RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE

ANNEXURE I

PROFORMA FOR REGISTRATION OF SUBJECTS

FOR DISSERTATION

1. / Name of the candidate and address / MISS JENCY JACOB
I YEAR M. Sc. NURSING
K. PANDYARAJAH BALLAL NURSING INSTITUTE,
COLLEGE OF NURSING,
MANGALORE
2. / Name of the Institution / K. PANDYARAJAH
BALLAL NURSING INSTITUTE, COLLEGE OF NURSING,
MANGALORE
3. / Course of study and subject / M. Sc. NURSING,
MEDICAL SURGICAL NURSING
4. / Date of admission to the course / 1.06.2011
5. / Title of the study:
“EFFECTIVENESS OF GLYCERINE MAGSULF APPLICATION
VERSUS HOT FOMENTATION IN RELIEVING PHLEBITIS AMONG IV CANNULATED PATIENTS IN A SELECTED HOSPITAL, MANGALORE”
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8 / Brief resume of the intended work
Introduction
Today in hospital setting, intravenous (IV) therapy has become a major component of patient care. Intravascular lines are used for purposes varying from monitoring pressures, administering drugs and fluids. A common problem encountered during IV therapy is the phlebitis, ie the inflammation of the venous wall near the point of entry of the cannula into the veins. It is often due to patient movement and disruption of vein at the site of insertion of the cannula. The patients who are on cytotoxic drugs, hyper osmolar agents and vaso active drugs are more prone to phlebitis.
The Infusion Nurses Society National standards of practice (Australia) stated that a nurse who administers IV medication or fluid must know its adverse effects and appropriate interventions to be taken before starting the infusion1. Although many strategies to reduce this failure have been suggested, because of its multi factorial etiology, IV administration still continues to fail. Hence nurses need to be aware of and consider certain interventions to reduce phlebitis when managing IV therapy in patients.
6.1 Need for the study
IV medication administration refers to the process of giving medication directly into a patient's vein. All medication administration carries certain risks, but IV therapy adds another level of complexity. Even when the nurse follows the ‘five rights’ she can go wrong if the practices do not meet the standard of care for intravenous therapy2. Phlebitis is a common complication associated with the use of peripheral IV catheters, affecting between 27% and 70% of all clients receiving intravenous therapy. The cause may be mechanical, chemical, or bacterial, with bacterial being rarest. Phlebitis is painful, and cause discomfort to patients. Most often it results in recannulation, not only incurs extra costs but also takes up staff time. Signs and symptoms of phlebitis are painful intravenous site, sluggish flow rate, red lines visible above the
venepuncture site and edema3.
A descriptive study conducted at University hospital, Turkey on ‘pre-disposing factors of phlebitis in patients with peripheral intravenous catheters’. Among 568 IV sites observed, 355 patients had IV catheter-related complications. Using a phlebitis evaluation scale, the degree of phlebitis was observed. More than half (54.5%) of the catheter sites had phlebitis. They concluded that phlebitis not only causes sepsis, pain, additional diagnostic investigations, treatments, increased duration of hospitalization, patient’s stress level, and financial burden, but also increases staff workload. They recommended that advanced practice nurses need to be aware of the factors that increase the likelihood of phlebitis and take appropriate action4.
Glycerine magsulf application and hot fomentation are effective and inexpensive interventions for relieving phlebitis. Glycerine magnesium sulphate gets absorbed into the skin easily, reduce inflammation and stiffness, thus alleviate pain and promote tissue metabolism as well as the process of healing. Hot fomentation causes vasodialation and thus improves blood flow to injured body part, promotes delivery of nutrients and removal of wastes, lessens venous congestion in injured tissues.Considering this aspect, the researcher felt the need for conducting study to reduce the phlebitis in patients with IV cannulation. The purpose of the study is to find out the effective intervention to reduce phlebitis, both glycerine magsulf and hot fomentation are cost-effective.
6.2 Review of literature
A prospective observational study was conducted on “peripheral intravenous catheter related phlebitis and its contributing factors among adult population” at Dhulikhel Hospital, Kathmandu, Nepal. Peripheral intravenous catheter-related phlebitis was reported as a common and significant problem in clinical practice. The study was carried out to determine the occurrence of peripheral intravenous catheter related phlebitis and to define the possible factors associated with its development. The study was carried out in 230 clients who were under first time peripheral infusion therapy, during two months period. Peripheral infusion site was examined for signs of phlebitis once a day. Jackson standard visual phlebitis scale was used to measure the severity of the phlebitis. Phlebitis developed in 136/230 clients (59.1%). It was very mild in most cases. Increased incidence rates of infusion related phlebitis were associated with males, small catheter size (20 gauge), insertion at the sites of forearm, IV drug administration and blood product transfusions. The incidence rate of phlebitis rose sharply after 36 hours of catheter insertion. Related risk factors found in the study were insertion site (forearm), size of catheter (20G) and dwell time (>36 hours). There was higher incidence of phlebitis among the clients with intravenous drug administration especially between 21-40 years. Therefore, the study suggested more attention and care was needed in these areas by the care- providers5.
A quasi experimental study was conducted on “the effectiveness of cold application, heparinoid and magnesium sulphate application on superficial thrombophlebitis” among patients in selected hospitals of Indore. A superficial thrombophlebitis scale and pain intensity distress scale were used for data collection. Following the pre-test, intervention with cold application was given to1st experimental group (C) for 20 mt, 2nd experimental group(H) was intervened with heparinoid application using thrombophob ointment and similarly in 3rd experimental group (M), magnesium sulphate dressing was done. All the interventions were given three times a day for three days. The findings of the study indicated that the computed ‘t’value of cold application group[t14=14.33], heparinoid application group[t14=20.82],and magnesium sulphate application group[t14=20.82] were statistically significant, which suggested that all three interventions were effective in reducing the signs and symptoms of superficial thrombophlebitis. The computed ‘F’ratio of all the three groups [F2.42=10.10] showed that three types of application differ significantly. However, the mean difference of magnesium sulphate group[18.34] was higher than the cold application[13.33] and heparinoid application[12.8] group. This concluded that magnesium sulphate application was most effective intervention in reducing the superficial thrombophlebitis6.
A quasi experimental study was conducted on “the effectiveness of hot fomentation in reducing the signs and symptoms of thrombophlebitis caused by intravenous infusion and medications” among in-patients in Medical or Surgical wards at RMMCH, Chidambaram, Tamilnadu. A sample of 30 patients with IV thrombophlebitis [15 in experimental and 15 in control groups] was selected. Experimental group was provided with the moist hot fomentation for 15 mts every 2 hrs upto a total of 8 hours[105-115o F / 40-460C]. Data collection was done using interview and observational method. The average pain level in the experimental group was 2.86 initially. At the end of the intervention, the pain was reduced from 2.86 to no pain in the experimental group. This showed the effectiveness of hot fomentation. To assess these variations, two way ANOVA repeated measures analysis was done {p<0.001}. The average level of swelling in the experimental group was 1.90 initially. At the end of the intervention, the swelling was reduced from 1.90 to no swelling (0.00) in the experimental group. This also showed the effectiveness of hot fomentation. To assess these variations, two way ANOVA repeated measures analysis was done (p<0.001)7.
A quasi-experimental study was conducted at Portland, on “effect of warm and cold application on resolution of IV phlebitis” .The purpose of the study was to determine the effect of cold application on the intensity of pain and speed of resolution of extravasation of a variety of commonly used intravenous solution. The findings revealed that application of warmth to sites of IV phlebitis produced faster resolution of extravasation than did cold application at a significant difference, F=14.38, p<0.0018.
A quasi experimental study was conducted on “the effectiveness of four modalities of nursing interventions on phlebitis -Icthamol belladonna, Icthamol belladonna with hot fomentation, glycerine magnesium sulphate, and glycerine magnesium sulphate with hot fomentation”. The research design adopted was pre- test post –test design. The sample size consisted of 60 patients. The sample was distributed among four groups with 15 patients in each group for different interventions. The tools included in the study were demographic data, phlebitis measurement chart, indurations and palpable venous cord, an observation check list and a visual analog pain scale. Comparison of four modalities of treatment for the management of peripheral intravenous infusion related phlebitis was done by using single factor ANOVA. There was a significant difference seen among the four modalities of treatment for the reduction of pain, erythema, swelling, induration, and palpable venous cord at the phlebitis site p<0.01. Mean pre score of all dependant variables among patients in all groups were almost same, but post treatment the maximum reduction was found among patients in Group III, ie who had treated with Icthamol belladonna with hot fomentation9.
A quasi experimental study was conducted on “the effectiveness of hot fomentation v/s cold compress for reducing intravenous infiltration” in a selected hospital of Pune city. Pre-test and post-tests were conducted in a sample of 60.Data collection tools included an observational check list which consisted of standardized infiltration scale and behavioral pain scale. Findings proved that the pre treatment mean score of degree of infiltration was 7.1667 and it was decreased to 0.7071 on the 3rd day of treatment with hot fomentation. The pre-treatment mean score of degree of infiltration was reduced from 6.9333 to 0.7571 on the third day of treatment with cold compress treatment. The intensity of pain was reduced from severe [56.66%] to no pain [93.4%] in hot fomentation group. In cold compress group, the intensity of pain was reduced from moderate[60%] to no pain[86.6%].The mean score of hot fomentation group was 6.5067 in reducing the degree of infiltration while cold compress the mean score was 6.6.It proved that the hot fomentation is slightly better than the cold compress10.
6.3 Statement of the problem
“Effectiveness of glycerine magsulf application versus hot fomentation in relieving phlebitis among patients with IV cannulation in a selected hospital, Mangalore.”
6.4 Objectives of the study
The objectives of the study are to :
1.  assess the degree of phlebitis among patients with IV cannulation.
2.  determine the effect of glycerine magsulf application in reducing phlebitis using Jackson’s visual infusion phlebitis scale.
3.  determine the effect of hot fomentation in reducing phlebitis using Jackson’s visual infusion phlebitis scale.
4.  compare the effectiveness between glycerine magsulf application and hot fomentation in reducing phlebitis.
6.5 Operational definitions:
Effectiveness: In this study, effectiveness refers to the degree of reduction in phlebitis either by application of glycerine magsulf or hot fomentation as measured in terms of Jackson’s visual infusion phlebitis scale.
Glycerine magsulf application: It refers to a gauze pad soaked in warm magnesium sulphate granules saturated with glycerine, topically applied and secured with a two inch roller bandage three times a day, continuously for two days which reduce inflammation, stiffness and, thus alleviate pain and promote tissue metabolism as well as the process of healing.
Hot fomentation: In this study, hot fomentation refers to application of a lint piece wrung from boiling water and covered with a cloth, applied for 15 minutes three times a day, continuously for two days.
Phlebitis: It is the inflammation of the veins. In this study, phlebitis means a painful swelling and raised temperature at the intravenous infusion site along with hardness (induration), redness (erythema), and palpable vein as measured of Jackson’s visual infusion phlebitis scale.
IV cannulated Patients: In this study, IV cannulated patient refers to medical and surgical patients in whom an IV cannula is inserted for the administration of medications and fluids.
6.6 Assumptions
The study assumes that,
1.  the patients exhibit relief by the application of glycerine magsulf and hot
fomentation at the site of phlebitis .
2.  phlebitis can be measured through Jackson’s visual infusion phlebitis scale.
6.7 Delimitations
The study is delimited to:
1.  patients with phlebitis related to IV cannulation.
2.  patients who are willing to participate in the study and who are admitted during the data collection period.
6.8. Hypotheses
The following hypotheses will be tested at .05 level of significance:
H1-There will be a significant reduction in phlebitis with glycerine magsulf application.
H2- There will be a significant reduction in phlebitis with hot fomentation.
H3- There will be a significant difference between the effect of glycerine magsulf and hot fomentation in reducing phlebitis.
Materials and methods
7.1 Source of data
Data will be collected from IV cannulated patients with phlebitis in a
selected hospital, Mangalore.
7.1.1 Research design
The research design selected for the present study is quasi experimental
two group pre-test and post-test design.


R1: Group I ; R2: Group II
X1: Glycerine magsulf application; X2: Hot fomentation
O1: Pre-test ; O2:Post-test
7.1.4 Setting
The study will be conducted in medical and surgical wards of a selected hospital, Mangalore.
7.1.5 Population
In the present study, population consist of all medical and surgical patients
aged 21-45years who are admitted in a selected hospital, Mangalore.
7.2 Method of data collection
7.2.1 Sampling procedure
In this study, the patients will be selected through simple random sampling.
7.2.2 Sample size
40 samples, 20 for each selected intervention.
7.2.3 Inclusion criteria
Patients who are:
1.  conscious and well oriented.
2.  admitted in the medical and surgical ward during the time of data collection.
3.  with phlebitis in the fore arm.
7.2.4  Exclusion criteria
Patients who are:
1.  critically ill.
2.  unconscious.
3.  known skin allergic.
4.  not willing to participate in the study.
5. on cytotoxic drugs.
7.2.5 Instruments intended to be used
1.  Tool 1: Base line Performa
2.  Tool 2: Jackson’s visual infusion phlebitis scale
7.2.5  Data collection method
Data collection period will be for 4-6 weeks. The researcher will get the permission from the concerned authority. The purpose of the study will be explained to the selected patients and informed consent will be obtained from them. First group of the patients will be treated with glycerine magsulf. A gauze pad soaked in warm glycerine magsulf applied on the affected site and secured with a two inch roller bandage three times a day, continuously for two days. In the other group, a lint piece wrung from boiling water is applied on the affected site for 15 mts, three times a day, continuously for two days. The phlebitis will be assessed by using Jackson’s visual infusion phlebitis scale before and after the test.