A3 PHLEBITIS SCORE POSTER 21174

1 PHLEBITIS ScoreAll patients with an intravenous access device shouldhave the IV site checked every shift for signs of infusionphlebitis. The subsequent SCORE and action(s) taken (ifany) must be documented on the cannula record form. The cannula site must also be observed: When bolus injections are administered IV flow rates are checked or altered When solution containers are changed012345No signs of phlebitisOBSERVE CANNULAP ossibly first signs of phlebitisOBSERVE CANNULAE arly stage of phlebitisRESITE CANNULAM edium stage of phlebitisRESITE CANNULACONSIDER TREATMENTA dvanced stage of PHLEBITIS or the start of thrombophlebitisRESITE CANNULACONSIDER TREATMENTA dvanced stage thrombophlebitisINITIATE TREATMENTRESITE CANNULAIV site appears healthyOne of the following signs is evident: Slight pain near IV site OR Slight redness near IV siteTWO of the following are evident: Pain at IV site Redness SwellingALL of the following signs are evident.

2 Pain along path of cannula Redness around site Swelling ALL of the following signs are evident and extensive: Pain along path of cannula Redness around site Swelling Palpable venous cordALL of the following signs are evident and extensive: Pain along path of cannula Redness around site Swelling Palpable venous cord PyrexiaWith permission from Andrew Jackson Consultant Nurse,Intravenous Therapy & Care, The Rotherham NHS Foundation Trust(Adapted from Jackson, 1998)A3 PHLEBITIS SCORE POSTER 21174 22/8/06 15:02 Page 1