Grade and document phlebitis according to the most severe presenting indicator.
| Box 16-2 | Phlebitis Scale | ||
| Grade | Clinical Criteria | Grade | Clinical Criteria |
|---|---|---|---|
| 0 | No symptoms | 4 | Pain at access site with erythema and/or edema Streak formation Palpable venous cord >1 inch in length Purulent drainage |
| 1 | Erythema at access site with or without pain | ||
| 2 | Pain at access site with erythema and/or edema | ||
| 3 | Pain at access site with erythema and/or edema Streak formation Palpable venous cord | ||
Source:Gorski, L. A., Hadaway, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., Meyer, B. M., Nickel, B., Rowley, S., Sharpe, E., & Alexander, M.; Infusion Nurses Society. (2021). Infusion therapy. Standards of practice, 8th edition. Journal of Infusion Nursing, 44(Suppl 1), S139. https://doi.org/10.1097/NAN.0000000000000396