement, site consideration should
  include
• Ease of access
• Use of the non-dominant extremity
• Avoiding joint areas
• Avoiding use of the lower extremities

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Contraindications

Pre-existing Vascular Compromise Lymphatic or venous drainage has been compromised, i.e. lymph node dissection accompanying mastectomy, A-V fistulas, injured extremities,
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Upper ExtremityIn most situations, intravenous
catheters are inserted in the antecubital fossa,
the forearm, the wrist, or the dorsum of the
hand.

• The three main veins of the antecubital fossa
  (the cephalic, basilic, and median cubital) are
  frequently used. These veins are usually large,
  easy to find, and accomodating of larger IV
  catheters. Thus, they are ideal sites when large
  amounts of fluids must be administered. However,
  their location in a flexor region is a drawback,
  as bending of the elbow can be uncomfortable to
  the patient and may occlude the flow of the
  intravenous solution. Cannulation of the
  cephalic, basilic, or other unnamed veins of the
  forearm is preferrable

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Veins of the forearm
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Veins of the hand

• The veins in the dorsal hand may be utilized if
  large bore access (18 gauge or larger) is not
  required. Care must be taken to find a vein that
  is straight and will accept the entire length of
  the catheter.
•  
• The portion of the cephalic vein in the region of
  the radial styloid is commonly known as the
  "student's" or "intern's" vein, as it is often a
  large, straight vein that is easy to cannulate

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Veins of the hand
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Veins of the feet

• Cannulation of the veins of the feet is not
  ideal. ADD REFERENCES Insertion can be
  quite painful, and the catheter may cause more
  discomfort than if it were started in the hand or
  forearm. Additionally, IV catheters placed in the
  feet are more likely to become infected, to not
  flow properly, and are more likely to produce
  phlebitis.
•  
• The great saphenous vein runs anteriorly to the
  medial malleolus, and may be accessed via a
  peripheral venous cutdown in emergent situations.
  The lesser saphenous vein runs along the lateral
  aspect of the foot. These two veins converge
  medially to form the dorsal venous arch. There
  are numerous unnamed vessels that are branches of
  these veins. (Clemente) Any vein in the foot
  large enough to accept the IV catheter may be
  used if necessary.

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Veins of the feet
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External Jugular Not to be cannulated by LPN

• The external jugular ("EJ") vein can be
  cannulated if necessary. It orginates near the
  angle of the mandible, and courses over the
  sternocleidomastiod muscle. Proximal to the
  clavicle, the EJ dives into the subcutaneous
  tissue, eventually emptying into the subclavian
  vein. (Moore)
• The EJ is a large vein that can accomodate a
  large bore IV catheter (18 gauge or larger), in
  most patients. It is especially useful in
  patients with poor access in the arms who require
  a large volume of fluid. Additionally, the EJ is
  often engorged in patients with heart failure and
  provides an alternative in these patients if
  other venous access sites are not available.
  Please refer to the Alternatives section for
  further discussion on utilizing the external
  jugular vein

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External Jugular Vein
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A little bit of info

• Peripheral intravenous (IV) catheter placement
  and phlebotomy are arguably the most commonly
  performed procedures in medicine, performed on
  over 25 million patients each year in US
  hospitals. (Soifer 1998). This skill should be a
  part of the basic skill set of any health care
  provider. Phlebotomy is simply drawing blood. IV
  catheterization allows blood sampling as well as
  ongoing direct access into the circulating
  bloodstream. The fundamental techniques are the
  same. As commonplace as these procedures are,
  however, they are not entirely without
  complications, local and systemic.

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Your patient needs an iv now what

• You need a doctors order for IV fluids and
  placement.
• Order must contain date/time, infusate name,
  route of administration, volume to be infused,
  rate of infusion, duration of infusion, physical
  signature.
• Never place an IV into the arm of a patient with
  a AV fistula or graft.
• Avoid extremities which are flaccid or contracted
  
• Avoid the arms on the side of recent mastectomy
  or axillary nodal removal

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For IV site selection consider the following

• Primary medical diagnosis
• Chronic diseased that increase complication
• Type of solution and duration of treatment being
  ordered.
• Any past history of vasovagal reactions
• Fragile/rolling veins
• Patients prior iv experience
• Condition of vein Avoid areas which are
  bruised, red and swollen, veins near infected
  areas, sites near previous dcd IVs

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Always try to be prepared

• In French, and in cooking, this means to lay out
  all of your expected ingredients and equipment
  ahead of time, prepared and within reach. It is
  often beneficial to have a selection of IV
  catheters available as well as extra blood tubes,
  tape, etc., should additional supplies be
  required.

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Predicting difficult access

• Difficult Access
• Conditions that may predict difficult access
  include
• Dehydration/intravascular depletion
• Chronic illness with venous scarring from
  frequent IV access
• IV drug use with venous scarring
• Obesity
• Significant edema
• Tortuous, fragile vessels due to advanced age
• Thin vessel walls due to age, steroid use,
  certain disease conditions
• When presented with these situations, using the
  vasodilating techniques below may facilitate
  cannulation. If you are unsuccessful, Alternative
  Techniques may be required.

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Dependent position
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Preparation of client

• Before Anything Else do an Assessment
• Determine the following
• The type and amount of solution to be infused
• The exact amount (dose) of any medications to be
  added to a compatible solution
• The rate of flow or the time over which the
  infusion is to be completed
• Assess for any allergies (e.g., to tape or
  povidone-iodine)

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Make sure you know why they are receiving the IV

• Purposes of Intravenous Therapy
• To supply fluid when clients are unable to take
  in an adequate volume of fluids by mouth
• To provide salts and other electrolytes needed to
  maintain electrolyte imbalance
• To provide glucose (dextrose), the main fuel for
  metabolism
• To provide water-soluble vitamins and medications
  
• To establish a lifeline for rapidly needed
  medications.

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Gather the equipment

• Prior to beginning the procedure, gather all the
  required equipment. Once the cannula has been
  inserted, it will be attached to a connecting
  tubing. This can be flushed with saline and
  secured to the arm without intravenous fluids
  attached (i.e. a "saline lock".) If IV fluids are
  going to be infused, the bag of fluid will need
  to be attached to IV tubing (a "drip set") prior
  to the procedure

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Obtain the following

• Assess the following
• Vital signs for baseline data
• Skin turgor
• Allergy to latex, tape or iodine
• Bleeding tendencies
• Disease or injury to extremities
• Status of veins to determine appropriate
  venipuncture site

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WIPE

• Preparation
• Introduce self and verify the clients identity.
• Explain the procedure to the client. A
  venipuncture can cause discomfort for a few
  seconds, but there should be no discomforts while
  the solution is flowing.
• Use a doll to demonstrate for children and
  explain the procedure to the parents.

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Prepare the patient

• Explain the procedure to the patient. Tell the
  patient that the procedure may be mildy painful,
  but is brief. Ask that he / she hold the extemity
  completely still until the completion of the
  cannulation. Take time to answer any questions
  that the patient might have.
• The patient should be laying in the bed, with the
  opposite bed rail up, to prevent injury should
  the patient faint during the procedure.

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Site Selection

• Select the venipuncture site
• a. Use the clients nondominant arm, unless
  contraindicated.
• b. Identify possible venipuncture sites by
  looking for veins that are relatively straight,
  not sclerotic or tortuous, and avoid venous
  valves.
• c. The vein should be palpable, but may not be
  visible, especially in clients with dark skin.
• d. Consider the catheter length look for a site
  sufficiently distal to the wrist or elbow that
  the tip of the catheter will not be at a point of
  flexion.
• e. Check agency protocol about shaving.
• f. Place a towel or bed protector under the
  extremity to protect linens.

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Site prep and tourniquet

• After selecting the site of insertion, a
  tourniquet should be applied to the extemity.
  This should be placed tight enough to engorge the
  vein, but not so tight that it causes the patient
  undue pain. If the vein fails to engorge, the
  extremity should be held in a dependent fashion,
  or warmed, as detailed in the Preparation
  section. The site should then be cleansed with an
  alcohol prep or povidone iodine swab. Use a
  circular motion, working your ways outwards from
  the site. Is alcohol is used, a moderate amount
  of friction should be applied, and the area
  should be rubbed for 60 seconds. A quick swipe is
  simply not effective. If iodine is to be used, it
  should be applied and allowed to dry for at least
  30 seconds, and then wiped cleaned with an
  alcohol prep.

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Patient Positioning for success

• As with any procedure, positioning of both the
  patient and the performer should be optimized.
  The patient should be seated or in a reclining
  position for comfort and safety. Immobilize the
  extremity, particularly for pediatric or
  uncooperative patients. Keep the extremity in
  full extension to make the vein taut, and place
  the intended cannulation site in a dependant
  position to engorge the vein.

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Dependent position
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• Lenhardt and associates showed in a randomized
  trial that actively warming patient's hands with
  a warming mitt prior to cannulation reduced the
  time needed to complete the procedure and
  increased success rates. (Lenhardt, 2002) While
  these warming mitts will not likely be available
  at your institution, cheap and conveinent
  alternatives (such as having the patient hold the
  hand in a bowl of warm water, or applying a warm
  towel will likley have the same effect.

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Air embolism

• While it is classically taught that 5 ml / kg of
  air is needed to produce an "air lock" of the
  right ventricle and pulmonary artery, circulatory
  collapse has been reported with as little as 20cc
  of air. Should signicant air embolization occur,
  the patient should be placed in a left lateral
  recumbent position to trap the air in the right
  atrium. Available interventions include
  aspiration via a central venous catheter,
  hyperbaric treatment, and in severe cases,
  thoractomy. (Feied 2002)
• To prevent air embolism, all tubing should be
  flushed prior to utilization. Additionally, all
  connections must be tight, and fluid bags should
  not be allowed to completely empty before
  replacement. If this occurs, the line should be
  removed from the catheter and re-flushed.