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Peripheral I.V. Line Checklist (Visual Infusion Phlebitis Score)

This document provides a checklist for monitoring peripheral intravenous (IV) lines using the Visual Infusion Phlebitis Score. The checklist collects patient information and details of IV line insertion including date, time, site and person who inserted the line. Nurses then assess and document the condition of the IV site each morning, noon and night using a 6 stage scale. Lines showing signs of infection or inflammation from stages 2-6 should be immediately removed and the doctor informed. The date and time of any line removal is also recorded.

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4K views1 page

Peripheral I.V. Line Checklist (Visual Infusion Phlebitis Score)

This document provides a checklist for monitoring peripheral intravenous (IV) lines using the Visual Infusion Phlebitis Score. The checklist collects patient information and details of IV line insertion including date, time, site and person who inserted the line. Nurses then assess and document the condition of the IV site each morning, noon and night using a 6 stage scale. Lines showing signs of infection or inflammation from stages 2-6 should be immediately removed and the doctor informed. The date and time of any line removal is also recorded.

Uploaded by

aashika15
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
  • Peripheral I.V. Line Checklist

PERIPHERAL I.V.

LINE CHECKLIST
(VISUAL INFUSION PHLEBITIS SCORE)
Patient Name: MR No:

Age: Gender:

Department: Bed No:


All Peripheral Lines should be removed or replaced within 72 hours of insertion
INSERTION

Inserted by
Aseptic technique used
Date of Insertion (to be also written on the tegarderm
while inserting lines Name Designation Signature
dressing)
Yes / No

Time of Insertion: Site of Insertion;

Note : One person should not attempt more than once.


Date
Morning Noon Night Morning Noon Night Morning Noon Night
1 Stages 0
IV site appears healthy
2 Stages 1
Patient complaints of slight pain /
redness near insertion (any one
is evident)
3 Stages 2
Pain at IV insertion site /
erythema / swelling (any two are
evident)
4 Stages 3

Pain along the paths of cannula /


erythema / induration (all are
evident and extensive)

5 Stages 4

Pain along the paths of cannula /


erythema / induration / palpable
venous cord (all are evident)

6 Stages 5

Pain along the paths of cannula /


erythema / induration / palpable
venous cord (all are evident and
extensive)

Name

Signature

Designation

if items 2 - 6 are identified the IV line should be removed immediately. If required, inform the Doctor for assessment under further management.

Line Removel : Date __________________________ Time : __________________AM / PM

MIOT/Nsg/IV-Line / / / 2019

Patient Name: MR No: Age: Gender: Department: Bed

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