Difficult Vein Access Assessment Form
Complete this assessment to evaluate factors contributing to venous access difficulty.
History of difficult venous access?
*
No prior difficulty
Occasional difficulty
Frequent difficulty
Number of previous venous access attempts in this session
*
Prior complications with venous access
*
None
Infiltration/extravasation
Phlebitis
Failed cannulation
Other
Vein visibility and palpability
*
Visible and palpable
Palpable but not visible
Neither visible nor palpable
Vein characteristics (select all that apply)
*
Small diameter
Deep location
Tortuous
Fragile
Sclerosed
None
Patient-related risk factors (select all that apply)
*
Obesity
Edema
Dehydration
History of IV drug use
Chronic illness (e.g., renal failure)
None
Use of vein visualization or assistive devices
*
None
Tourniquet only
Warm compress
Vein finder/ultrasound
Previous interventions for venous access
*
Peripheral IV
Central venous access
Midline catheter
None
Other
Observable challenges during current attempt (check all that apply)
*
Vein rolls on palpation
Vein collapses easily
Bleeding at site
Patient discomfort
None observed
Overall difficulty rating for venous access (1 = very easy, 5 = very difficult)
*
Very easy
1
2
3
4
Very difficult
5
1 is Very easy, 5 is Very difficult
Submit Assessment
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