Appendix 2 Peripheral IV Cannula Visual Inspection of Intravenous Access Devices (VIIAD) VIIAD 1 Ensure that this form is completed each shift by registered nurse. Document any variance overleaf. Use separate form for every peripheral IV cannula. Peripheral Indication for Cannula ……………………………… Insertion……………………………………………………….. Note: Use appropriate form for central lines. Unit Insertion date No. ………………………………….. …………………… Time …………………………… Ward Cannula Site ……………………………………… size/colour/type …………………. …………………………… ……………………… Designation Inserted by…………………………… ……………………… Skin disinfected with Date …………………………. Is venous access required E L N E L N E L N for longer? Yes No V.I.P. Score 0 5 (see overleaf) – Rationale for keeping cannula over 72 hrs. Yes/No/NA ………………………………… Flushed? Yes/No/NA ………………………………… Shift …………. Time Flow problems? Yes/No/NA Signature………………. Moisture/leak from site? Yes/No/NA Referred by Needle-free device/Octopus used? ……………………….. e.g bionector Yes/No/NA Referred on Registered Nurse Signature .…/…/…. Printed Name TO BE COMPLETED ON TIME ON TIME OF REMOVAL. Date line removed Time ……/…../…… ……………….………………….. Reason for removal (circle) Elective VIP > 1 Dislodgement Other Removed using aseptic technique Signature ……………………… by……………………………… ……………………… If yes, refer to IV Therapy Team on 285 4696.
Appendix 2 VIIAD 1 Peripheral Cannula Note: Use appropriate form for central lines. Peripheral IV Cannula Visual Inspection of Intravenous Access Devices (VIIAD) Ensure that this form is completed each shift by registered nurse. Document any variance overleaf. Use separate form for every peripheral IV cannula. ……………………………… Indication for Insertion……………………………………………………….. Unit No. ………………………………….. Insertion date …………………… Time …………………………… Ward ……………………………………… Cannula size/colour/type …………………. …………………………… Site ……………………… Inserted by…………………………… Designation ……………………… Skin disinfected with …………………………. Date V.I.P. Score 0 – 5 (see overleaf) Flushed? Yes/No/NA Flow problems? Yes/No/NA Yes/No/NA Shift Time E L N E L N E L N Rationale for keeping cannula over 72 hrs. ………………………………… ………………………………… …………. Signature………………. Is venous access required for longer? Yes No Moisture/leak from site? Yes/No/NA Needle-free device/Octopus used? e.g bionector Yes/No/NA Registered Nurse Signature Printed Name TO BE COMPLETED ON TIME ON TIME OF REMOVAL. Date line removed ……/…../…… Time ……………….………………….. Reason for removal (circle) Elective VIP > 1 Dislodgement Other ……………………… Removed using aseptic technique by……………………………… Signature ……………………… If yes, refer to IV Therapy Team on 285 4696. Referred by ……………………….. Referred on .…/…/….