Abnormal findings are charted as a chain — finding, severity, comparison to baseline, the risk it creates, and the skilled action taken.
Site erythema, purulence, tenderness, or warmth with or without fever — concerning for a device-related or central-line-associated bloodstream infection.
Inability to flush, loss of blood return, or resistance — concerning for occlusion or malposition.
Migration, a change in external length, or partial or complete dislodgement — risking loss of access or misdelivery.
Sudden dyspnea, chest pain, or hypotension during line manipulation — concerning for air embolism.
Infiltration or extravasation — swelling, coolness, or pain at a peripheral site, with the risk of tissue injury from a vesicant.
Arm, neck, or facial swelling on the side of a central catheter — concerning for catheter-associated venous thrombosis.
For enteral tubes — dislodgement, an inability to confirm placement, high residuals, or signs of aspiration.
Site bleeding, especially in a patient on an anticoagulant — requiring control and bleeding-risk review.
