What is the appropriate site for an IV?: A Guide to Vascular Access

October 2, 2025 •

4 min read

According to the Infusion Nurses Society, upper extremities are the preferred site for most peripheral IV insertions, minimizing complications like thrombophlebitis and promoting self-care. Selecting what is the appropriate site for an IV requires careful consideration of the patient's condition and the planned therapy.

Quick Summary

For most adult patients requiring a peripheral IV, the most appropriate sites are the dorsal and ventral surfaces of the upper extremities, specifically the veins in the hands and forearms, as these locations help reduce complications and increase dwell time.

Key Points

Start Distally: Begin IV site selection on the most distal veins of the upper extremities and move proximally as necessary to preserve future access points.
Prioritize Upper Extremities: For most adults, peripheral IVs should be placed in the hands or forearms to minimize complications like thrombophlebitis.
Avoid Areas of Flexion: Steer clear of joints, especially the antecubital fossa, for continuous IV infusions to prevent mechanical occlusion and improve patient comfort.
Consider Patient-Specific Factors: Age, clinical condition, and therapy type all influence site selection; special considerations apply to pediatric, geriatric, and CKD patients.
Incorporate Patient Preference: Ask the patient about their nondominant arm preference to promote comfort and independence.
Utilize Visualization Techniques: For difficult venous access, using ultrasound or other visualization technology can significantly increase the success rate of IV insertion.

Choosing the Optimal Peripheral IV Site

Site selection is a critical step in initiating intravenous (IV) therapy, impacting patient comfort, safety, and the longevity of the access device. A systematic approach, prioritizing distal veins in the upper extremities and moving proximally as needed, is standard practice. A thorough assessment involves both visual inspection and palpation to find a vein that is straight, resilient, and easy to access. The nondominant arm is often the preferred choice to maximize patient independence.

The Upper Extremities: Preferred Peripheral Sites

For adults, the veins of the upper extremities are the gold standard for peripheral IV placement due to lower rates of thrombosis and phlebitis compared to lower limbs.

Dorsal Metacarpal Veins: These veins on the back of the hand are a common and easily accessible starting point, especially for short-term therapy. However, they are smaller and more prone to movement, potentially causing discomfort or dislodgement.
Cephalic and Basilic Veins: Located in the forearm, these are excellent alternatives offering larger size and better stability. Using the forearm increases the dwell time of the catheter and reduces pain.
Median Cubital Vein: This large vein in the antecubital fossa (inner elbow) is often used for blood draws but is generally avoided for continuous IV infusions due to joint movement, which can cause mechanical obstruction. It may be used for rapid or short-term access.

Factors Influencing IV Site Selection

Beyond anatomical location, several factors guide the decision-making process for optimal IV placement.

Patient Age and Condition: Pediatric and geriatric patients often have more fragile veins, necessitating smaller catheters and careful site selection. For infants, the scalp and foot veins might be considered, while elderly patients may require special techniques to prevent vein rolling.
Type and Duration of Therapy: The nature of the medication or fluid influences the catheter size and site. Rapid infusions or viscous fluids like blood products require larger, more resilient veins, often in the forearm. Long-term therapy may require a peripherally inserted central catheter (PICC) rather than a short peripheral catheter.
Vein Health: It is crucial to assess the condition of the potential vein. Compromised veins—bruised, infected, or scarred—should be avoided. Palpating for knobby areas can help identify valves, which can impede catheter advancement.
Contraindications: Certain patient conditions and histories preclude using specific sites. These include the side of a mastectomy, lymphedema, or the presence of an arteriovenous fistula or graft.
Patient Preference: Engaging the patient in the decision, especially regarding the dominant versus nondominant arm, improves cooperation and satisfaction.

Special Patient Considerations

Chronic Kidney Disease (CKD): For patients with CKD, unnecessary venipuncture of peripheral veins in the upper extremities should be avoided to preserve future vascular access for hemodialysis. The hand may be the preferred site in these cases, steering clear of the forearm and upper arm.
Pediatrics and Neonates: With smaller, more delicate veins, alternative sites are often necessary. In addition to the hands and forearms, veins in the foot or scalp can be used for infants, provided they are not yet walking. Careful splinting is required to prevent accidental removal.

Comparison of Common Peripheral IV Sites


IV Site	Advantages	Disadvantages	Best For	Considerations
Hand (Dorsal Metacarpal Veins)	Easily visible; distal starting point	Smaller size; prone to dislodgement; more sensitive	Short-term therapy; initial access attempts	Splinting may be needed; avoid in mobile infants
Forearm (Cephalic/Basilic Veins)	Larger veins; less pain; longer dwell time	Can be challenging in obese or muscular patients	Most routine IV fluids and medications	Preferred site for standard adult therapy
Antecubital Fossa (Median Cubital Vein)	Large, easy-to-find veins	Position dependent; prone to mechanical occlusion with elbow flexion	Rapid fluid bolus; emergency access; blood sampling	Use with caution for continuous infusion; avoid in active children
Foot Veins	Can be used in non-ambulatory infants or as a last resort in adults	High risk of thrombophlebitis and infection in adults	Neonates; when upper extremities are compromised	Avoid in adults unless medically necessary; ensure proper splinting in neonates

Advanced Techniques and Conclusion

For patients with difficult venous access, advanced techniques can be used. Visualization technologies, such as infrared light or ultrasound, can aid in identifying and selecting suitable veins. Ultrasound guidance, in particular, can increase the success rate of peripheral IV placement in adults and children with poor veins. After two failed insertion attempts, clinicians should seek assistance from a more skilled colleague or a specialized vascular access team. For comprehensive guidelines on infusion therapy, consult the official Infusion Nurses Society website.

In conclusion, deciding what is the appropriate site for an IV is a multifactorial process balancing clinical need, patient safety, and comfort. By following established guidelines and considering individual patient factors, healthcare professionals can ensure effective and successful IV therapy while preserving the patient's venous health.

Frequently Asked Questions

The most common and preferred sites for a peripheral IV in adults are the dorsal metacarpal veins on the back of the hand and the cephalic or basilic veins in the forearm.

The veins in the antecubital fossa are large and easy to access, but bending the elbow can obstruct the IV catheter, leading to mechanical failure and discomfort during continuous infusions.

In adults, using the veins of the lower extremities for peripheral IVs is generally avoided due to the higher risk of thrombophlebitis and embolism. They are typically only used as a last resort.

For patients with CKD, healthcare providers must preserve the veins of the forearm and upper arm for future hemodialysis access. In these cases, the veins of the hand are often the preferred choice for peripheral IV placement.

For pediatric patients, suitable IV sites include the hands, forearms, and upper arms. For infants, the foot or scalp veins may also be used. The chosen site must be properly splinted to prevent accidental dislodgement.

Veins that are bruised, scarred, infected, or feel hard and cord-like (sclerosed) should be avoided. Also, areas with skin breakdown or a history of previous infiltration are not appropriate.

In cases of difficult venous access, a provider may use visualization technologies, such as ultrasound, to help locate and cannulate a suitable vein.