Dissertation Proposal

DISSERTATION PROPOSAL

“A COMPARITIVE STUDY TO ASSESS THE EFFECTIVENESS OF HOT AND COLD APPLICATION IN REDUCTION OF PAIN AND OEDEMA ON INTRAVENOUS INFILTRATION SITE AMONG THE PATIENTS ADMITTED IN ICU AT SELECTED HOSPITALS, BANGALORE, KARNATAKA”

SUBMITTED BY

MR.YUVARAJA.A

I YEAR M. Sc NURSING

MEDICAL & SURGICAL NURSING

SMT.LAKSHMI DEVI COLLEGE

OF NURSING, BANGALORE (RURAL)

2011 - 2013.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

ANNEXURE-2

1. / NAME OF THE CANDIDATE AND ADDRESS / : / MR.YUVARAJA.A
I YEAR M.Sc NURSING
MEDICAL-SURGICAL NURSING
SMT.LAKSHMI DEVI COLLEGE OF NURSING, HOSKOTE.
BANGALORE (RURAL)
2. / NAME OF THE INSTITUTION / : / SMT.LAKSHMI DEVI COLLEGE OF NURSING.
3. / COURSE AND SUBJECT / : / I YEAR M.Sc NURSING
MEDICAL-SURGICAL NURSING
4 / DATE OF ADMISSION TO COURSE / : / 16-06-2011
5. / TITLE OF THE TOPIC / : / A COMPARITIVE STUDY TO ASSESS THE EFFECTIVENESS OF HOT AND COLD APPLICATION IN REDUCTION OF PAIN AND OEDEMA ON INTRAVENOUS INFILTRATION SITE AMONG THE PATIENT ADMITTED IN ICU AT SELECTED HOSPITAL, BANGALORE, KARNATAKA.

INTRODUCTION

“An ounce of prevention is worth a pound of cure”

-Gregory Y

The history of intravenous therapy began with the discovery by Sir. Williams Harvey. The first practical application was by Dr. Thomas Latta, who used infusion of saline to treat the intractable diarrhea. Approximately 90% of patients in acute care setting receive some form of intravenous infusion therapy.

The intravenous infusion is an important aspect of therapy under both medical and surgical conditions. Physiologic homeostasis with in the body requires the presence of an adequate supply of fluids. The fluids circulating the body are composed of water, electrolytes, minerals and cells. Their imbalances may result from many factors like injury, surgery and different kinds of medical illnesses. These imbalances can be corrected by intravenous therapy. Intravenous therapy has become a lifesaving as well as life sustaining therapy and the intravenous therapy is increasingly being performed by nursing staff in hospitals. So, starting IV infusion is more challenging skills in nursing1.

Administering drugs by the intravenous route has advantages. Often the nurse uses the intravenous route in emergencies when a fast acting drug must be delivered quickly. The intravenous route is also best when constant therapeutic blood levels must be established. Some medications are highly alkaline and irritating to muscles and subcutaneous tissues. These drugs cause less discomfort when given intravenously.

Infiltration occurs when a catheter (or) needle penetrates the vessel wall during venipuncture (or) later slip out of the vein and allows intravenous solution to flow into surrounding tissues. This is manifested as swelling from increased tissue fluid around the venipuncture site, pallor, warmth, decreased flow of rate, stop of flow and pain resulting from oedema and increasing proportionately as the infiltration worsens2

The interior wall of a vein (the tunica intima) consists primarily of a single layer of tightly packed endothelial cells. Injury to (or) irritation of this layer causes the release of histamines, bradykinin and serotonin. These in turn initiates the pain response, dilatation of the vein and increasing blood flow to the area. Capillary permeability also increases, allowing fluids and proteins to leak into the interstitial space and causing oedema and tenderness3.

Factors associated with the development of infiltration are integrity and state of veins, insertion technique, cannula location, insertion into the bony extremity (or) movable joints, size of cannula, use of steel needles, infusion of certain drugs, duration of therapy, increased length of time over 24 hrs, interruptions in blood flow, hyperosmolar parenteral fluids, PH, acidic infusates, chemotherapeutic drugs and duration of soft tissue exposure to vesicants.

When infiltration occurs infusion must be discontinued and if necessary re-inserted into another extremity. To reduce discomfort caused by infiltration, the nurse should elevate the extremity, which promotes venous drainage and helps to decrease Oedema, and wrap the extremity in a warm towel for 20 minutes which increases circulation and reduces pain and oedema. 4

Local responses to heat and cold occur through stimulation of temperature sensitive receptors in the skin. Impulses travel from the periphery to the hypothalamus and the cerebral cortex. The hypothalamus then initiates heat producing (or) heat reducing location of the body. The conscious sensation of temperature is aroused in the cerebral cortex. These interventions are effective by decreasing swelling through cold application, decreasing stiffness through hot application and increasing large diameter nerve fiber input to block small diameter pain fiber messages by cold and hot application.

Managing an intravenous therapy regimen has become a common nursing responsibility and it is the part of extended role of nurses. While, due to advances in technology intravenous therapy is now relatively safe, it is still possible for serious complication to arise. Unfortunately, these complication are sometime regarded as routine occurrence (or) a mere ‘nuisance’, but to overlook or underestimate the potential risk of intravenous therapy is to lose site of the aim of therapy, which is to effectively replace fluid and electrolytes without causing the patient discomfort (or) further injury5.

Studies to evaluate the effect of icepack application 15 minutes for four times daily and have suggested local cooling to minimize injury by reducing the cellular uptake of chemotherapeutic agents and found that in 89% the cellular uptake of the drug is decreased and thus suggest local cooling for extravasation of vesicants.

Warm application Cold application

Vasodilation Vasoconstriction

Improved blood flow to the injured part decreased blood flow

Increases capillary permeability promotes Increased blood Decreased Delivery of Oxygen and nutrients viscosity swelling

Increases tissue metabolism Decreased cell metabolism

Promotes removal of waste products and Decreased sensitivity of nerve

pain producing prostaglandin fibers and receptors.

Reduces muscle tension Decrease local pain

6.1 NEED FOR THE STUDY

In keeping with the latest research, current guidelines from the center for Disease control and prevention [CDC] state that, even when no problem arise in association with catheter use, peripheral venous catheters should be replaced and sites rotated at least every 96 hrs. The practice of not changing a catheter because the patient shows no signs of complications such as infiltration, thrombophlebitis should be avoided, especially in patients who are neutropenic, immuno suppressed or malnourished as these conditions delay the appearance of symptoms7.

The practice of infusion therapy had become such a considerable component of nursing practice that in 1981 congress proclaimed January 25th as national Intravenous nurses Day. The Intravenous Nurses Society (INS) is the professional organization that establishes standards of practice to promote excellence in intravenous nursing to ensure the highest quality, cost effective care for all individuals requiring infusion therapy.

The nurse practicing in today’s world is faced with a myriad of duties and responsibilities involving specialized skills and techniques. IV infusion therapy is one of the major responsibilities of the nurse in her day to day practice and an area that is continually expanding.

Intravenous sites are selected to accommodate the intended solution. The nurse should inspect and palpate the site for oedema, erythema, warmth, induration (hardness), pain and discomfort. When palpating the site, the nurse will find that an infiltrated area is warm/cool and the skin may have blanched appearance. The site of the infiltration is to be monitored quickly because usually fluid reabsorbs within 24 hrs8.

Pain at the intravenous site is the primary warning that more serious complications may ensue. Since pain is subjective, it is extremely important for the nurse to assess, intervene and evaluate each patient’s discomfort on an individual basis. Oedema may indicate an infiltration has occurred. The extremity should be compared with the opposite hand or arm if the site seems edematous.

The application of hot or cold may relieve pain through a ‘counter-irritant’ effect as well as by direct effect on peripheral and free nerve endings. Before applying hot or cold therapies, the nurse has to assess the patient’s physical condition for signs of potential intolerance to heat and cold. The nurse is legally responsible for safe administration of hot and cold application.

Both of these nursing interventions (Hot and Cold application) has therapeutic effect in reducing pain and oedema as follows;

Symptoms / Hot application / Cold application
Pain / Promotes muscle relaxation and decrease pain from spasm /stiffness / Decreases nerve conduction velocity, induce numbness/ paresthesia
Oedema / Increases absorption of fluid by capillaries and promotes removal of excess fluid from interstitial spaces, thereby reducing oedema. / Controls swelling by reducing the permeability of capillary walls and the escape of extra cellular fluids.

Because of the similar therapeutic effect of these two interventions especially in reducing pain and Oedema of intravenous infiltration site, it makes lot of confusion among nurses to practice the ideal choice of intervention which promotes patient comfort by relieving pain and Oedema. This made the investigator to be more interested to compare the effectiveness of hot and cold application in reducing pain and Oedema of intravenous infiltrated site. This research found useful to identify the ideal method of intervention which helps to relieve the discomfort and promote the comfort of the patient with intravenous infiltration9.

6.2. REVIEW OF LITERATURE

This chapter is designed to include the review of literatures and the conceptual framework adapted for this study.

The review of literature entails the systematic identification, reflection, critical analysis and report of existing information in relation to the problem of interest. Review of research topic serves several purposes. A familiarity of previous study is useful in suggesting research topics in identifying aspects of a problem about which more research is being done.

The investigator reviewed literature available on IV infiltration – development, complications and management, and the effect of hot and cold application in reducing pain and Oedema. Part – I consists of the related literature for the study and part –II the conceptual framework.

PART – I : REVIEW OF RELATED LITERATURE

This is classified under three sections.

Section A: Studies related to development of IV infiltration.

Section B: Studies related to management of IV infiltration.

Section C: Studies related to effectiveness of hot and cold application in reducing pain and Oedema.

Section A - Studies related to Development of IV infiltration:

A retrospective study on the complications of peripheral intravenous catheters in hand and forearm with the aim of identifying the most common sites for developing infiltration. The records of 67 patients from Komagone city hospital were reviewed. By using Mean and standard deviation, the study found that, there were 56 minor complications which comprises of 26 intravenous infiltrations out of 11 major complications as phlebitis, 6 skin necrosis, 2 compressive nerve lesions, digital stiffness is one and compartment syndrome is one10.

A descriptive study to identify the risk factors of intravenous related complications with 40 patients. By using observation check list the signs & symptoms were assessed which reveals that, the type of infusates, duration of cannulation more than 3 days (50%), IV antibiotics (12%), female sex(12%), catheter material PEO - vialon and Teflon (6%), anatomic site - forearm related (12%) and wrist(8%)11.

A descriptive study on incidence and complication of intravenous infusion with the aim of identifying the IV related complication. The samples were 650 patients with IV cannula from Nice University Hospital, among whom 219 were women (46%) and 331 were men (54%). The Chi-square findings show that 54(13.6%) had thrombophlebitis, 50(13.2%) had Infiltration and 9 (2.3%) had swelling and local infection12.

A descriptive study on peripheral intravenous complications and its risks with the aim to identify the relationship between peripheral intravenous catheters dwell time and the development of phlebitis and infiltration in medical surgical units of Iowa City. Log rank tests were used to test for an association between the covariates and the time until failure. The Correlation findings show that, the total differences in the estimated failure rates item. The catheter lasting 6 days versus a new catheter inserted for another 3 days is 1.3% because the conditional failure probability estimates for days 4, 5 and 6 are slightly higher than for day 1, 2 and 313.

A descriptive study on complications of peripheral vein with the aim to identify the causes of complications and its incidence with 50 inpatients, Toronto Research institute, Toronto. By using mean and standard deviation, the findings stated that infiltration and Extravasation (62%), subcutaneous hematoma (21%), spontaneous rupture of vein (6%), obliteration of Vessel (2%), superficial phlebitis (2%), external bleeding (0.5%) and the cause is due to incorrect techniques of insertion, placement and administration of IV solution14.

A comparative study on complications of intravenous therapy with steel needles and Teflon catheters with 954 cannula insertions. The risk of phlebitis was significantly greater with Teflon catheters (18.8 % with Teflon catheters, 8.8 % with steel needles), steel needles were significantly associated with infiltration (17.9 % with Teflon catheters, 40.1% with steel needles). The overall rate of complications was significantly greater for the group in which steel needles were used (53.8 % versus 64.0 %), basically due to the increased risk of infiltration with steel needles15.

A descriptive study on infectious complications among patients receiving home intravenous therapy with peripheral, central or peripherally placed central venous catheters in Springfield Clinic, Illinois, with 300 patients from two hospitals based home IVT services over 29 months. 6 bacteremia’s (one death), 2 subclavian thrombosis, 13 catheter site infections, and 1 additional death occurred. Among PICC patients mean duration of therapy was 24 days (0-67) and was completed in 51 patients; others completed therapy with standard peripheral catheters a mean of 6 days later. Complications included 17 obstructions by clot, 11 cases of phlebitis, 6 catheter fractures, 5 punctures, 2 accidental removals and 1 infiltration. They conclude that home IVT is safe via many means of access with fewer infections than with hospital care. Such infections may be termed “nosohusial.” 16