Hello:

I was wondering if there is a standard scale used to assess:

1.  Infiltration

2.  Extravasation

 

Thanks,

Mary Lynn Rae-Zahradnik, RN, MSN, CPON

Children's Memorial Hospital

Chicago, IL

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This is what our neonatal

This is what our neonatal nurses use: 

Infiltration: Practice Criteria for NEONATAL patients

(Adapted from University Children’s Hospital at UCI Medical Center, Orange, California)

B. The Infiltration Scale should be standardized and used in documenting the infiltration; grade according to the

most severe presenting indicator.

Grade: 0

Clinical Criteria: No symptoms

Grade: 1

Clinical Criteria:

Pain at site.

Crying when IV cannula is flushed

Difficulty with IV cannula flushes

No redness or swelling

Grade 2

Clinical Criteria:

ı Pain at site.

ı Redness at site; no blanching..

ı Slight swelling (0-20% above baseline)

ı Good pulse below infiltration site

ı Brisk capillary refill below infiltration site.

Grade: 3

Clinical Criteria:

ı Pain at site.

ı Marked swelling (30-50% above baseline).

ı Bl anching of area.

ı Skin cool to touch.

ı Good pulse below infiltration site.

ı Brisk capillary refill below site.

Grade: 4

Clinical Criteria:

ı Pain.

ı Very marked swelling (>50% above baseline).

ı Blanching of area.

ı Skin cool to touch.

ı Area of skin necrosis or blistering.

ı Prolonged capillary refill time (>4 seconds)

ı Decreased or absent pulse.

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RN VA-BC
Nurse Educator IV Therapy/Vascular Access Fletcher Allen Health Care

Do you know if this scale

Do you know if this scale can be used in pediatrics?  Some of the criteria for edema would be too big espeically in a neonate: 

Grade 2 is listed as (for edema)Edema 6 inches in a neonate would be much more than a grade 2…. 

Mary Lynn

Mary Lynn Rae-Zahradnik, RN, MSN, CPON

Clinical Educator-Heme/Onc/SCT

Children's Memorial Hospital

Chicago, IL 60614

Mary Lynn Rae, RN, MSN, CPON
Clinical Educator-Hem/Onc/SCT
Ann & Robert H. Lurie Children's Hospital of Chicago

Staff R.N. with no

Staff R.N. with no affiliation to any product or health care company(your basic front line grunt/wage slave)

 Also check out http://www.nursingcenter.com/Library/JournalArticle.asp?Article_ID=743824

Speaking of Standards...Standard 53 Phlebitis
Lisa A. Gorski MS, APRN, BC, CRNI©, FAAN 

Peter Marino R.N. BSN CRNI VA-BC Hospital based staff R.N. with no affiliation to any product or health care company.

Yes, it is published in the

Yes, it is published in the Infusion Nursing Standards of Practice. 

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861