Infusion Therapy Complication Chart.docx

Infusion therapy complication chart S. no.

Date & Gauge time of insertion

Attempt

Site

Date & time of removal

Total indwelling time in hours

Catheter Flushing material done Y/N

Reason of removal (tick the applicable option ) Phlebitis grade

0

1.

16/18/20/ 22/24/26

PTFE/ Vialon

2.

16/18/20/ 22/24/26

PTFE/ Vialon

3.

16/18/20/ 22/24/26

PTFE/ Vialon

4.

16/18/20/ 22/24/26

PTFE/ Vialon

5.

16/18/20/ 22/24/26

PTFE/ Vialon

6.

16/18/20/ 22/24/26

PTFE/ Vialon

Define the dwelling time as per protocol ……………..hrs.

1

2

3

In filt ra tio n

Hem ato ma

Extr avas atio n

Status of catheter on removal As per protocol

Fibrin clot

Kin ked

4

checked and signed

Tip dam age

PATIENT LIST PATIENT LIST ON DATE ……………………../………………./20…………………( Ward…………………………………………..) S.no. Room / bed Patient name Age/sex DOA 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Pre total patient ……………………………………………

IPD

Consultant

Diagnosis

Remarks

Admission …….. Tr. In …..…… Tr. Out …………. Discharge ………… Death ……… Total venti….. Total NIV ………. Total TT ……. Vulnerable patient …………………………………………. Special care ……………………………………….. Total patient ……………………………………………. Signature of staff nurse

Signature of supervisor