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PharMerica Resources

Phlebitis Grading Scale

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.

PHLEBITIS GRADING SCALE

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:
  • Pain at IV site
  • Redness
 
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