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Green Card Report - please enter all available details

Male Female Age
Height(m)          Weight(kg) Ethnic Origin
Drug causing extravasation Dose

Given as

Infusion fluid and volume

Given via size over mins hours
The above drug formed part of course no in the following regime

Is the Patient on any of the following Therapies?

Anticoagulants Antiplatelets
Antihistamines Diuretics
Hormone Therapy Antifibrinolytics
Vasodilators Steroids

 

 

 

 

 

 

 

 

 

 

 

Has the patient received I.V antibiotics in the last 3 months? Yes No
If YES please specify
Has the patient had previous :- Drug Hypersensitivity Phlebitis
Were the drugs being administered via a pump or syringe driver? Yes No
If YES please indicate model
Time of Cannulation
No of attempts at cannulation
Ease of Cannulation
Other Method of Administration         Other (please specify)

Details of Extravasation Treatment (Drug, Dose, Procedure)
Did the Patient experience any of the following prior to or after the suspected extravasation?
Prior
Post
Time Post Extravasation
Pain
Tingling
Swelling
Redness/Flare
Itching
Cold
Date of Extravasation
Time of Extravasation Acute extravasation treatment started at

THIS SECTION IS NOT COMPULSORY

Contact Name for Further Details:

 

 Dr Nurse Pharmacist

Tel no

Email

Does the patient suffer from any of the following possible contributary factors?

Raynaud's Disease
Diabetes
Peripheral Vascular Disease
Lymphoedema

Has the patient had either of the following in the last month, to the affected side?

Surgery Date
Radiotherapy Date

Additional Comments:
Was the patient able to communicate adequately in English? Yes No
If not, please give reason

 

This page last updated 30/6/2007

© The National Extravasation Information Service, 2000-2007