Montgomery et al reported stages of infiltration and extravasation injury.
Parameters:
(1) appearance
(2) temperature to touch
(3) pain or tenderness
(4) swelling
(5) pulse below site
(6) IV line flushing
(7) capillary refill below site
|
Parameters
|
Stage 0
|
Stage I
|
Stage II
|
|
appearance
|
normal skin
|
normal skin
|
redness
|
|
temperature
|
normal
|
normal
|
|
|
pain or tenderness
|
none
|
present
|
present
|
|
swelling
|
none
|
none
|
slight
|
|
pulse below site
|
good
|
good
|
good
|
|
IV line flushing
|
easy
|
difficult
|
difficult
|
|
capillary refill
|
1-2 seconds
|
1-2 seconds
|
1-2 seconds
|
|
Parameters
|
Stage III
|
Stage IV
|
|
appearance
|
blanching
|
blanching, skin necrosis or breakdown
|
|
temperature
|
cool
|
cool
|
|
pain
|
present
|
present
|
|
swelling
|
moderate
|
severe
|
|
pulse below site
|
good
|
decreased or absent
|
|
capillary refill
|
1-2 seconds
|
> 4 seconds
|
