Nurses know that phlebitis is the inflammation of the vein and is considered an adverse patient outcome. Vascular access sites should be routinely assessed for signs and symptoms of phlebitis , as well as the severity of phlebitis. According to the Infusion Nurses Society(INS) Standards of Practice, a standardized scale that is valid, reliable, and clinically feasible should be used. For the adult population, two phlebitis scale have demonstrated validity and reliability.
One of the two scales is the phlebitis scale from the Infusion Nurses Society that many infusion nurses have used for years.
Phlebitis Scale (from the Infusion Nursing Standards of Practice 2011 S47)
Grade 0 – No symptoms
Grade 1 – Erythema at access site with or without pain
Grade 2 – Pain at access site with erythema and/or edema
Grade 3 – Pain at access site with erythema and/or edema, streak formation, palpable venous cord.
Grade 4 – Pain at access site with erythema and/or edema, streak formation, palpable venous cord greater than 1 in in length; purulent drainage.
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