INFUSION THERAPY COMPLICATION CHART

bengal
faith
Bengal FAITH Hospital
A Unit of Bengal Faith Healthcare Pvt Ltd

Patient Name: Age: Date of Admission: Indication:

Patient detail sticker here Inpatient Reg No: Sex: Ward/Unit: Name of Dr.:

Total indwelling time

I.V.Cannula used
Catheter Insertion Flushing Catheter Removal Reason for removal Status of the Daily assessment

Name of the

As per protocol

Pt discharged
Extravasation

IV terminated
Attempts

in hours

Hematoma
Gauge

Occlusion

Tip damage
Fibri n/clot
No Date Time Yes/No Date Time Date Shift Sign
Phlebitis grade Kinked
0 1 2 3 4 Hub Shaft
1 16 1 M
18 2 E
20 3 N
22 M
E
N
M
E
N
M
E
N
2 16 1 M
18 2 E
20 3 N
22 M
E
N
M
E
N
M
E
N
3 16 1 M
18 2 E
20 3 N
22 M
E
N
M
E
N
M
E
N
Phlebitis scale 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, streak formation. palpable venous cord
Grade 4: Pain at access site with erythema, streak formation, palpable venous cord> 1 inch in length, purulent drainage
Name of Person inserting-
For Phlebitis- Drugs given and dose:
Name of Persons involved in maintaining
BFH/INF-THERAPY/MOM/11/2020 Tip damage - Before insertion/ After removal