Vascular Access Device Assessment
Comprehensive evaluation of a vascular access device and insertion site.
Device Type
*
Peripheral IV
Central Venous Catheter (CVC)
Peripherally Inserted Central Catheter (PICC)
Midline Catheter
Other
Insertion Site
*
Hand
Forearm
Upper Arm
Neck
Chest
Other
Dwell Time (days)
*
Dressing Condition
*
Intact and Clean
Soiled
Loose
Dislodged
Patency / Flush Status
*
Patent, flushes easily
Occluded / sluggish
Unable to flush
Signs of Infection (select all that apply)
*
Redness
Swelling
Warmth
Discharge
Pain/Tenderness
None
Complications Observed
*
Phlebitis
Infiltration
Occlusion
Dislodgement
None
Other
Securement Device/Method
*
Sutureless securement
Sutured
Adhesive dressing
Other
Patient Symptoms (select all that apply)
*
Pain
Fever
Chills
None
Other
Overall Assessment Notes
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