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