EFFECT OF INTERVENTIONS ON REDUCING THE RISK OF THROMBOPHLEBITIS AMONG IV CANNULATED PATIENTS.

Shiwani Devi 1 , Kanika 2 , Pooja Jaswal 3 and Dr. (Mrs.) Jyoti Sarin 4 . 1. M.Sc. (Nursing) Student, Department of Medical Surgical Nursing, M.M College of Nursing, Maharishi Markandeshwar (Deemed to be University) Mullana, Ambala, Haryana, India. 2. Professor, Department of Medical Surgical Nursing, M.M College of Nursing, Maharishi Markandeshwar (Deemed to be University) Mullana, Ambala, Haryana, India. 3. Assistant Professor, Department of Community Health Nursing, M.M College of Nursing, Maharishi Markandeshwar (Deemed to be University) Mullana, Ambala, Haryana, India. 4. Principal cum Professor, M.M. College of Nursing, Maharishi Markandeshwar (Deemed to be University) Mullana, Ambala, Haryana, India. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 15 April 2019 Final Accepted: 17 May 2019 Published: June 2019

A quasi experimental study was done to assess the effect of proximal massage, palm fisting and hot application on reducing the risk of thrombophlebitis among 105 IV cannulated patients admitted in selected hospital of Ambala Haryana. The sample was selected by purposive sampling technique and divided into four groups: PFG (15), PMG (30), HAG (30) and CG (30). The interventions used were palm fisting exercise, proximal massage, and hot application. Data was collected by using VIP scale and VRS scale. Findings revealed that pre test and post test phlebitis mean rank scores at 3 rd day were 2.00 (Z=-1.73, p=0.08), 5.00 (Z=-2.89, p=0.00), 6.00 (Z=-3.13, p=0.00) and 8.04 (Z=-3.3, p=0.00) in PFG, HAG, PMG and CG respectively and pain scores were 5.50 (Z=-3.05, p=0.00), 7.00 (Z=-3.29, p=0.00), 4.50 (Z=-2.59, p=0.01) and 8.50 (Z=-3.63, p=0.00) in PFG, PMG, HAG, and CG respectively. There was an association of risk of thrombophlebitis with method of drug administration (ᴎ=1, p=0.04) and with use of anticoagulant drugs (ᴎ=1, p=0.04) in PFG group and pain score with method of drug administration (ᴎ=5.0, p=0.05) in PFG and age (ᴪ=10.48, p=0.01) in CG. The use of hot application was most effective and palm fisting exercise was least effective.

…………………………………………………………………………………………………….... Introduction:-
Peripheral venous cannulation is indispensable in the practice of modern medicine. It is the commonest and frequently used route of drug administration in hospitals. As compared to other routes, intravenous route delivers fluids and medications very rapidly throughout the body (Saji J, Korula SV et al., 2015), (Verma P, Thakur AS et al., 2010).Although it is a frequently used method of drug administration but it is not free of complications like catheter-related bloodstream infection, extravasations, bleeding at puncture site, infiltration and phlebitis. Among hospitalized patients, 5% to 70% of patients receiving peripheral intravenous therapy develop phlebitis which may lead to mortality and morbidity, increased duration of hospital stays and significant cost (Kaur P, Thakur R et al., 966 2011), (Waitt C, Waitt P et al., 2004). Local irritation of vein is a common side effect of infusion and drug administration for peripheral venous cannulation. In histological investigation, thrombus formation occurs due to acute inflammation related to several stimuli which are responsible for infusion phlebitis such as use of infusion pump, flow rate of infusion, osmolarity of solution and pH of solution which are infused cannula material cannula width and length (Lanbeck P, Odenholt I et al. 2002). Regarding the incidence in India, about 50% was found in Kolenchery, and 29.8% of phlebitis Chandigarh (Saini R, Agnihotri M et al. 2011). Peripheral intravenous cannulation is affected by characteristics of person such as age, sex, disease condition, presence of co-morbidities and conscious level and cannula related factors such as site and flushing after insertion. Many factors namely chemical factors (drugs and fluid), mechanical (catheter material size and duration of cannulation) and infectious agents may have an effect on cannulation (Rajappa T, Malviya SD 2015). It has been found that 60% of all blood stream infections occur due to venous cannulation. (Curran ET, Coia JE et al., 2000). There are various methods used to reduce the risk of thrombophlebitis and other complications (blood infection). (Rajappa T, Malviya SD 2015).
Peripheral venous cannulation is the most commonly performed invasive procedure that nurses perform. Nurses are mostly responsible for administering intravenous medications and infusion and providing education to patients related to this in the hospital. Phlebitis is still an ongoing problem in medical practice (Scales K. 2005), (Singh R, Bhandary S et al., 2008). Patients require courses of medication repeatedly, that can cause skin and some allergic reactions at the site of cannulation. Because of these skin reactions, the veins may get damaged, so the placement of the cannula often becomes a cause of pain to the patient (Chemocare), (Soysal S, Topacoglu H et al., 2012). Hot application has mainly four effects on tissues of body, including muscle relaxation, pain relief, and dilation of vessels and relaxation of connective tissue. Blood flow increases to injured part due to dilation of blood vessels (Kaur M, Kaur S et al., 2011). In IV infusion, the development of thrombophlebitis requires withdrawal of cannula and reinsertion of cannula. An exploratory study was done to assess Intravenous cannula associated factors of phlebitis. The results showed that 67.2% cannula removals occur due to complications (Maria S, Enes S et al., 2016).

Research Design
Quasi Experimental i.e. Non equivalent control group pretest post test design.

Setting
Maharishi Markandeshwar Institute of Medical Sciences And Research Hospital Mullana, Ambala, Haryana.

Sample size
Power analysis was done with the help of review of literature; in consideration with time frame of the study, and availability of sample (includes exclusion and inclusion criteria).

Inclusion criteria
The study included patients who were: • Willing to participate in the study.
• Undergoing IV cannulation during data collection.
• Having IV cannula in upper extremities.

Exclusion criteria
The study excluded patients who were: • Critically ill.

Ethical consideration
Ethical approval was obtained from Institutional Ethical Committee of M. M. (Deemed to be University), Mullana, Ambala, Haryana (IEC number -1158).

Period of investigation
October 2018 to December 2018

Hypotheses
All hypotheses were tested at 0.05 level of significance: H 1 : There will be a significant difference in mean post-test risk of thrombophlebitis in terms of scores of Visual Infusion Phlebitis Scale and Verbal Rating Scale between PMG, PFG, HAG and CG. H 2 : There will be a significant difference in mean pre-test and post-test risk of thrombophlebitis in terms of scores of Visual Infusion Phlebitis and Verbal Rating Scale in PMG, PFG, HAG and CG. H 3 : There will be a significant association of Visual Infusion Phlebitis and Verbal Rating Scale scores of risk of thrombophlebitis with selected demographic and clinical variables in PMG, PFG, HAG and CG.
Operational definitions 1. Effectiveness: It refers to the extent to which interventions (proximal massage, palm fisting and hot application) are able to achieve desired effect in reducing the risk of thrombophlebitis among IV cannulated patients as assessed by the appearance of the site of cannula in terms of pain, redness near IV site, swelling, erythema, induration and palpable cord surrounding to IV cannula. 2. Proximal massage: It is the massage given by the researcher on the proximal area about two centimetres away from cannulation site in the direction of blood flow that allows blood to move in one direction after pouring a drop of oil on the site. Gentle massage is provided for a total of 5-10 minutes at an interval of 30 seconds to one minute in sessions of about 20 strokes per session using palmer surface of fingers and given twice a day for three days. 3. Palm fisting: It is the exercise performed by patients under the supervision of researcher by squeezing the soft ball in the cannulated hand for 5-10 minutes at an interval of 30 seconds to one minute in sessions for about 20 times in each session and is performed twice a day for three days. 4. Hot application: It is the application administered by researcher using towel (12×24 inches) soaked in warm water with temperature range from between 40 ºC-45ºC and squeezed in such a way that it retained some water and applied to area about two centimetres away from cannulation site in direction of blood flow for 5-10 minutes, twice a day for three days. 5. Thrombophlebitis: It is pain, redness near IV site, swelling, erythema, induration and palpable cord surrounding to IV cannula and pyrexia after cannulation and assessed by VIP Scale and VRS and categorized as no signs of phlebitis, possible first signs, early stage, mild stage, advanced stage of phlebitis and advanced stage of thrombophlebitis. 6. IV cannulated patients: patients who undergo IV cannulation in MMIMS&R Hospital.

Tools and techniques Demographic profile proforma:
It included five items i.e. age, gender, previous history of smoking and alcohol, current alcoholic status, and current smoking status. A self report method was used to collect the data regarding sample characteristics of the patient.

Proforma for Clinical variables:
It included 12 items i.e. cannula size, purpose of cannulation, body part of cannula insertion, anatomical region, number of needle pricks, method of drug administration, patient's relative doing any cannula site care, any bleeding disorder, patient is prescribed for any anticoagulants, previous hospitalization, previous thrombophlebitis and any medication prescribed for cannula site.

Visual Infusion Phlebitis Scale (VIP):
VIP scale is a standardized zero to five points rating scale and used to assess the phlebitis and thrombophlebitis. VIP scale was developed by Andrew Jackson (1998).

Verbal rating scale (vrs):
Keele in 1948 described the verbal rating scale. This scale is used to assess pain intensity of patients and comprised of a score from 0-10. Patients were asked to rate the pain intensity at cannula site. There are six adjectives on the list that range from "no pain" to "worst possible pain".
The inter-rater reliability was determined by using Cohen's kappa and inter-rater reliability was found to be 1 for Visual Infusion Phlebitis Scale and 1 for Verbal Rating Scale. Pre assessment at 6 hours and administration of proximal massage, palm fisting, hot application and no intervention; post assessment of risk of thrombophlebitis in PMG, PFG, HAG and CG using VIP scale and VRS scale was done at 18 hours, 24 hours, 30 hours, 48 hours, 54 hours and 72 hours after cannulation. The intervention was administered once a day on day of cannulation and twice a day for next two days and last assessment was done on 72 hours. The data was collected by record analysis, observation and self reporting.

Statistical Analysis
The data was organized and, analyzed and interpreted by using descriptive and inferential statistics using SPSS version 20.0. A p value <0.05 was considered significant for the present study.

Conclusion:-
The use of hot application was more effective in reducing risk of thrombophlebitis and palm fisting exercise was least effective. Therefore, it is recommended that the 'hot application' can be used among peripheral venous cannulated patients to prevent complications and increase the patient comfort.

Discussion:-
In the present study more than half (56.53%) of patients were males. This finding was similar with the study conducted by Daud  In the present study the mean post test of comparison group was 2.73 ± 0.980 and in hot application group was 0.87 ± 1.224. This finding was similar with the study conducted by Shilpa, M Kaur et al. (2015), which showed that, the mean post test of control group was 1.5 ± 0.71 and in hot application group was 0.95 ± 0.59 and findings of the study was similar conducted by Packialakshmi K, Vidhya T (2017), which showed the mean post VIP score of hot application group was 0.8 ± 0.8.In the present study the mean post test VRS score in hot application group was 1.07 ±1.46. This finding was similar with the study conducted by Packialakshmi K, Vidhya T (2017), which showed the mean post test VRS was 2.4±1.1.

Financial support
The researcher received no grant from any funding agency.