Phlebitis Grading
VIP Score: 0 (none), 1 (tenderness), 2 (redness +/- tenderness), 3 (redness, swelling, pain), 4 (red line, swelling, palpable cord), 5 (above + purulent drainage). Score >=2: remove catheter, document, new site. Score 3-4: warm compress, notify. Score 5: culture, antibiotics.
Infiltration Grading
INS Scale: 0 (none), 1 (blanched, edema <1 inch, cool), 2 (blanched, edema 1-6 inches, cool), 3 (blanched, edema >6 inches, cool), 4 (same + deep tissue injury, ulcer). Grade 1-2: remove, elevate, document. Grade 3-4: remove, elevate, compress, notify, photos.
Documentation
Document: assessment findings, grade/scale score, interventions, education, follow-up. For infiltration: type/amount of fluid, volume infiltrated. For phlebitis: onset, progression, treatment. For extravasation: vesicant name, volume, antidote, photos. Report as incident for Grade 4 or any extravasation. Monitor 24h for delayed reactions.
Important Notes
- VIP score >=2 requires catheter removal — do not wait for progression.
- Any extravasation of a vesicant must be documented as an incident and followed up for tissue injury.
Clinical Tips
- Assess IV sites at least every 4 hours for high-risk medications and every shift for routine fluids.
- A cool, swollen IV site with continued IV flow indicates infiltration — stop immediately.
Summary
Phlebitis and infiltration grading (VIP and INS scales) standardize assessment — scores guide interventions from site removal to provider notification.
