BKJ-BOR-PPK-10 Pind.

1/2015
THROMBOPHLEBITIS CHART
MINISTRY OF HEALTH
4 HOURLY OBSERVATION CHART

Name : R/N : Age : Sex :

Site of canulation :

Thrombo

Rednes

Rednes

Venous
Palpabl
Swellin
Additive SCORE VISUAL INFUSION PHLEBITIS SCORE

Slight

Slight
Time 4 phlebitis

cord
Pain

Pain
Date Name & Signature

e
s

s
hourly Medication Blood Tx Plain I/V drip Yes No 1 2 3 4 5 SITE OBSERVATON SCORE ACTION

No Signs of phlebitis
IV Site appears healthy 0
OBSERVE CANNULA

One of the following signs is evident:

Possibly first signs of
phlebitis
* Slight Pain (pain score 6) near IV 1
site OR

* Slight redness near IV site OBSERVE CANNULA

Two of the following signs are evident:

Early stage of phlebitis

* Pain at IV site
2
RESITE CANNULA
* Redness near IV site

* Swelling

ALL of the following signs evident:

Medium stage of phlebitis

* Pain along path of cannula

3

* Redness around site RESITE CANNULA

* Swelling CONSIDER TREATMENT

ALL of the following signs evident and
extensive: Advanced stage of phlebitis
OR the start of
thrombophlebitis
* Pain along path of cannula

4
* Redness around site

* Swelling RESITE CANNULA

* Palpable venous cord CONSIDER TREATMENT

ALL of the following signs Advanced stage

evident and extensive: thrombophlebitis

* Pain along path of cannula

5
* Redness around site INITIATE TREATMENT

* Swelling RESITE CANNULA

* Palpable venous cord

* Pyrexia
Notes: 1. This format should be filled by Staff Nurse KUNCI Adapted from Andrew Jackson 1998
2. One form to be use for one canulation Tick in relevant column
3. Keep in patient's casenote after discharge