PCA Setup Part 2

What exactly is Phlebitis.....

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.

The other is the Visual Infusion Phlebitis (VIP) scale, developed by Andrew Jackson, Consultant Nurse Intravenous Therapy and Care, Rotherham General Hospitals, NHS Trust. This scale was evaluated in a study by Gallant and Schultz.  (Gallant P and Schultz AA (2006) Evaluation of a visual infusion phlebitis scale for determining appropriate discontinuation of peripheral intravenous catheters. Journal of Infusion Nursing. vol. 29, no. 6, p. 338-45.)




Phlebitis resulting from peripheral IV’s should be monitored and the incidence should be calculated. A consistent,  standard, and clinically feasible calculation based on point prevalence should be use to monitor phlebitis rate.
So next time you find yourselves looking at an arm with possible phlebitis,  use a phlebitis scale to assess and document the severity of your findings! No guessing required….

For more information or to purchase the 2011 Infusion Nursing Standards of Practice, click here. 

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IV Push Medications-Example, see your study guide

Injectable Medications: IV Push

1. Complies with established guidelines related to medication administration
2. Selects the prescribed medication using the medication administration record MAR
3. Records the correct calculation of the prescribed dose on the Simulation Laboratory Recording Form before administering the medication
4. Measures the prescribed dosage
5. Identifies the patient immediately before administering the medication by comparing two of the following pieces of patient information against the MAR- a. Patient name, DOB, MR #
6. Uses the prescribed route and/or site for administering the medication
7. Administers the prescribed medication to the designated patient
8. When IV medication is to be administered by push-a. records the volume and the time of medication to be administered on the Simulation Laboratory Recording Form before administering the medication-b. Assesses the insertion site for dislocation, infiltration, or other complications immediately before administering the medication by- a. feeling around the skin for changes in temperature or by b. palpating the surrounding tissue for edema
9. Injects the medication at the designated rate
10. When an Intermittent venous access device is used: a. Aspirates for blood return unless contraindicated
11. Flushes with prescribed solution prior to medication administration
12. Records the medication administered on the medication administration record (MAR)
13. Maintains asepsis
14. Completes all of these Critical Elements within 15 minutes

HAVE YOU COMPLETED ALL CRITICAL ELEMENTS FOR THIS STATION ?