RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

Ms. KALPANA KHANAL

I YEAR M.Sc. NURSING
MEDICAL SURGICAL NURSING
YEAR 2011-2013

PADMASHREE INSTITUTE OF NURSING

BANGALORE -560 060

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

NAME OF THE CANDITATE

AND ADDRESS

Ms. KALPANA KHANAL

I Year M.Sc. Nursing,
Padmashree Institute of Nursing,
Kommagatta,
Bangalore 560 060.

NAME OF THE
INSTITUTION

COURSE OF THE STUDY I Year M.Sc. Nursing,

AND SUBJECT

Medical surgical Nursing.

DATE OF ADMISSION TO
THE COURSE

Padmashree Institute of Nursing, Bangalore.

TITLE OF THE STUDY

31-10-2011
Effectiveness of moist heat therapy on the
visibility and palpability of peripheral veins
before peripheral venous cannulation among
patients undergoing intravenous cannulation
in a selected hospital, Bangalore.

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION
Every human being is the author of his own health. As the heart beats, it pumps blood
through a system of blood vessels, called the circulatory system. The blood vessels are the elastic
tubes that carry blood to every part of the body. The three types of blood vessels are arteries,
veins and capillaries. Arteries carry blood away from heart; veins return blood back to heart.
Capillaries exchange water and chemicals between blood and tissues.1
Veins are carrying deoxygenated blood from the capillaries in the extremities back to the
heart. Peripheral Veins are the veins in the arms, hands, legs and feet. Peripheral veins of the
body are: radial vein, basilic vein, cephalic vein, median vein, median cubital vein, superficial
dorsal vein, dorsal venous arch, dorsal plexus, and great saphenous vein.2
Intravenous cannulation is the most frequently used procedure in the wards, casualty and
in preoperative surgical patients. It is a very painful and stressful procedure, thus emotions may
become exaggerated at times, triggering vasovagal reaction. Patients anxiety and fears
concerning needles are real and may even prevent them from seeking health care.3
According to a report Intravenous (IV) cannulation is a significant source of adult pain
and distress. Accumulating evidence has demonstrated that pain from IV cannulation is a
significant source of adult pain and distress with effects far more reaching than the presenting
event. When describing worse pain experiences in hospitalized adult, IV cannulation pain was
found second reason in hospitalized patient. Practitioners recognize the need to mitigate or
decrease adult IV cannulation pain and distress in emergency department patients, yet often do
not provide the relief measures that are available.4
Many patients admitted in the hospital undergo cannulation. Intravenous cannulation is
done on casualty, ICU or in the wards according to the need of the patient. Intravenous
cannulation used for Intravenous therapy for patients, for some patients it may be a means to
rehydrate patient; for others it may be a way to administer antibiotics. Intravenous therapy may

be used to correct electrolyte imbalances, to deliver medications, for blood transfusion, fluid
replacement to correct dehydration and it can be used for chemotherapy patients.
In modern medical practice, more than 60% of hospitalized patients receive intravenous
therapy at some point during their admission. Medication, fluids, nutrition, and blood products
can all be given via the intravenous route, which can be either peripheral or central. Although
common, these practices are not devoid of complications, which may lead to mortality and
morbidity, increased duration of hospital stay, and significant costs.5
Peripheral veins are the most common intravenous access method in both hospitals and
paramedic services for a peripheral intravenous cannulation for intravenous therapy. Intravenous
therapy is the infusion of liquid substances directly into a vein. The word intravenous simply
means "within a vein". Therapies administered intravenously are called intravenous therapy.
Compared with other routes of administration, the intravenous route is the fastest way to
deliver fluids and medications throughout the body so most of the hospitals prepared for the
peripheral cannulation procedure to administering medication. Insertion of intravenous cannula
is probably the most commonly performed invasive medical procedure. Insertion is usually
technically easy and causes patients only mild distress and for some patients it is not easy to
identify the veins for cannulation, so it takes time to do cannulation.6
Cannula insertion is notorously difficult in intravenous drug users and patients having
repeated course of chemotherapy. The procedure is also difficult in infants and children, obese
patients and black people. It is often complicated in patients who are afraid of needles or have
bad experiences because fear activates the sympathetic nervous system there by provoking
peripheral vasoconstriction.7
Palpation of the vein is important in determining the condition of the vein, the criteria for
good vein are: bouncy and soft, well supported, refill when depressed, visible and straight, have
a large lumen.8
Peripheral venous cannulation is the commonest method used for intravenous therapy.
There are numerous well recognizedindications and contraindications for peripheral venous
4

cannulation, but, despite these, there is no doubt that many intravenous lines are inserted
unnecessarily. A study conducted on 1000 patients in general medical wards shows that idle
intravenous cannula present in 33% of patients.9
Most common veins on the non-dominant forearm are most suitable, if the cannula has to
remain in position for any length of time. Veins on the dorsum of the hand are easiest to
cannulate, but are more uncomfortable for the patient and more liable to block. Veins in the
lower limb should be avoided where possible because of the increased incidence of
thrombophlebitis and thrombosis.10
Insertion of intravenous cannula often is a source of patients anxiety and discomfort.
About 20% of adults experience a mild to moderate fear of needles and have anxiety leading to
bradycardia and hypotension. Thus, because of the fear of intravenous insertion sometimes
multiple attempts may occur, which can further lead to distress and anxiety in the patient.11
Various strategies can be used, if it is difficult to identify a vein that is suitable for
cannulation. A tourniquet should be applied 510 cm proximal to the selected site. Warming of
the limb improves peripheral vasodilatation. This can be done with warmed poultices or a basin
of water. Using a carbon fibre warming mitt, which was designed to provide reproducible
amounts of heat,the study concluded that local warming facilitates the insertion of peripheral
venous cannula, reducing both the time and number of attempts required. The study shows that
topical venodilatation may also be achieved by applying 4% nitroglycerine ointment, smeared
onto the skin and left for 23 minutes.12
A prospective study was conducted on intravenouscannula patients. Sample size was
500. The study shows that 500 intravenous cannula inserted, 37% were 18 gauge, 46% were 20
gauge and 18% were 22 gauge. Gauge of intravenous cannula was the most significant predictor
of increased longevity of intravenous cannulas. The median survivals of 18, 20 and 22 gauge
were 57 hour, 43 hour, and 29 hour respectively. The site of intravenous cannulas placement
influenced the longevity of intravenous analysis, the most marked effect on intravenous cannula
longevity was evident in those patients with 18 gauge placed in the forearm/wrist (median 72
hour) with less marked changes in other site/gauge combinations. In contrast, 22 gauge ICs
placed in the hand had a median lifespan of 29 hour.13
5

When peripheral venous access cannot be obtained and there is a need for intravenous
therapy, placement of a central venous line should be considered. Although this is a last resort as
a simple substitute for peripheral access, central venous access may be indicated for other
reasons. In addition, the morbidity rate in critically ill patients is lower from centrally inserted
central catheters than from peripheral intravenous catheters.14
The most common complications of peripheral venous cannulation are thrombophlebitis
and extravasation. These result in an inflammatory reaction, which is manifested as pain,
swelling, and erythema. In some patients, this can progress to local or systemic infection and, in
rare cases, may result in a pulmonary embolism. This inevitably leads to increased workload for
medical and nursing staff, and in some cases prolongs the duration of hospital stay.15
The rate of phlebitis increases with the time that the cannula remains in place, and, for
this reason, it is currently recommended those intravenous cannulas are routinely changed after
4872 hours. However, more recent studies have shown no increase in cannula related
complications, including thrombophlebitis, when the duration was prolonged to 96 hours. This
suggests that routine replacement is not necessary, but that each cannula should be inspected
daily and removed should there be any clinical evidence of infection.6
The various warming methods includes immersion of patients hand and arm in warm
water, wrapping the arm with a moist towel, application of dry heat chemical warm pack and use
of a micro waved wheat filled bag for easy visible and palpation of veins. Others procedure
which have been demonstrated to improve venous visibility include gently tapping over the site,
applying tourniquets or asking the patients to clench and relax their hands and by hanging the
arms down.12
Application of heat increases in cutaneous blood flow in attributed initially to withdraw
of sympathetic vasoconstrictor activity and increases in sympathetic vasodilator activity.
Application of heat at the intravenous insertion site has been shown to increase the vein
visualization. Heat applications have four main effects on body tissues including pain relief,
muscle relaxation, blood vessel dilatation and connective tissue relaxation. The dilatation of the
blood vessels leads to the increase in the blood flow to the injured part.

6.2 NEED FOR THE STUDY

A study was conducted regarding IV cannulation in a hospital setting carried out by
the Agency for Healthcare Research and Quality. The report concluded that hospitalized IV
cannulated patients have increased by more than 80% from 1993 to 2006.8
According to a report in 2006, there were 503,300 hospital stays with IV cannulated
noted an increase of nearly 80% since 1993. More than 90% of the patients had IV cannula in
general ward and post-operative ward 100 % of patients had IV cannula line.In comparison
56.5% of male patients and rest of them were female and children. The cross sectional study
results shows that complication are phlebitis rates reported for patients receiving intravenous
therapy have been as high as 80%, with the rates in most hospitals ranging between 20% and
80%. Other complications resulting from intravenous cannulation include thrombophlebitis,
extravasation, and infection resulting from bacteremia and septicaemia.16
According to study 40 million people have intravenous catheters placed each
year.Intravenous catheters are a very important part of medical treatment for acute illness, cancer,
surgery, anesthesia, and trauma, allowing medications to reach as quickly and effectively as
possible via the blood stream to the parts of the body where they work.17
Veins suitable for peripheral intravenous cannulation are those on the dorsum of the hand,
cephalic and basilic vein of the forearm. Heat application produces vasodilatation which
increases the blood flow to the affected area by bringing more oxygen and nutrients. The
temperature elevation appears to have direct effects on the state of dilatation of the capillaries,
arterioles and venules. The increased metabolism leads to release of carbon dioxide, lactates and
promotes movements of waste products from the affected area.
Peripheral intravenous cannulation is a skilled process that involves a number of stages
and is increasingly being performed by nurses in a variety of clinical settings. Intravenous
therapy is an indispensible part of treatment for many patients. Patient value the time that nurses
spend finding the appropriate vein. Moreover they appear to gain a sense of a control from being
asked their preference of vein to cannulate.18

Peripheral venous cannulas are commonly used in hospitalized patients for the
administration of fluids, blood products, drugs and nutrition. Nurses are increasingly responsible
for selecting and placing cannulas particularly in specialty areas such as medical imaging,
emergency departments, intensive care units and oncologyunits. The average time requirement
for peripheral intravenous cannulation is reported at 2.5 to 13 minutes with difficult IV access
requiring as much as 30 minutes.19
An experimental study was conducted on the effect of dry versus moist heat application
on the improvement of intravenous insertion rates. The study suggests that dry heat was 2.7 times
more likely than moist heat therapy to result in successful intravenous insertion on the first
attempt had significantly lower insertion times and was more comfortable.20
Heat application decreases the likelihood of multiple intravenous insertion attempts and
procedure time and it is comfortable, safe and economical to use in patient and it does not cause
any harm to the patient.
A study conducted on local warming and insertion of peripheral venous cannulas. A study
shows that ten minutes of active warming significantly increased vein scores, thermal comfort,
and skin temperature. Patients were assigned to active warming, the success rate for insertion of
the cannula in these patients was 95% versus 73% in the passive warming group (P<0.001). The
time elapsing from beginning to search for an appropriate vein until successful cannulation was
20 seconds (8 to 32) shorter with active warming than with passive insulation (P=0.02. Skin
irritation was not seen.21
A delay in establishing vascular access can result in a delay in the administration of fluids
and or medications. Patients frequently experience delays in diagnosis and initiation of treatment.
In addition multiple attempts at attaining peripheral vascular cannulation result in frustration and
a loss of productivity by the treating team.22
Serious complications related to peripheral intravenous cannulation are uncommon but
problems can occur with prolong use. As with any side effects or complications of health care
procedures early detection and good communication between the patient and health care provider
are important. The complications are phlebitis, thrombophlebitis, septic thrombophlebitis, local
infection, infiltration, and hematoma and nerve damage.14
8

A study on gender variation in pain perception after intravenous cannulation in adults.

Immediately after the intravenous cannulation using 20 gauge intravenous cannula the subjective
pain was assessed by using Visual Analogue pain scale (VAS) on 0 (No pain) 10 (Max pain).
Pain perception was moderate to severe (5-10) in 64% of females as compared to 12% in males.
There was significant increase in pain perception in females compared to males.23
Patient admitted in the hospital for long term duration of hospital stay, they need long
duration intravenous cannula for intra venous therapy and administering medication but
according to hospital policy cannula should be changed every 48-72 hours to prevent cannula site
infection. So, the patient has to go frequent re - insertion of cannula and it makes difficult to
identify the vein due to repeated vein puncture. Many methods are available to easy
identification of venous, in one of

the beneficial method is application of heat on the

visualization and insertion of IV cannula have been reported but there is scarcity of information
on the effects of moist heat on the accessibility of peripheral veins. Thus the researcher
undertakes this study with an objective to assess effectiveness of moist heat therapy on the
visibility and palpability of peripheral veins for cannulation.
The investigator from the clinical experience has observed that most of the patients
admitted in the hospital undergo intravenous cannulation. During cannulation it was difficult to
find the vein and the patient has to be pricked many times. Hence the investigator felt a need to
apply moist heat therapy before cannula insertion to a patient undergoing intravenous cannula
insertion.

6.3 STATEMENT OF THE PROBLEM

A study to assess the effectiveness of moist heat therapy on the visibility and palpability
of peripheral veins before peripheral venous cannulation among patients undergoing intravenous
cannulation in a selected hospital, Bangalore.

6.4 OBJECTIVES
1) To assess the visibility and palpability of peripheral veins before application of moist heat
therapy among patients undergoing intravenous cannulation.
2) To assess the visibility and palpability of peripheral veins after application of moist heat
therapy among patients undergoing intravenous cannulation.
3) To compare the pretest and posttest visibility and palpability of peripheral veins among
patients undergoing intravenous cannulation.
4) To associate the pretest visibility and palpability of peripheral veins among patients with
intravenous cannulation with their selected demographic variables.

6.5 OPERATIONAL DEFINITIONS

Effectiveness: - It refers to the changes in the visibility and palpability of peripheral
veins which is elicited through vein assessment scale.
Moist heat therapy: - It refers to gauze piece soaked in water of 39.5 degree Celsius
temperature and kept on the vein which is chosen for IV cannulation.
Visibility: - It refers to the quality or degree of peripheral veins being visible; perceptible
by the eye. This is measured by using vein assessment scale.
Palpability: - It refers to the degree of peripheral veins being touched or felt. This is
measured by using vein assessment scale.
Peripheral veins: -It refers to the veins of the hand such as cephalic vein, basilica vein,
and dorsal venous arch.
Peripheral venous cannulation: - It refers to a process of inserting small tube made of
plastic used for giving drugs and fluids through intravenous route in peripheral veins.

6.6 ASSUMPTIONS
1) Moist heat therapy may increase the visibility and palpability of peripheral veins.
2) Visibility and palpability of peripheral veins may vary among patient undergoing
intravenous cannulation with their selected demographic variables of patients.

10

6.7 RESEARCH HYPOTHESIS

H1:-

There will be a significant difference between the mean pretest and posttest

visibility and palpability score of peripheral veins among patient undergoing intravenous
cannulation.
H2:- There will be a significant association between the pretest visibility and
palpability score of peripheral veins among patient undergoing intravenous cannulation
with their selected demographic variables.

6.8 REVIEW OF LITERATURE

A literature is a summary of previous research on a topic which can be either part of a
research project, a thesis or a bibliographic essay that is published separately in a scholarly
journal. The purpose of a literature review is to convey to the reader what knowledge and ideas
have been established on a topic and what are the strength and weakness. The investigator
carried out extensive review of literature on selected topics both research and non-research in
order to gain maximum relevant information and to perform in a scientific manner.24

Review of literature related to intravenous cannulation

A prospective cohort study was conducted on predictive factors for difficult intravenous
cannulation. Sample size was 1083 in operating room and 178 in the outpatient care unit. Times
to successful intravenous cannulation, success at first attempt, and potential predictors for
difficult cannulation were recorded. Success at first attempt was 73% and 81%, respectively.
This study shows that in one-fifth to one-third of the patients, intravenous cannulation required
more than one attempt. It is difficult to predict with accuracy the difficulty of intravenous
cannulation solely with easily obtainable patient characteristics.25
A prospective randomized study was conducted on ultrasound guided peripheral
intravenous catheter placement versus traditional techniques in difficult assess in pediatric
patients. Sample size was 50, with 25 patients randomized to each group. The overall success
11

rates for the ultrasound-guided group were 80% and for the traditional-attempts group, 64%,
with a difference in proportions of 16% (95% confidence interval, -9% to 38%, P = 0.208). The
ultrasound-guided group required less overall time (6.3 vs. 14.4 minutes, difference of -8.1
minutes [95% confidence interval, -12.5 to -3.6], P = 0.001), fewer attempts (median, 1 vs. 3; P =
0.004), and fewer needle redirections (median, 2 vs. 10; P G 0.0001) than traditional approaches.
The study concluded that ultrasound guided peripheral cannulation is effective than traditional
method.26
The descriptive study was conducted on gender variation in pain perception after intravenous
cannulation in adults. Sample sizes were 250. The study results shows that Thirty-nine percent of
the respondents experienced some discomfort, 39% some pain, and 17% some distress. No
patient reported an infection. Distress was more likely to be reported if there was no
understanding of why the IV cannula was placed. Pain perception was moderate to severe (5-10)
in 64% of females as compared to 12% in males. There was significant increase in pain
perception in females compared to males (X2 = 31.84, p<.001).Study concluded that the patients
with IV canulation felt discomfort and pain. 23
A cross sectional study was conducted on out of hospital intravenous cannulation. Sample
size was 450. The study results shows that complication are phlebitis rates reported for patients
receiving intravenous therapy have been as high as 80%, with the rates in most hospitals ranging
between 20% and 80%. Other complications resulting from intravenous cannulation include
thrombophlebitis, extravasation, and infection resulting from bacteremia and septicemia. Patients
also experience unnecessary discomfort or pain related to resting. Study concluded that 80% of
patients had phlebitis.27
A study was conducted on variables influencing intravenous catheter insertion difficulty
and failure, 339 intravenous catheter insertion were observed total of 77% of the IV insertions
were successful. The study results shows that nurses who were older, had more years of
experience, were certified in a specialty, and rated themselves higher in insertion skill had
significantly more successful insertions than their younger and less-experienced and less-skilled
counterparts (P< .001). Successful IV insertions were significantly faster (mean 32 seconds) than
unsuccessful ones (mean 66 seconds) (P< .001), and were rated as significantly less difficult
12

(P< .001). Failed IV insertions were associated with higher degrees of difficulty arising from
vein variables, such as vein rolled or vein was resistant to puncture, and patient variables, such as
tough or dark skin and patient movement. 28
An observational study was conducted on heart rate response to intravenous catheter
placement. Sample size was 80. Patients who required IV placement as part of their management
were considered as possible subjects. Heart rates were recorded. Subjects had a mean age of 48
years, and 54% were women. There was a normal distribution of heart rate changes, with greater
than 80% of all subjects having a 10% or less change in heart rates. The results of the analysis of
pain scores versus percentage change in heart rate at IV placement yielded a Pearson correlation
coefficient of 0.13 (p = 0.2). The results of the analysis of anxiety scores versus percentage
change in heart rate at tourniquet placement yielded a Pearson correlation coefficient of 0.014 (p
= 0.9).29
A prospective study was conducted on relevance and complications of intravenous
infusion at emergency unit, six hundred and thirty of 2515 patients (25%) received a peripheral
venous cannulation (290 women (46%) and 340 men (54%); mean age 58 years). Indication for
the peripheral venous cannulation was considered unjustified in 24.8% of cases upon arrival at
the emergency department, and 33.8% upon leaving the emergency department. Out of 318
patients, the peripheral venous cannula was left in place for no reason in 63 (20%). Overall, 390
peripheral venous cannulations were followed until the time of their removal. Mean duration of
IV infusion was 28 hour. Among these 390 patients, 62 (15.9%) developed complications, of
which 54 (13.6%) had thrombophlebitis and 9 (2.3%) developed local infection. Mean duration
of peripheral venous cannula left in place for patients with complications was 50 hours vs. 25
hours for patients with no complications (P<0.001). 30
A descriptive study on peripheral intravenous catheters in patients admitted in a hospital
over a 5-month period, 496 peripheral intravenous catheters (PIVs) inserted into neonates,
infants, and children were prospectively studied. Data were collected on demographic patient
characteristics, PIV indications for use, dwell time, and reasons for removal, together with
nursing actions. The results showed that most PIVs were removed within 72 hours. In 6.6% of
cases, some degree of phlebitis was present at PIV removal. The risk of phlebitis increased when
the PIV remained in place longer, the child was younger, or medication was administered. The
13

greatest risk was age, with neonates being 5 times more likely to have some degree of phlebitis
than non-neonates.31
A comprehensive epidemiologic study was conducted on the risks associated with
intravenous catheters. Sample size was 3,094 adult patients with 5,161 total episodes of PIVs. It
found an overall phlebitis rate of 2.3% and a catheter-associated bacteremia rate of 0.08%. The
study concluded that the current recommendation to replace adult peripheral intravenous cannula
every 48 to 72 hours seemed appropriate. 32

Review of literature related to moist heat therapy on intravenous cannulation

A study was conducted on effect of heat therapy on the visibility and palpability of veins
before intravenous cannulation in a patient undergoing chemotherapy. Sample size was 60.
Visibility and palpability of the veins was observed for the insertions of intravenous cannula.
Moist heat application produces vasodilation which increases the blood flow to the affected area
by bringing more oxygen and nutrients. Status of vein was assessed by using vein assessment
scale; the status of the vein was improved. The study concluded that following the intervention
40% had vein status score of 5 that is vein were clearly visible and palpable.33
A crossover study was conducted on local warming and insertion of peripheral venous
cannulas. A study consists of 100 neurosurgical and 40 leukemia patients. In neurosurgical
patients, it took 36 seconds (95% confidence interval 31 to 40 seconds) to insert a cannula in the
active warming group and 62 (50 to 74) seconds in the passive insulation group (P=0.002). Three
(6%) first attempts failed in the active warming group compared with 14 (28%) in the passive
insulation group (P=0.008). The study result showed that insertion time with leukemia patients
was reduced by 20 seconds (8 to 32, P=0.013) with active warming and that failure rates at first
attempt were 6% with warming and 30% with passive insulation (P<0.001).21
An observational study was conducted on validation and refinement of the difficult
intravenous access score: a clinical prediction rule for identifying children with difficult venous
access. Sample size was 366 (mean age = 5.4 years, SD 5.6 years) and of them, 118 (32.2%)
14

subjects failed the first IV attempt. The original four-variable model tested in this data set
resulted in an area under the curve of 0.72 (95% confidence interval = 0.67 to 0.78). Patients
with a difficult venous assess score of 4 or greater had more than 50% likelihood of failed first
IV attempt. A three-variable rule (vein palpability, vein visibility, and patient age) was evaluated
and found to possess similar discriminating ability (AUC = 0.72, 95% CI = 0.67 to 0.78). The
study concluded that the previously derived four-variable DIVA score. A simpler three-variable
rule was as predictive of failed IV placement on first attempt as the four-variable rule. Validation
in non-pediatric emergency department is needed to thoroughly evaluate generalizability.34
A study was conducted on effect of moist heat therapy on visibility and palpability of
veins.Sample size was 60. Prior to intervention none of the patients had visible and palpable
veins. After the intervention 40 subjects had clearly visible and easily palpable veins.33.3% had
the score of 4 that is visible and palpable veins. In 11.7% subjects the veins were visible but not
palpable after the intervention. The study concludes that heat therapy shows significant
difference in visibility and palpability of veins.33
An experimental study was conducted on application of EMLA (eutectic mixture of local
anesthetics) cream and application of heat to facilitate peripheral venous size before cannulation.
30 subjects were studied. Vein visibility was assessed prior to EMLA Cream application, one
hour after EMLA Cream, and two minutes after heat application. The study had an 80% first
cannulation rate. The baseline mean vein size was 0.243cm which decreased to 0.205cm after
EMLA cream application, with heat application the vein size increased to 0.253cm. The study
conclude that it increases in vein size and visibility when heat applied which counteracted the
vasoconstrictive effect of EMLA.35
A prospective study was conducted on vascular access for fluid infusion. Sample size
was 104. One randomized controlled trial assessed the effect of moist heat in adults. The study
shows that moist heat positively affected venous dilatation (P<0.01), and ease of cannulation
(P<0.001). The study concluded that moist heat is effective in venous dilatation and it facilitates
easy intravenous cannulation.36

7. MATERIALS AND METHODS OF STUDY

15

7.1 SOURCE OF DATA

The data will be collected from the patient undergoing intravenous cannulation.

7.2 METHODS OF DATA COLLECTION

i) Research design
Quasi-experimental, one group pretest posttest design.37

ii) Research variables

Dependent variables
Visibility and palpability score of peripheral veins.
Independent variables
Application of moist heat therapy.
Demographic variables
It includes the base line information of patient such as age, sex, education, family
income, marital status, occupation, diagnosis, previous experience of cannula insertion, blood
pressure, and site of cannulation.
iii) Setting
The study will be conducted in K. C. General Hospital Bangalore.
iv) Population
The population consists of all the patients in K. C. General Hospital undergoing
intravenous cannulation.
v) Sample
Patient who fulfills inclusion and exclusion criteria and the sample size is 60.
vi) Criteria for sample selection
16

Inclusion criteria
The study includes:1)
2)
3)
4)

Patients age between 18 to 55 years.

Patients who are undergoing intravenous cannulation.
Both the male and female patients.
Patient who can understand Kannada or Hindi or English.

Exclusion Criteria
The study excludes:1) Patient who have been previously sensitized with same or similar intervention.
2) Patient who are undergoing central venous cannulation.
3) Patient who are critically ill such as coma, stroke and patient on ventilator.
vii) Sampling technique:Simple random sampling technique. Samples will be selected through lottery method.38
viii) Tool for data collection
Tool consists of two sections:-

Section A
Demographic Performa of patients includes age, sex, education, family income, marital
status, occupation, and diagnosis, previous experience of cannula insertion, blood pressure and
site of cannulation.
Section B
A five point vein assessment scale used to assess the visibility and palpability of
peripheral veins before and after the application of moist heat therapy.
VEIN ASSESSMENT SCALE
17

Neither visible

clearly visible &

nor palpable

palpable

Scores
1 Vein neither visible nor palpable
2 - Vein visible but not palpable
3 - Vein is barely visible and palpable
4 - Vein is visible and palpable
5 - Vein is clearly visible and palpable

ix) Method for data collection

After obtaining the required permission from the concerned authorities and informed
consent from the samples, the investigator will collect the data pertaining to demographic
variables. The study will be conducted in the following phases.
Phase I
The investigator will assess the visibility and palpability of peripheral veins before
application of moist heat therapy by using vein assessment scale.
Phase II

18

Moist heat therapy will be applied on cannulation site of the patient. Gauze will be
soaked in 39.5 degree Celsiuswarm water and it will be applied for five minutes in vein
continuously then the gauze piece will be taken out again dipped in 39.5 degree Celsius warm
water and reapplied for another five minutes. Total 10 minutes heat will be applied.
Phase III
After the end of the intervention posttest visibility and palpability score will be assessed
by using same vein assessment scale.

x) Plan for data analysis

The data will be analyzed by means of descriptive statistics and inferential statistics.
Descriptive statistics
1) Frequency and percentage distribution will be used to describe demographic variables.
2) Mean and standard deviation will be used to analyze the pretest and posttest visibility and
palpability score among patient undergoing intravenous cannulation.
Inferential statistics
1) Wilcoxons test will be used to compare the pretest and posttest visibility and palpability
2)

score of peripheral veins of patients undergoing intravenous cannulation.

Chi square test will be used to associate visibility and palpability score among patients
undergoing intravenous cannulation with their selected demographic variables.

xi) Projected outcome

Moist heat therapy can increase the visibility and palpability of peripheral veins among
patient undergoing intravenouscannulation in a cost effective manner.

7.3 Does the study require any investigations or interventions to the patients or human
being or animals?
Yes, moist heat therapy will be administered as an intervention for patients who are
undergoing intravenouscannulation.

19

7.4 Has ethical clearance been obtained from your institution?

Yes, permission will be obtained from concerned authorities and informed consent will be
obtained from samples. The privacy and confidentiality of the data will be maintained.

8. LIST OF REFERENCES
1. Regina bailey. Blood vessels. Available from:
http://biology.about.com/od/humananatomybiology/ss/blood_vessels.htm
2. Potter Perry. Fundamental of nursing. 6th Edition. Elsevier publishers; 2006.
3. Lewis, Heitkemper, Dirksen, OBren, Bucher. Medical Surgical Nursing. 7th Edition.
New Delhi: Elsevier publication; 2011.
4. Barbara k Timy, Nancy E smith. Introductory medical surgical nursing. Philadelphia
9thEdition. Published by Linton William and wikins.
5. Wilson J. Infection control in clinical practice. 2nd Edition. BailliereTindall. 2011.
6. Cleary M. Peripheral intravenous cannulation. Aust Fam Physician 1991; 20: 12851288.
7. John stone M. The effect of lorazepam on the vasoconstriction of fear. Anesthesia 1976;
31: 868-872.
20

8. Dougherty L. Intravenous cannulation. Nursing standard1996; 11: 47-54.

9. C Waitt, P Waitt, M Pirmohamed. Intravenous therapy. Postgraduate medical journal
2004; 80: 1-6.
10. Jackson A. Performing peripheral intravenous cannulation. Professional nurse 1997
October; 13: 21-25.
11. Rosenthal K. Tailor IV insertion technique for special populations. Nursing 2005 May;
35: 36-41.
12. Mbamalu D, Banerjee A. Methods of obtaining peripheral venous access in difficult
situation. Postgraduate Med Journal 1999; 75: 459-462.
13. M. F. Dillon, J.Curran, R. Martos, C. Walsh, D. Oshea. Factors that affect longevity of
intravenous cannula: a prospective study. International Journal of medicine 2008 March
31; 101: 731-735.
14. Perry S, Tepperman M. Therapeutic use of heat and cold. Can Fam Physician 1986 May;
32: 1110-14.
15. Perucca R, Micek J. Treatment of infusion related phlebitis: review and nursing
protocol. Journal of intravenous nursing 1993; 16: 282-286.
16. Collignon P. Intravascular catheter incidence and associated sepsis: a common problem.
The Australian study on intravascular catheter-associated sepsis. Med J Aust. 1994; 161:
374378.
17. Norwood MA. Policies and procedures for infusion nurse. J Infus nurse 2006 July; 44:
11.
18. Scales K.Vascular access: a guide to peripheral venous cannulation. Nursing standard
2005; 19: 48-52.
19. Leidel B.A, Kinchnoff C, Bonger V, Stegmaier J, Mutschler W, Kanz KG, Braunstein V.
Is the intraosseous route fast and efficacious compared to conventional central venous
catheterization in adult patient under resuscitation in the emergency department? A
prospective pilot study. Patient safety in surgery 2009; 3: 24-31.
20. Fink MR, Hjorte E, Wenger B, Cook FP, Cuningham M, Orf A etal. The impact of dry
versus moist heat on peripheral IV catheters insertion in hematology oncology out
patient population. Oncology nurse forum 2009 July; 36: 1-11.
21. Rainer Lenhardt, Tanja Seybold, Oliver Kimberger, Brigitte Stoiser. Daniel I Sessler.
Local warming and insertion of peripheral venous cannulas. BMJ 2002 August24; 325:
409.
22. Rauch D, Dowd D, Eldridge D, Mace S, Schears. Peripheral difficult venous access in
children. Clinical pediatrics 2009; 48: 895-901.

21

23. Jagadamba

A,

KarthiyaneeKutty,

Vinutha

Shankar,

NachalAnnamalai,

Ravi

Madhusudhana. Gender variation in pain perception after intravenous cannulation in

adults. The internet journal of Anesthesiology 2011; 28: 1.
24. Basvanthappa B T. Textbook of research.5th Edition. New Delhi: Jaypeebrothers
medical publishers; 2008.
25. Natascha J.Cuper, Jurgen C.de Graaff, Atty T.H. Van Dijk,Rudalf M,Verdaasdonk,
Desiree B.M. etal. Predictive factors for difficult intravenous cannulation. Pediatric
anesthesia 2012 March; 22: 223-229.
26. Doniger SJ, Ishimine P, Fox JC, Kanegaye JT. Randomized controlled trial of ultrasound
guided peripheral intravenous catheter placement versus traditional techniques in
difficult access pediatric patients. Medline 2009 March; 25: 154-9.
27. Halter M, Lees-Mlanga S, Snooks H, Koenig KL, Miller K. Out-of-hospital intravenous
cannulation. Acad Emerg Med. 2000 Feb7; (2): 127-33.
28. Ann F. Jacobson, Elizabeth H. Winslow. Variables influencing intravenous catheter
insertion difficulty and failure. The journal of acute and critical care 2005 September;
34: 345-359.
29. Joel M. Bartfield, John S. Janikas, Ryan S, Lee BS. Heart rate response to intravenous
catheter placement. Academic emergency medicine 2003 September; 10: 1005-1008.
30. F Vandenbos, ABasar, S Teppesta, JP Fournier, F Bertrand.Relevance and complications
of intravenous infusion at the emergency unit at nice university hospital. Journal of
infection 2003; 46: 173-176.
31. Foster Lynelle, Wallis Marianne, Paterson, Barbara, James, Heather. A descriptive study
on peripheral intravenous catheters in patients admitted in one Australian hospital.
Journal of infusion nursing 2002 May/June; 25: 159-167.
32. Tager IB, Ginsberg MB,Ellis SE. An epidemiological study of the risks associated with
intravenous catheters. AM J Epidemiol 1983; 118: 839-851.
33. ManinderdeepKaur, SukhpalKaur, Firuza D Patel. Effect of moist heat therapy on the
visibility and palpability of peripheral veins before peripheral venous cannulation of
patients undergoing chemotherapy. Nursing and midwifery Journal 2011 July; 7: 99-104.
34. Michael W. Riker, Chris Kennedy, Brad S. Winfrey, Kenneth yen, M. Denise Dowd.
Validation and refinement of the difficult intravenous assess score: A clinical prediction
rule for identifying with difficult intravenous access. Academic emergency medicine
2011 November; 18: 1129-1134.

22

35. Huff, L, Hamlin A, Wolski D, McClure T, &Eliades A.B. A traumatic care: EMLA cream
and application of heat to facilitate peripheral venous size in children. Issues in
Comprehensive Pediatric Nursing 2009; 32: 65-76.
36. Nikolaus A Hass. Vascular access for fluid infusion. Critical care 2004; 8: 478-484.
37. Denise F Polit, Cheryl Tatano Beck. Nursing research generating and assessing evidence
for nursing practice.9th Edition. India: Wolters Kluwer Publishers; 2011.
38. Suresh K Sharma. Nursing Research and Statistics. 1 st Edition. India: Elsevier
Publishers; 2011.

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