RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
Proforma for registration of subjects for dissertation
1. Name of the candidate and address : Nisha Daniel
1st year M.Sc Nursing Mallige Institute of Nursing HMT Sector-2, Bangalore-13
2. Name of the Institution : Mallige Institute of Nursing
HMT Sector-2, Bangalore-13
3. Course of Study and Subject : 1st year M.Sc nursing
Medical and Surgical Nursing
4. Date of Admission to Course : 26/06/2009
5. Title of the Topic : “A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING COMPLICATIONS OF INTRAVENOUS THERAPY, ITS PREVENTION AND MANAGEMENT AMONG FINAL YEAR BASIC B.Sc NURSING STUDENTS AT SELECTED COLLEGE, BANGALORE.”
6.Brief resume of the intended work
6.1 NEED FOR THE STUDY:
“Education brings desired behavior among the students”
Fluid and electrolyte balance is a dynamic process that is crucial for life. Approximately 60%of a typical adult weight consists of fluid. Body fluids are located in two fluids compartments: the intracellular space and the extra-cellular space. Body fluids normally shift between the two major compartments or spaces to maintain equilibrium. Sometimes fluid is not lost from the body but it is unavailable for use by either ICF or ECF. Potential and actual disorders of fluid and electrolyte balance occur in every setting, with every disorder and with a variety of changes that affect well people (eg: Increased fluid and sodium loss with strenuous exercises and high environmental temperature; inadequate intake of fluid and electrolyte) as well as those who are ill.1
Today in any hospital intravenous therapy has become a major component of patient care. In hospital practice intravascular lines are used for various purposes, for recording pressures and administer drugs and fluids. The most common complications of peripheral intravenous cannulation are infiltration; this results in an inflammatory reaction, which is manifested as pain, swelling and erythema: extravasation, phlebitis, thrombophlebitis, sepsis, venous air embolism and this prolongs the hospital stay.1
According to the study on the epidemiology of peripheral vein infusion thrombophlebitis, it seen that Peripheral vein infusion thrombophlebitis occurs in 25% to 35% of hospitalized patients with peripheral intravenous catheters and has both patient-related implications (e.g., sepsis) and economic consequences (e.g., extra nursing time). The duration of catheterization, catheter-related infection, and catheter material are important risk factors for peripheral vein infusion thrombophlebitis. 2
According to the study of Uslusoy E and Mete S on predisposing factors to phlebitis in patients with peripheral intravenous catheters, found that infusion through an infusion pump and insertion of catheters in the veins around the elbow increased the risk of phlebitis. Also, the number of times infusions were started led to an increased rate of phlebitis. Phlebitis causes sepsis, pain, additional diagnostic investigations, and treatments, and may lead to increased duration of hospitalization, patient's stress level, and financial burden, as well as increasing staff workload. Advanced practice nurses need to be aware of the factors that increase the likelihood of phlebitis and take appropriate measures to prevent it.3
MandakiniPawar,et al, conducted a study at Escorts Heart Institute and Research Centre, New Delhi, India on central venous catheter-related bloodstream infections(CVC-BSIs) among One thousand three hundred fourteen consecutive patients undergoing cardiac operations who were admitted to the intensive care unit with CVC. The study shows that the mortality was increased with CVC-BSI. The mortality rate in CVC-BSI was 22.9% as compared with 0.2% in non-CVC-BSI cases (p < 0.001). 4
Infiltration of medications during infusion therapy results in complications ranging from erythema and pain to tissue necrosis requiring amputation. Infiltration occurs from improper insertion of the cannula, separation of the cannula from the vein, penetration of the vein by the cannula during movement, and response of the vein to the medication.5
Infiltration and extravasation are complications that can occur during intravenous therapy, administered via either peripheral or central venous access devices. Both can result in problems with the site of future venous access devices, nerve damage, infection and tissue necrosis. The nurse is the key to reducing the risk of infiltration and extravasation, through her knowledge and skill in cannulation and the intravenous administration of drugs (by bolus injection or infusion). The nurse must also be able to recognize the early signs and symptoms of infiltration and extravasation and act promptly and effectively to limit tissue damage. The first sign of possible leakage of drugs into the tissues is pain and discomfort, so patients must be informed of what symptoms to look out for and be asked to report any change in sensation as soon as they are aware of it. An accurate documentation of the event is vital to facilitate patient care and in case of litigation.6
An article in Indian Journal of Critical Care Medicine 2009 showed that air embolism can complicate peripheral IV fluid therapy or central venous catheter monitoring, including problems with IV infusion pumps, improper flushing of IV sets, incorrect injection of drugs into the infusion system, and accidental disconnection of the hub or removal of central venous catheters. The open to air system in glass bottles is also a potential hazard for life-threatening complications. Air embolism can cause blockage of small vessels in the pulmonary vasculature with compromise of gas exchange, cessation of ventricular pumping caused by blockage of air and arrhythmia7.
Ung L, et al conducted a study at Cabrini hospital, Malverin, Australia on the impact of nurses' education and experience and the characteristics of their patients on their performance of peripheral intravenous cannulation. A researcher-developed peripheral intravenous cannulation assessment tool was used to assess nurses' behavior during cannulation. Nurses' education and experience significantly predicted overall ratings of peripheral intravenous cannulation. Educational preparation at a postgraduate level was a significant positive predictor, and the years of experience in general nursing were a significant negative predictor of overall ratings of peripheral intravenous cannulation. The results from the current study highlight the importance of applied education, such as that indicated by a graduate degree, in providing and maintaining advanced clinical skills for specialty practice.8
Nurse educators are being challenged to maintain quality of increasing numbers of students in spite of declining numbers of experienced faculty, societal mandates, and rapid changes in health care. The scholarship underlying the practice of nursing education, or evidence-based education, must continue to be explored through the design, testing, and refinement of education strategies from nursing and other disciplines. The involvement of every educator in this process will help create institutional valuing that serves to retain inquisitive and reflective educators in academic settings, while expanding evidence-based education in nursing.9
The preparation of nursing students for the real world of practice is a significant contemporary issue for health care and education institutions globally. Positive learning experiences are enabled through positive role models and attitudes which impact on ward culture. Although these best practices have been described, they have not been assimilated into the health-care system as the uptake of evidence is fraught with difficulties. Use the problem-solving approach of fitting evidence into practice--Read, Think and Do. The effective strategies that take into account the clinical context, such as displaying posters, demonstration of problem resolution in small group sessions and role modelling, and a presence in the clinical area. All of these contribute to the uptake of the guidelines to improve student experiences within the clinical setting.
Complications have been noted in 50-75% of the patients due to deficient routines in use, care, handling and documentation of peripheral intravenous vein cannulae. Considering the above mentioned facts it was very clear that complications of intravenous therapy is a relevant problem need to be tackled with great importance and more over today's student nurses are tomorrow’s staff nurses, so they need to be educated regarding the intravenous therapy, complications and its prevention and management, thus helps to reduce the complications of intravenous cannulation and provide a good care to the patients. Hence the investigator felt the need to take up the study.
6.2 REVIEW OF LITERATURE
Review of literature is a key step in research process. Review of literature refers to an extensive, exhaustive and systematic examination of publications relevant to the research project. A review of research and non research literature relevant to the study was undertaken which helped the investigator to develop deeper insight into the problem and gain information what has been done in the past.
Kagel EM, Rayan GM.[2004] conducted a study at University of Oklahoma and Integris Baptist Medical Center, Oklahoma City, US on Intravenous catheter complications in the hand and forearm over a 3-year period. The sample was 67 patients who developed i.v. catheter-related complications. The study shows that the most common sites for developing complications in order of frequency were the forearm, hand, wrist, and antecubital fossa. There were 56 minor and 11 major complications. More than 50% of minor complications occurred in the hand and wrist, and more than 50% of major complications occurred in the hand. Minor complications comprised 26 intravenous infiltrations, 23 cases of thrombophlebitis, and 7 cases of cellulitis. Major complications included septic thrombophlebitis in three; hematomas resulting in skin necrosis in two; and infiltration related complications in six, resulting in skin necrosis in two, compressive nerve lesions in two, digital stiffness in one, and compartment syndrome in one. Ten patients with major complications were over the age of 50 years and nine were women. Peripheral i.v. line complications are not uncommon and can result in morbidity and increased health care costs from prolonged hospitalization, extended use of i.v. antibiotic therapy, and surgical intervention.10
Barbut F,et al,[2003] conducted a study on Complications due to peripheral venous catheterization. Peripheral venous catheter (PVC)-associated complications were prospectively evaluated in a 2 month-study performed in 3 different wards. A total of 525 PVC were included. Main clinical complications were erythema (22.1%), tenderness (21.9%), swelling or induration (20.9%), palpable cord (2.7%) and purulence (0.2%). Phlebitis was observed in 22%. Catheter colonization occurred in 13%.Risk factors for phlebitis were skin lesions, active infection unrelated to PVC, "poor quality" peripheral vein and > 72 hour-catheterization. The study shows that Complications associated with peripheral venous catheters are frequent but remain benign. They could probably be reduced by a systematic change every 72-96 hours as recommended by different guidelines.11
Pujol,et al [2007] conducted a study at university hospital, Barcelona, Spain to determine the clinical epidemiology and outcomes of bloodstream infections caused by short- and mid-line peripheral venous catheters among a group of non-intensive care unit patients. Cases of peripheral venous catheter-related bloodstream infections (PVC-BSIs) were compared to cases of central venous catheter-related bloodstream infections (CVC-BSIs). From October 2001 to March 2003, 150 cases of vascular catheter-related bloodstream infections were identified among 147 patients. Seventy-seven episodes were PVC-BSIs and 73 episodes were CVC-BSIs. Compared with CVC-BSIs, patients with PVC-BSIs more often had the catheter inserted in the emergency department (0 vs 42%), had a shorter duration from catheter insertion to bacteraemia (mean: 15.4 vs 4.9 days) and had Staphylococcus aureus (33 vs 53%) more frequently as the causative pathogen. Among patients with PVC-BSIs, catheters inserted in the emergency department had a significantly shorter duration in situ compared with those inserted on hospital wards (mean: 3.7 vs 5.7 days). Patients with PVC-BSIs caused by S. aureus had a higher rate of complicated bacteraemia (7%) and higher overall mortality (27%) than patients with PVC-BSIs caused by other pathogens (0 and 11%, respectively). Bloodstream infections remain underestimated and potentially serious complications of peripheral vascular catheterization Targeted interventions should be introduced to minimize this complication. 12
Vesely TM [2001] conducted a study on Air embolism during insertion of central venous catheters, to determine the clinical consequences of air embolism occurring during insertion of central venous catheters. A computer search of interventional radiology database revealed that 11,583 central venous catheters were inserted between January 1, 1995 and August 1, 2000: 7,178 were nontunneled and 4,404 were tunneled. Air embolism was reported to have occurred in 15 patients. The study shows that all 15 patients had an air embolism occur during insertion of a tunneled central venous catheter. These included eight Ash catheters, five chest wall ports, one Tesio catheter, and one Pheres-Flow catheter. Four patients remained asymptomatic. Six patients had mild symptoms that quickly resolved with supplemental oxygen. Four had moderate symptoms that also resolved with supplemental oxygen. One patient died acutely as a result of the air embolism. The study also shows that air embolism is a rare but potentially fatal complication of central venous catheter procedures, all occurred during insertion of a tunneled catheter through a peel-away sheath. The administration of supplemental oxygen was an effective treatment in the majority of patients.13
Creedon SA.[ 2001] conducted a study on healthcare workers' handwashing/hand hygiene practices compliance with recommended guidelines. A quasi-experimental design with nurses, doctors, physiotherapists and care assistants involved in direct patient care in the study unit participated in the study and the data were collected in 2001. Healthcare workers' handwashing practices (observation of behaviour, n = 314) and their predisposition (attitudes, beliefs and knowledge) towards compliance with hand hygiene guidelines (questionnaire, n = 62) were studied. The interventional hand hygiene programme aimed to predispose healthcare workers to adopt hand hygiene behaviour (poster campaign and educational handout), reinforce (feedback on pretest results) and enable the behaviour (provision of an alcohol hand rub beside each patient’s bedside). The study shows that Implementation of the multifaceted interventional behavioural hand hygiene programme resulted in an overall improvement in compliance with hand hygiene guidelines (51-83%). Furthermore, an increase in knowledge about handwashing guidelines was also found .In order to be effective, efforts to improve compliance with handwashing guidelines must be multifaceted. Alcohol hand rubs (with emollients) need to be provided at each patient's bedside.14
Nishanth S,et al[2009] conducted a randomized control study at Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry aimed to evaluate the effect of elective re-siting of intravenous cannulae every 48 hours on the incidence and severity of PVT in patients receiving intravenous fluids/drugs. A total of 42 patients who were admitted for major abdominal surgery selected randomly to either the control or study group (n = 21 in either group). Informed consent was obtained from all of them. Cannulae in the control group were removed only if the site became painful, the cannula got dislodged or there were signs and symptoms suggestive of PVT, namely pain, erythema, swelling, excessive warmth or a palpable venous cord. Cannulae in the study group were changed and re-sited electively every 48 hours. All the patients were examined every 24 hours for signs and symptoms of PVT at the current and previous sites of infusion. The incidence of PVT was 100% (21/21) in the control group and only 9.5% (2/21) in the study group (p < 0.001). The severity of PVT was also less in the study group compared with that in the control group. Day-wise correlation of the incidence of PVT showed that 82.6% of the episodes of PVT occurred on day 3. The study showed that elective re-siting of intravenous cannulae every 48 hours results in a significant reduction in the incidence and severity of PVT. The study recommends that this should be adopted as standard practice in managing all patients who require prolonged intravenous therapy.15