Thrombophlebitis is inflammation of a vein caused by a blood clot. It commonly occurs at intravenous cannulation sites and is monitored by the Malaysian Ministry of Health. Nurses are responsible for preventing thrombophlebitis by following aseptic technique, regularly checking IV sites, changing dressings and cannulas as needed, and documenting assessments using standardized forms and flowcharts to collect monthly incidence data.

1. RECOGNISING
THROMBOPHLEBITIS
Bahagian Kejururawatan, KKM

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.

6. COMMON VEINS USED FOR SETTING IV LINES
Bahagian Kejururawatan, KKM

7. COMMON VEINS USED FOR SETTING IV LINES
Bahagian Kejururawatan, KKM

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

9. Bahagian Kejururawatan, KKM

10. SCORE 0
IV site appears healthy
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

22. Bahagian Kejururawatan, KKM
BORANG THROMBOPHLEBITIS
Borang BKJ-BOR-PPK-10 Pind. 1/2018
Borang BKJ-BOR-PPK-11 Pind. 1/2018
Borang BKJ-BOR-PPK-12 Pind 1/2018
Borang BKJ NNIA-2 pind.1/2018
( Hyperlink )

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