Question

List the signs and symptoms for the IV phlebitis score chart from 0 to 5 and specify appropriate nursing actions.

Answer 1

Score 0

The site of IV insertion will be appear healthy

The nursing action is to observe the site for sign of phlebitis ,

Score 1

The IV inserted site can have redness or mild tenderness on touch and during injecting fluid or medication in it.

The nurse can understand this is the start of phlebitis so administration should be slow and steady to avoid pain

Score 2

Pain and redness are actively observable

The nurse has to respite the cannula.An ice application can relieve pain

Score 3

Pain along the path of cannula generally the vein will be tender to touch,redness around the site, sweling is present ,erythema,induration

The nurse has yo immediately resite the cannula, ice application, elevation of the limb will reduce swelling

Score 4

Pain,redness,palpable venous cord,swelling are note

The nurse has to immediately respite the cannula,apply thrombophelebitic agents

Score 5

Pain,tenderness ,swelling, palpable venous cord with fever as a sign of infection is notable

The nurse as to immediately respite the cannula, apply thrombolytucs,ice application and anti pyrectic and analgesics as per the order,topical anti inflammatory,