2. DEFINITION
• Thrombophlebitis is the inflammation of a
vein with blood clot formation inside the vein
at the site of the inflammation.
Thrombophlebitis also is known as phlebitis,
phlebo thrombosis and venous thrombosis.
• http://www.mayoclinic.org>syc-203... retrieved 25/03/2018
3. INTRODUCTION
• Thrombophlebitis frequently occurs with an
intravenous cannula.
• Either the cannula or the infusion, including
drugs, may have caused the inflammation.
• The common sites coincide with those of
common medical interventions (arm or neck
with external jugular vein cannulation).
4. INTRODUCTION
• The MOH has been closely monitoring the
incidence of thrombophlebitis among adult in-
patients since 2003 under QAP.
• The standard set has been reviewed in 2014
from 0.9% to ≤ 0.5%
• Periodically based on the data collection over
the years.
5. SIGNS AND SYMPTOM
• Pain at cannulation site
• Redness and inflammation of the skin along a
vein.
• Warmth of the skin and tissue around the vein.
• Tenderness and pain that worsens with added
pressure.
• Pain in the limb.
• Darkening of the skin over the vein.
• Hardening of the vein.
8. Areas to Avoid setting IV Cannulae
Areas of joint flexion
Hardened / Sclerosed veins
Veins near arteries
Veins in lower extremities
Areas of surgery
small veins
Previously cannulated veins
( Ddehn & Asprey, 2007)
Bahagian Kejururawatan, KKM
11. One of the following sign is evident :
i) Slight pain ( pain score 1-3) near IV site or
ii) Slight redness near IV site
May not require analgesic
Score 1
Bahagian Kejururawatan, KKM
12. Score 2
Two of the following signs are evident:
i) Pain at IV site (pain score 4-6)
ii) Redness near IV site or
iii) Swelling
interferes with activities
Bahagian Kejururawatan, KKM
13. SCORE 3
All of the following signs are evident:
i) Pain along path of cannula – Moderate pain
(pain score 4-6 )
i) Redness around site
ii) Swelling iii) Warmth
Interferes with concentration
Bahagian Kejururawatan, KKM
14. SCORE 4
All of the following signs evident and extensive:
i) Pain along path of cannula - severe pain (pain score 7-9)
ii) Redness around IV site
iii) Swelling
iv) Palpable venous cord
Interferes with basic needs
Bahagian Kejururawatan, KKM
15. SCORE 5
All of the following signs are evident & extensive:
i) Pain along the path of cannula (worst pain possible) Pain
score 10
ii) Redness around IV site
iii) Swelling palpable venous cord
iv) Pyrexia
Bed rest required Bahagian Kejururawatan, KKM
16. NURSING RESPONSIBILITIES :-
1. Hand Hygiene :-
Hands are decontaminated immediately
before and after each episode of patient
contact using the correct hand hygiene
technique. (5 moments of hand hygiene)
Bahagian Kejururawatan, KKM
17. 2. Observe aseptic technique :-
Alcohol wipes are used to
decontaminate port and surrounding
area, and allowed to dry prior to the
administration fluid or injections via
the cannula.
Patency is maintained.
Bahagian Kejururawatan, KKM
18. 3. Monitoring :-
Monitor intravenous therapy
Check the infusion and the IV cannulation
site at least every 4 hours or when necessary
Flow of fluid
IV site: erythema, wetness, and edema
Phlebitis
Infiltration
Assess for chills, fever, headache, nausea,
vomiting, anxiousness, and dyspnea.
Cannula should be removed where it is no
longer indicated.
Bahagian Kejururawatan, KKM
19. 4. Dressings :-
A sterile , semi-permeable,
transparent dressing is used allowing
observation of insertion site made
accessible. Ensure that the IV line is
anchored & secured properly.
Bahagian Kejururawatan, KKM
20. 5. Cannula replacement :-
Resite cannula after 72 hours or
as clinically indicated
eg. blood transfusion eg. Size 18G
Document each time after change
of IV site
Bahagian Kejururawatan, KKM
21. 7. Documentation :-
Document in Thrombophlebitis
observation chart and in the
Patient’s case notes the date and
time of removal of cannula and
signature of the nurse undertaking
the task.
Bahagian Kejururawatan, KKM
23. Bahagian Kejururawatan, KKM
Where: Data will be collected from every
ward of the hospital.
Who: Data will be collected by ward manager,
staff nurse / personnel in-charge of the ward.
How frequent: Monthly data collection.
Who should verify: All performance data must
be verified by the Head of
Department / KPJH /Hospital
Director.
How to collect: Data will be collected from
Form BKJ-BOR-PPK-10 Pind 1/2018 & record
book / patient casenote.
24. INDICATOR AND FORMULA
Indicator:
Incidence of Thrombophlebitis Among In-patients with
cannulation
Formula :
Numerator : Number Incidence of Thrombophleblitis ( Score 2- 5) x 100
Denominator : Total number of inserted peripheral IV cannula
(Indicator monitoring is every three monthly.)
25. FLOW CHART FOR MONITORING THROMBOPHLEBITIS
PATIENT ADMISSION / TRANSFER IN
CANULLATION
CANULA FOR
-IV DRIP - MEDICATION
-BLOOD TRANSFUSION
NO MONITORING
ASSESSMENT FORM
BKJ-BOR-PPK-10 Pind 1/2018 &
4HLY BY NURSE
(KEEP IN BHT )
WD SISTER/KUP ENTER DATA IN
BKJ-BOR-PPK-11 Pind. 1/2018
SEND TO COORDINATOR
COORDINATOR COMPILE AND ENTER DATA IN
BKJ -BOR-PPK-12 Pind. 1/2018
SEND TO STATE MATRON
IF CANULLATION IS REQUIRED
STATE MATRON COMPILES AND ENTERS IN BKJ –
NNIA -2 Pind.1/2018
BKJ-NNIA- 2Pind.1/2018 SENT
TO QUALITY UNIT BHG.
KEJURURAWATAN KKM
NO YES
Reviewed 18.01.2018
26. Bahagian Kejururawatan, KKM
NURSING DIVISION
MINISTRY OF HEALTH MALAYSIA
First Edition Mei 2017
1. nursing.moh.gov.my
2. Click “Acts & Guidelines”
3. Search for No.23 & click
on the title
27. THANK YOU FOR YOUR ATTENTION !
Bahagian Kejururawatan, KKM
