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:
|
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