Phlebitis should be documented using a uniform standard scale for measuring grade and severity. Any incidence of phlebitis greater than grade 2 should be reported to the physician and other appropriate healthcare personnel. Ongoing observation of sites should continue for 48 post removal to detect post-infusion phlebitis. All patients with an intravenous access device should have the IV site checked every shift for signs of infusion phlebitis. The subsequent score and action(s) taken (if any) must be documented.
Download a printable copy of the
Phlebitis Grading Scale Poster
This reference correlates to the online continuing education course
Basics of Peripheral IV Therapy.
|
Site Observation |
Score |
Stage/Action |
|
IV site appears healthy
|
0 |
No signs of phlebitis
OBSERVE CANNULA |
One of the following signs is evident:
-
Slight pain near the IV site OR
-
Slight redness near IV site
|
1 |
Possibly first signs of phlebitis
OBSERVE CANNULA |
TWO of the following are evident:
|
2 |
Early stage of phlebitis
RESITE CANNULA |
ALL of the following are evident:
-
Pain along path of cannula
-
Redness around site
-
Swelling
|
3 |
Medium stage of phlebitis
RESITE CANNULA
CONSIDER TREATMENT |
ALL of the following signs are evident and extensive:
-
Pain along path of cannula
-
Redness around site
-
Swelling
-
Palpable venous cord
|
4 |
Advanced stage of phlebitis
Or the start of thrombophlebitis
RESITE CANNULA
CONSIDER TREATMENT |
ALL of the following signs are evident and extensive:
-
Pain along path of cannula
-
Redness around site
-
Swelling
-
Palpable venous cord
-
Pyrexia
|
5 |
Advanced stage thrombophlebitis
INITIATE TREATMENT
RESITE CANNULA |
With permission from Andrew Jackson – Consultant Nurse,
Intravenous Therapy & Care, The Rotherham NHS Foundation Trust