EFFECTIVENESS OF NORMAL SALINE LOCK VS HEPARIN LOCK ON THE PATENCY OF PERIPHERAL INTRAVENOUS CANNULA AMONG
PATIENTS RECEIVING INTRAVENOUS MEDICATIONS IN SELECTED HOSPITALS, SALEM.
By
Ms. ANISHA CHAKKO
Reg. No. 30099401
A DISSERTATION SUBMITTED TO
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY, CHENNAI, IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE
DEGREE OF MASTER OF SCIENCE IN NURSING (MEDICAL SURGICAL NURSING)
CERTIFICATE
Certified that this is the bonafied work of Ms. ANISHA CHAKKO, Final year M.Sc. (N ursing) student of Sri Gokulam College of Nursing, Salem, submitted in Partial fulfillment of the requirement for the Degree of Master of Science in Nursing to The Tamil Nadu Dr. M.G.R. Medical University, Chennai, under the Registration No. 30099401 .
College Seal:
Signature : ……….
PROF. A. JAYASUDHA, M.Sc. (N)., Ph.D., PRINCIPAL,
SRI GOKULAM COLLEGE OF NURSING, 3/836, PERIYAKALAM,
NEIKKARAPATTI, SALEM – 636 010.
EFFECTIVENESS OF NORMAL SALINE LOCK VS HEPARIN LOCK ON THE PATENCY OF PERIPHERAL INTRAVENOUS CANNULA AMONG
PATIENTS RECEIVING INTRAVENOUS MEDICATIONS IN SELECTED HOSPITALS, SALEM.
Approved by the Dissertation Committee on : 20 -12-2010
Signature of the Clinical Speciality Guide:………...………
Mrs. N. ANITHA, M.Sc. (N)., Associate Professor & H.O.D, Medical Surgical Nursing, Sri Gokulam College of Nursing, Salem – 636 010.
Signature of the Medical Expert: ……….
Dr. K. SELVAKUMARI , M.D., Consultant Physician,
Sri Gokulam Hospital, Salem – 636 004.
ACKNOWLEDGEMENT
ACKNOWLEDGEMENT
First of all, my heartfelt thanks to the Lord God Almighty for his abundant blessings and the grace shown towards me to complete the study successfully.
I take this opportunity to thank Dr. K. Arthanari, M.S., Managing Trustee, Sri Gokulam College of Nursing, for giving me a chance to upgrade my education.
Its my privilege to express the deepest sense of gratitude to Prof. A. Jayasudha, M.Sc (N), Ph.D., Principal, Sri Gokulam College of Nursing for her patience, warmth inspiration, showing immense interest and support throughout the study.
I express my profound gratitude to Dr. K. Tamizharasi, Ph.D., Vice Principal, Sri Gokulam College of Nursing, Salem for her valuable suggestions and guidance.
It is my pleasure to indebt my sincere gratefulness and genuine thanks to Speciality Guide Mrs. N. Anitha, M.Sc. (N)., Associate Professor, Medical surgical Nursing Department, Sri Gokulam College of Nursing, for her invaluable help, support, guidance and encouragement throughout the study.
I extend my thanks to Dr. K. Selvakumari, M.D., Consultant Physician and Dr. S. Sentilkumaran, M.D., Emergency and Critical Care Physician, Sri Gokulam Hospital, Salem for their professional guidance and support throughout the study.
Grateful acknowledgement is extended to Nursing Experts who have contributed their valuable suggestions in validating the tool and content.
I humbly thank Mrs.Heps i Charles, M.Sc.(N), Mrs. B. Sumathi, M.Sc(N), Mrs.Bhuvana, M.Sc.(N), Ms. Kanmani, M.Sc (N), and Mrs.Kavitha, M.Sc (N), Lecturers, Medical surgical Nursing Department, for their support and guidance throughout the study.
I express my sincere thanks to my class coordinator Mrs.LalithaVijay, M.Sc(N), Professor for the guidance at every possible level.
I would like to extended my thanks to All Faculty Members , who gave suggestions, timely help and support to complete the study.
I render my sincere thanks to Mr. Bhaskar, M.L.I.S., Librarian of Sri Gokulam College of Nursing for helping to collect the literature and extending library facilities throughout the study.
I would like to acknowledge the input received form Dr.C.Nandakumar, Ph.D., and Mr.Sivakumar, M.Sc, M.Phil., Ph.D., Bios tatisticians, for their guidance in the statistical analysis and interpretation of the data.
I express my special thanks to Golden Printers and Mr. V. Murugesan, Shri Krishna Computer, Salem for carefully printing my dissertation.
I render my deep sense of gratitude to My Department Friends and My Classmates for their constant help throughout the study.
I express my sincere thanks to My Lovable Parents, Sister and Brothe r for their strong support and encouragement throughout my career.
TABLE OF CONTENTS
CHAPTER CONTENT PAGE NO
I INTRODUCTION 1-10
? Need for the study 2
? Statement of the problem 4
? Objectives 4
? Operational definitions 5
? Assumptions 5
? Hypotheses 6
? Delimitation 6
? Projected Outcome 6
? Conceptual framework 7
II REVIEW OF LITERATURE 11 -15
? Literature related to complications of intravenous devices
11
? Literature related to effectiveness of normal saline lock versus heparin lock in main taining the patency of peripheral intravenous cannula
13
III METHODOLOGY 16 -22
? Research approach 16
? Research design 16
? Population 18
? Description of setting 18
? Sampling 18
? Variables 19
? Description of the tools 19
? Validity and reliabilit y 21
? Pilot study 21
? Method of data collection 21
? Plan for data analysis 22
IV DATA ANALYSIS AND INTERPRETATION 23-30
V DISCUSSION 31-33
LIST OF TABLES
TABLE. NO. TITLE PAGE NO.
3.1 Scoring procedure for assessing patency of peripheral intravenous cannula through Phlebitis scale (Standardized)
20
3.2 Scoring procedure for assessing patency of peripheral intravenous cannula through infiltration scale (Standardized)
20
3.3 Interpretation of Scoring procedure 21
4.1 Frequency and percentage distribution of patients in experimental group-I and experimental group-II according to their demographic variables.
24
4.2 Comparison of mean, standard deviation and mean percentage of normal saline lock and heparin lock on the patency of peripheral intravenous cannula among patients receiving intravenous medications in experimental group-I and II
27
4.3 Comparison of the effectiveness of normal saline and heparin lock on the patency of peripheral intravenous cannula among patients receiving intravenous medications in experimental group-I and II
28
4.4 Association between patency of peripheral intravenous cannula among patients receiving intravenous me dications in experimental group-I and II with their selected demographic variables
29
LIST OF FIGURES FIGURE.
NO. TITLE PAGE NO.
1. 1 Theoretical framework Based on Wiedenbach’s
Helping Art of Clinical Nursing Theory (1964) 9 3.1 Schematic Representation of Research Methodology 17
4.1
Percentage distribution of patients receiving intravenous medications according to their patency in experimental group I & II
26
LIST OF ANNEXURES
ANNEXURE. TITLE PAGE
NO.
A. Letter seeking permission to conduct a research
study i
B. Tool for data collection iii
C. Letter requesting opinion and suggestion of experts
for content validity of the research tool ix
D Certificate of validation x
E. List of Experts xi
F. Chi-square test xii
G. Certificate of Editing xvi
H. Photos xvii
ABSTRACT
ABSTRACT
A quasi experimental study was conducted to evaluate the effectiveness of normal saline lock versus heparin lock on the patency of peripheral intravenous cannula among 60 patients receiving intravenous medications in experimental group-I and experimental group-II. Samples were selected by using Non probability / convenience sampling technique and observational tool was used to assess the patency of peripheral intravenous cannula. Data was analyzed by using descriptive and inferential statistics.
Findings reveals that, in experimental group-I 11(36.67%) and experimental group-II, 12 (40%) of them were in 50-59 years. In experimental group-I 24(80%) and experimental group-II 20 (66.6%) of them had cannula size 20 gauge. In experimental group-I and experimental group-II 30(100%) of them had antibiotics as type of medication. In experimental group-I 13( 43. 3%) and experimental group-II 5(16.6%) had first grade clinica l symptoms during third day in phlebitis scale. In experimental group-I, 15(50%) and experimental group II, 7(23.3%) had first grade clinical symptoms during third day in infiltration scale.
In experimental group-I phlebitis and infiltration mean scores were 0.43 ? 0.50 and 0.50?0.51 respectively, whereas in experimental group-II phlebitis and infiltration mean scores were 0.17 ? 0.38 and 0.23?0.43 respectively. Coefficient of variation for phle bitis and infiltration scores of patients received heparin lock consistent than normal saline lock. The calculated ‘Z’ value (2.36, 2.25) was greater than tabulated value (1.96) at 5% of significance. It reveals that heparin lock was effective than normal saline lock. There was no association between the patency of intravenous cannula among patients receiving intravenous medications in both experimental group I and II with their demographic variables at p <0.05 level.
CHAPTER - I
Introduction
CHAPTER - I INTRODUCTION
Fluid maintains all body system functions. These balances are maintained by the intake and output of water. Physical, behavioral and environmental factors affect the body’s ability to regulate fluids. Imbalances of fluid necessitate the fluid therapy by means of intravenous fluids. Intravenous fluid administration is performed in the hospital, outpatient diagnostic and surgical setting, clinic, and home to replace fluids, administer medications, and provide nutrients when no other route is available.
Equipment used to gain access to the vasculature includes cannula, needless intravenous delivery systems, and peripherally inserted central catheter or midline catheter access line. Most peripheral access devices used are cannula. Catheter and cannula are terms that are used interchangeably. These are easy to insert, but because they are small and non-pliable, infiltration occurs easily. (Smeltzer, 2008)
P atency of the intravenous needle or catheter means that there are no clots at the tip of the needle or catheter and that the catheter or needle can affect the rate of infusion of the intravenous fluids. An occluded or blocked cannula affects the infusion rate of the intravenous fluids. Infiltration, obstruction or kink in the tubing, height of the solution and position of the extremity also affects the intravenous flow rates. Whenever a peripheral intravenous cannula is present, perform assessment of the intravenous system until you locate the problem. Start the assessment at the venous access site for signs and symptoms of infiltration and phlebitis. (Patricia.
2005)
Maintenance of catheter lumen patency is an ongoing challenge. Catheter flushing is the primary nursing intervention used to prevent lumen occlusion from thrombotic and precipitate causes. The technology of catheter flushing includes the
flush solution itself, the source of these solutions, syringe design, mechanical pumps, needle -less injection systems, and the design of the catheter. Effective catheter flushing is a combination of a technique and technology that requires an understanding of how both must work together. (Hadaway, 2006)
Each year, millions of patients admitted in the hospitals require some form of vascular access as a critical component to their medical care. The intravenous cannulas are inserted in the superficial veins as these are easily accessible. In adults, it is strongly recommended to use veins of upper extremity for venipunctures. Use of the lower extremities is little dangerous because of the danger of pulmonary embolism caused by a thrombus extending into the deep veins. Simple, safe and reliable venous access is essential for the patients requiring intravenous treatment. A peripheral intravenous cannula cannot be left in the vein indefinitely, because of the risk of insertion-site infection leading to phlebitis, cellulites and sepsis. (Lakhwinder Kaur, 2007)
Intermittent injection ports may be flushed with sterile saline prior to and after medication. Most agencies use saline flushes with medication administration through peripheral intravenous lines. Some agencies use the saline -administer drug-saline- heparin (SASH) for maintaining patency of the intravenous catheter. (Kozier, 2008)
Need for the Study
The intravenous route is necessary for biochemical, pharmacological, nutritional support including the transfusion of blood and blood products. Catheter
Phlebitis is a inflammation of vein related to a chemical or mechanical irritation or both. Clotting of the needle or cannula may be prevented by not permitting the intravenous solution bag to run dry, Need for the taping the tubing to prevent kinking and maintain patency, maintaining adequate flow rate, and flushing the line after inte rmittent medication or other solution administration. In some cases, a specially trained nurse physician may inject a thrombolytic agent in to the catheter to clear an occlusion resulting from fibrin or clotted blood. (Smeltzer, 2008)
A prospective randomized double blind study to compare the efficacy of two available preparations (normal saline and heparin ) used for maintaining the patency in peripheral intravenous cannula at a large academic medical center, United state of America. A convenience sample included 73 hospitalized pregnant women. The finding showed that both normal saline and heparin equally effective in the maintenance of peripheral intravenous block. (Niesen, 2003)
A prospective nonrandomized sequential blinded study to compare the effectiveness of normal saline lock versus heparin lock solution in maintaining the patency of peripheral intermittent infusion devices. The sample consists of 134 catheters in 61 patients in intensive care unit, at Dartmouth-H itchcock medical center, childre n’s hospital, United State of America. The finding showed that heparin is more effective than saline in maintaining the patency of intravenous cannula.
(Mudge, 1998)
Nursing practice no longer relies on tradition or ritual instead, it is based on research and empirical evidence. The emphasis on evidence based nursing, as well as standardization of nursing practice has resulted in the production of policies, has resulted in the production of policies, protocols and guidelines aimed at directing numerous aspects of nursing care. (Flynn, 2005)
Assessment of local and systemic complication is a major nurse’s responsibility. Clotting in the intravenous cannula can be prevented by flushing the line after intermittent medication administration. The investigator while working in the wards observed that the intravenous cannula patients are frequently had intravenous cannula related complications. Hence investigator got a insight to help these patient by focusing on effectiveness of normal saline versus heparin lock on patency of intravenous cannula.
Statement of the Problem
A Comparative Study to Evaluate the Effectiveness of Normal Saline Lock Vs Heparin Lock on the Patency of Peripheral Intravenous Cannula among Patients Receiving Intravenous Medications in Selected Hospitals, Salem.
Objectives
1. To evaluate the effectiveness of normal saline lock versus heparin lock on the patency of peripheral intravenous cannula among patients receiving intravenous medication in experimental group I and experimental group II.
2. To compare the effectiveness of normal saline lock versus heparin lock on the patency of peripheral intravenous cannula among patients receiving intravenous medication between experimental group I and group II.
3. To associate the patency of peripheral intravenous cannula among patients receiving intravenous medications in experimental group I and group II with their selected demographic variables.
Operational Definitions 1. Effectiveness
Effectiveness is the outcome of normal saline lock and heparin lock on maintaining the patency of peripheral intravenous cannula.
2. Normal saline lock
Administration of 1ml of 0.9% of sterile normal saline through 2ml syringe to the intravenous cannula.
3. Heparin lock
Administration of 1ml of (1 I.U) of heparin through 2ml syringe to the intravenous cannula.
4. Patency
Free flow of fluids without any obstruction and resistance.
5. Peripheral intravenous cannula
It is an infusion device in limbs (arm or leg) through which medications administrated intravenously.
6. Patients
Persons admitted and are receiving intravenous medications for atleast 3 days through intravenous cannula.
7. Intravenous medications
Medicines introduced in to a vein for therapeutic purpose.
Assumptions
1. Normal saline lock and heparin lock may have some effect on maintaining the patency of peripheral intravenous cannula.
2. Intravenous cannula may get blocked if not flushed properly.
Hypotheses
H1: There will be significant difference between normal saline lock and heparin lock on patency of peripheral intravenous cannula among patients receiving intravenous medications in experimental group-I and experimental group-II at p< 0.05 level.
H2: There will be significant association between patency of peripheral intravenous cannula among patients receiving intravenous medications in experimental group-I and experimental group-II with their selected demographic variables at p < 0.05 level.
Delimitations
1. The study will be limited to the patients admitted in the selected hospitals with intravenous cannula.
2. The sample size will be limited to 40 samples.
3. The study period will be limited to 4 weeks.
Projected Outcome
? The study will help to determine empirically the need for normal saline lock or heparin lock to prevent intravenous complications and the need for observing the intravenous site meticulously by the nurses.
? The finding of the study will help the nurses to initiate intravenous lock prescription and administration.
? It helps the health personnel to adopt any one of the techniques ie, normal saline lock or heparin lock to flush the intravenous cannula
Conceptual Framework
Conceptual models are made up of concepts, which are words describing mental images of phenomena and propositions which are statements about concepts. It provides a schematic representation of some relationship among phenomena.
Ernestine Wiedenbach’s proposed a prescriptive theory for nursing which is described as conceiving of a desired situation & the ways to attain it.
The investigator adopted the Wiedenbach’s Theory of helping art of clinical nursing 1964, for Conceptual Framework, According to this theory, nursing practice consists of 3-steps which include.
Step-I Identifying the need for help Step-II Ministering the needed help
Step-III Validating that the need for help was met.
This theory shows nursing as an art based on a goal (or) central purpose. It consists of 3 factors central purpose, prescription & realities.
Step–I: Identifying the need for help
This involves determining the need for help. The investigator identified the need for maintaining the patency of intravenous cannula in patients receiving intravenous medications through peripheral intravenous cannula.
Step–II: Ministering the needed help
The provision of required help for the identified need. It has 2 components (i) Prescription
(ii) Realities
i. Prescription
It involves the plan of care to achieve the purpose, in this investigator administer normal saline lock to experimental group-I and heparin lock to the experimental group -II.
ii. Realities
The five realities identified by Wiedenbach’s are agent, recipient, goal, means activities and framework.
Agent The investigator is the agent.
Recipient Recipient is the patient who is receiving intravenous medications.
Goal Maintains the patency of per ipheral intravenous cannula.
Means and Activities Heparin lock and Normal saline lock.
Framework Sri Gokulam Hospital and Vinayaka Mission’s Hospital.
Step-III Validating that the need for help was met
It is accomplished by comparing the effectiveness of normal saline lock versus heparin lock in maintaining patency of peripheral intravenous cannula by using phlebitis scale and infiltration scale.
9 Central Purpose
Maintaining the patency of peripheral intravenous cannula
Ministering the needed help
Experimental group - I Realities
Agent: Nurse investigator.
Recipient: Patients who are getting intravenous medications through intravenous cannula.
Goal: Maintain the patency of intravenous cannula.
Mean and activities: Administration of normal saline lock to the first experimental group and heparin lock to the second experimental group.
Framework: Vinayaka Mission’s hospital , Salem
Post-test assessment on patency peripheral intravenous cannula among
patients receiving intravenous medication in
experimental group-I and experimental group-II (Phlebitis scale, infiltration
scale) Identifying the need
for help
Validating that the need for help was met
STEP-III STEP-II
STEP-I
? Patients with intravenous cannula receiving intravenous medication.
Compare the effectiveness of normal saline lock and heparin lock Experimental group - II
Realities
Agent: Nurse investigator.
Recipient: Patients who are getting intravenous medications through intravenous cannula.
Goal: Maintain the patency of intravenous cannula.
Mean and activities: Administration of normal saline lock to the first experimental group and heparin lock to the second experimental group.
Framework: Sri Gokulam hospital, Salem.
Experimental Group II (Heparin lock) Experimental Group I
(Normal saline lock)
Significant
Figure – 1.1: Theoretical framework Based on Wiedenbach’s Helping Art of Clinical Nursing The ory (1964)
Summary
This chapter dealt with introduction, need for study, statement of the problem, objectives, operational definitions, assumptions, hypotheses, delimitations, projected outcome, and conceptual framework.
CHAPTER - II
Review of Literature
CHAPTER - II
REVIEW OF LITERATURE
This chapter deals with review of available literature from published articles, text books, research and non research articles on the subjects related to the topic of the research study.
The available literature was organized under the following headings,
? Literature related to complications of intravenous devices.
? Literature related to effectiveness of normal saline lock versus heparin lock in maintaining the patency of peripheral intravenous cannula.
Literature related to Complications of Intravenous Devices.
Barker, P., et.al., (2006 ) conducted a study to investigate the effect of elective change of intravenous cannula on the incidence of peripheral venous thrombophlebitis among the hospital inpatients. General and medical inpatients requiring intravenous therapy were randomized in to control or study groups. Cannula in the control group was removed only if the site become painful, the cannula dislodged, or there were signs of thrombophlebitis. Cannula in the study group was changed electively during every 48 hours. All patients were examined daily for sig ns of thrombophlebitis. Peripheral venous thrombophlebitis developed in 11/26 patients in the control group (p=0.003) elective change of cannula resulted in a reduction in the incidence of infusion phlebitis.
Kagel, (2004) conducted a study to assess the complications of peripheral
developing complications in order to frequency were the forearm, hand, wrist, antecubital fossa. There were 56 minor and 11 major complications. Minor complication comprised 26 intravenous infiltrations, 23 cases of thrombophle bitis minor and major intravenous related complications.
Barbut, F., et.al, (2003) conducted a study to evaluate the peripheral venous catheter associated complications in a two month study performed in a three different wards at Saint–Antoine Hospital, Paris. A total of 525 peripheral venous catheters were included and phlebitis was observed in 22%. They concluded that complication associated with peripheral venous catheter were frequent could probably be reduced by a systemic change of intravenous site at every 72 to 96 hours.
Varden Bos F, et.al, (2003) conducted a study at the Nice University, Edinburgh and out of 2515 patients reported that 650 patients were reported on intravenous cannula. In this study 219 patients were women (46%) and 390 patients were men (34%) with mean age of 58 years and 390 patients were followed until the removal of cannula. These findings indicate that 54(13.6%) had thrombophlebitis and swelling, 9(2.3%) of them developed local infections.
Lanbeck P., (2002) conducted a study to test the hypotheses that antibiotics differ in their tendency to cause infusion phlebitis at Mamo university Hospital, Sudan among 550 patients. The incidence of phlebitis was 18.5%with antibiotics and 88% without Dicloxacillin, erythromycin and cloxacillin had the greatest tendency to cause phlebitis whereas ampicillin, vancomycin and clindamycin were not associated with risk of phlebitis.
Intravenous Nurses Society, (2001) expressed that intravenous nurses society formed a scale to identify the complaints like infiltration and phlebitis for nurses and also it formed a intravenous standards of practice for each step of
intravenous infusion which helps to minimize the both local and systemic complication of intravenous infusion.
Chukhraver, AM., (2000) conducted a study to analyses the causes of complications after nursing interventions on peripheral venous catheters at Toronto research institute in Tornado. In 21%of all venipunctures involves complications.
Mainly subcutaneous hematomas (62% of all complications) spontaneous rupture of the vein, obliteration of vessel, superficial phlebitis, external bleeding from vein, and local allergic reactions. The complications are caused mainly by incorrect techniques.
Cooper (2000) says that the federal centre for disease control and prevention in United States has reported an average catheter related blood stream infection rate of 2.8 to 12.8 infections per 1000 catheters for all types of Intensive Care Unit patients and average rate of 4.5 to 6.1 infections per medical surgical ward patients.
Lai, (1998) conducted a prospective nonrandomized study was conducted to compare the rate of phlebitis of peripheral intravenous line left for 72 hours versus rates of those left in place for 96 hours. The samples were the adult patients those who receive peripheral intravenous therapy and were admitted to the wards and whose phlebitis rates were monitored by the intravenous team for 1 month. The overall phlebitis rate for lines left for 72 hours and 96 hours w ere not significantly different.
Literature related to Effectiveness of Normal Saline Lock and Heparin Lock in Maintaining the Patency of Peripheral Intravenous Cannula
Doroborah , J ., (2009) conducted a retrospective study to evaluate the effect
thrombosis of peripheral venous catheters and may decreases catheter related bacteraemia. Hence concluded that heparin administration effectively reduces thrombus formation and may reduce catheter related infections in children who have peripheral venous and artery catheter in place.
Esther Mok., (2007) conducted a prospective, randomized controlled, double- blind study, one hundred and twenty-three subjects with 123 intravenous locks were randomly chosen to receive 1 unit/ml of heparin saline, 10 units/ml of heparin saline and normal saline to evaluate length of catheter use, survival rate and incidence of intravenous complications. The group that received 1 unit/ml of heparin saline demonstrated the highest rate of survival. The mean length of catheter use of the group that received 1 unit/ml of heparin saline (49.8 hours) was 17 hours longer than the group that received normal saline (32.5 hours).
Gunji, (2007) conducted a experimental study to evaluate the effectiveness of normal saline lock versus heparin lock for preventing blood clotting in peripheral vein catheter among sixty patients at Kanazava University. The result showed that heparin lock was more effective in preventing thrombus formation in the peripheral vein catheter than the normal saline lock
Shah, P. (2005) conduc ted randomized and quasi experimental study to assess the effectiveness of heparin on catheter blockage, phlebitis or catheter related sepsis and complication among patients. Result showed that the administration of heparin flush in the peripheral intravenous catheter prevented the blockage. This concluded that heparin was effective in maintaining the patency of peripheral intravenous catheter.
Adrienne,(2004) conducted critical appraisal and meta analysis of randomized controlled study, among twenty six samples to evaluate the effect of heparin on
duration of the catheter patency and prevention of complication associated with the use of peripheral venous and arterial catheter at Children’s hospital Harvard Medical School, California, United State. Result showed that heparin significantly increased the duration of patency of peripheral and radial artery catheters and decreased the risk of clot formation than the use of normal saline lock.
Summary
This chapter dealt with review of literature related to complications of intravenous devices and literature related to normal saline lock versus heparin lock in maintaining the patency of peripheral intravenous cannula.
CHAPTER - III
Methodology
CHAPTER – III METHODOLOGY
This study is designed to evaluate the effectiveness of normal saline lock versus heparin lock on maintaining the patency of peripheral intravenous cannula among patients receiving intravenous medications. This chapter include research design, description of setting, variables, population and sample, sampling technique and sample size, criteria for sample selection, description of tool, validity and reliability, pilot study, data collection procedure and data analysis method .
Research Approach
Quantitative evaluative research approach was adopted for the study.
Research Design
The research design selected for the study is Quasi Experimental Research Design, in which post test only design
E1 X1 O1
E2 X2 O2
E1 = First experimental group E2 = Second experimental group X1 = Normal saline lock
X2 = heparin lock
O1 = Post test assessment of experimental group I O2 = Post test assessment of experimental group II
Figure -3.1: Schematic Representation of Research Methodology Setting
Sri Gokulam and Vinayaka Mission Hospital, Salem
Population
Patients who are admitted and having intravenous cannula in hospitals, Salem.
Sample
Patients who are admitted and having intravenous cannula in selected hospitals, Salem
Experimental Group - I
Vinayaka Mission Hospital Experimental Group - II
Sri Gokulam Hospital
Data analysis and interpretation by using descriptive and inferential
statistics.
Data collection
Experimental group-II Experimental
group-I
Research Approach Quantitative Evaluative Approach
Research design
Quasi experimental research design
Post assessment on peripheral intravenous cannula by using phlebitis and infiltration scale.
Intervention Normal saline lock
Intervention Heparin lock
Population
The population of this study is patients who are admitted and having intravenous cannula in hospitals Salem.
Description of the Setting
The study was carried out in Vinayaka Mission hospital (Experimental group-I) and Sri Gokulam Hospital (Experimental group-II) and Salem. There are 15 Private Hospitals around Salem city. The investigator had selected two hospitals to conduct this study. Sri Gokulam hospital is 9 kilometers away from Sri Gokulam College and Vinayaka Mission Hospital is 7 kilometers away from Sri Gokulam College. The investigator selected this setting for the availa bility of the sample and feasibility of the study.
Sampling Sample
The sample of this study comprises of patients admitted and having intravenous cannula in selected Hospitals, Salem.
Sample Size
The sample size was 60. 30 patients in experimental group I from Vinayaka Mission Hospital, Salem and 30 patients in experimental group II from Sri Gokulam Hospital Salem.
Sampling technique
The investigator selected samples by Non-probability / convenience sampling technique.
Criteria for sample selection Inclusion criteria:
1. Patients who require intravenous injections through intravenous cannula.
2. Patients who were conscious and able to follow instructions.
3. Patients who were co-operative and willing to participate in the study.
4. Patients who are admitted in Sri Gokulam Hospital and Vinayaka Mission Hospital.
Exclusion criteria:
1. Patients with thrombocytopenia, bleeding disorders, hypersensitivity to heparin.
2. Patients receiving anticoagulant therapy.
3. Patients on maintenance drip.
Variables
1. Independent variable: Normal saline lock and heparin lock.
2. Dependent variable: Patency of peripheral intravenous cannula.
Description of Tool
Observational tool was used for data collection.
Section-I:
This section consists of Demographic data such as age, sex, size of intravenous cannula, presence of intravenous cannula, site of intravenous cannula, type of medication administered through intravenous cannula and diagnosis.
Section-II:
This section deals Phlebitis scale and infiltration sca le.
Table -3.1: Scoring procedure for assessing patency of peripheral intravenous cannula through Phlebitis scale (Standardized)
Grade Clinical criteria
0 No clinical symptoms
1 Erythema at access site with or without pain.
2 Pain at access site erythema, edema or both
3 Pain at access site erythema, edema, or both streak formation palpable venous cord (1 in. or shorter)
4 Pain at access site with erythema formation, palpable venous cord (longer than 1in.)
Each response was given a score of 0, 1, 2, 3, 4, according to their grade of symptoms.
Table -3.2 : Scoring procedure for assessing patency of peripheral intravenous cannula through infiltration scale (Standardized)
Grade Clinical criteria
0 No symptoms
1 Skin blanched, edema less than one inch in any direction, cool to touch, with or without pain.
2 Skin blanched, edema 1 to 6 inches in any direction, cool to touch, with or without pain.
3 Skin blanched, translucent, gross edema greater than 6 inches in any direction, cool to touch, mild to moderate pain, possible numbness.
4 Skin blanched, translucent, skin tight, leaking, skin discoloured, bruised, swollen, gross edema greater than 6 inches in any circulatory
Table -3 .3: Interpretation of scoring procedure
Phlebitis scale Minimum Score – 0
Maximum Score – 4 Infiltration scale Minimum Score – 0 Maximum Score – 4 Validity and Reliability
Validity of the tool and content was established by consultation with the guide and experts. The tool was validated by two medical experts in the field of General Medicine and four nursing experts. Minor modifications given by the experts in demographic variables were incorporated.
Internal consistency of the tool was checked by inter-rater method. The observation tool was administered to 6 patients in S.K.S Hospital, Salem. The reliability obtained for this study was r1= 1. It showed that the tool is reliable.
Pilot Study
The pilot study was conduc ted to find out the feasibility. It was conducted with a sample size of 6 patients in S.K.S. Hospital, Salem. The investigator used observation tool, phlebitis scale and infiltration scale to assess the patency of peripheral intravenous cannula. During pilot study pretest score was zero in both experimental group I and II. It was consulted with experts, according to their suggestions post test only design was adopted for the study.
Method of Data Collection Ethical consideration:
Prior to the collection of data written permission was obtained from the Managing Director of the Vinayaka Mission hospital and Sri Gokulam hospital, Salem.
Data collection procedure
The data was collected over a period of four weeks from 05.07.2010 to 31.07.2010. The 60 samples were selected from medical ward and surgical ward by Non-probability / convenience sampling technique. The investigator selected 60 patients, in that 30 from Vinayaka Mission Hospital, Salem were assigned as experimental group - I ( normal saline lock) and 30 patients from Sri Gokulam Hospital, Salem were assigned as experimental group - II ( Heparin lock). Patients of experimental group - I were given normal Saline lock and experimental group - II were given heparin lock after every intravenous injections for three days. On third day post assessment was done using phlebitis scale and infiltration scale to check the patency of peripheral intravenous cannula.
Plan for Data Analysis
The statistical method will be used for analysis are descriptive statistics of frequency percentage, mean, standard deviation and coefficient of variation to assess the patency of intravenous cannula among patients receiving intravenous medication.
Inferential statistics of Z-test will be used to evaluate the effectiveness of normal saline lock versus heparin lock on patency of intravenous cannula and chi-square test will be used to associate the patency of intravenous cannula among patie nts with their selected demographic variables.
Summary
This chapter consists of research approach, research design, population, description of the setting, sampling, variables, description of the tool, validity and
CHAPTER - IV
Data Analysis and
Interpretation
CHAPTER - IV
DATA ANALYSIS AND INTERPREATION
This chapter deals with analysis and interpretation of data collected to evaluate the effectiveness of normal saline lock versus heparin lock in maintaining the patency of peripheral intravenous cannula among patients receiving intravenous medications.
The collected data was tabulated, organised and analysed by using descriptive and inferential statistics as follows,
Section–A: Distribution of patients according to their demographic variables.
Section–B:
a Comparison of patency peripheral intravenous cannula after intervention in experimental group I and II.
b Comparison of mean, standard deviation and mean pe rcentage of normal saline lock and heparin lock on the patency of peripheral intravenous cannula among patients receiving intravenous medications in experimental group-I and II.
Section–C: Hypotheses testing
a. Comparison of the effectiveness of normal saline and heparin lock on the patency of peripheral intravenous cannula among patients receiving intravenous medications in experimental group-I and II.
b. Association between patency of peripheral intravenous cannula among patients receiving intravenous medication in experimental group-I and II with their selected demographic variables.
Section – A
Distribution of Patients According to their Demographic Variables.
Table– 4.1:
Frequency and percentage distribution of patients in experimental group-I and experimental group-II according to their demographic variables.
n=60 Experimental
group-I ( n =30)
Experimental group -II
(n =30) S. No Demographic variables
F % F %
Age (in years)
a. 20 – 29 5 16.67 2 6.67
b. 30 – 39 3 10.00 7 23.33
c. 40 – 49 7 23.33 3 10.00
d. 50 – 59 11 36.67 12 40.00
1.
e. 60 – 69 4 13.33 6 20.00
Sex
a. Male 14 46.67 19 63.33
2.
b. Female 16 53.33 11 36.67
Size of the intravenous cannula
a. 18 gauge 6 20.00 10 33.33
3.
b. 20 gauge 24 80.00 20 66.67
Presence of intravenous cannula
a. Day one 12 40.00 12 40.00
4.
b. Day two 18 60.00 18 60.00
Site of intravenous cannula
a. Metacarpal vein 14 46.67 14 46.67
b. Cephalic vein 15 50.00 16 53.33
5.
c. Antecubital vein 1 3.33 - -
Type of medication 6.
a. Antibiotics 30 100 30 100
7. Diagnosis
a. Respiratory disorder 8 26.67 7 23.33
b. Nervous disorder 1 3.33 - -
c. Skin disorder 1 3.33 - -
d. Endocrine disorder 6 20.00 5 16.67
e. Musculoskeletal disorder 9 30.00 15 50
f. G.I tract disorder 3 10.00 - -
g. Genito urinary tract disorder
2 6.67 2 6.67
h. Others - - 1 3.33
The above table -4.1 shows the distribution of patients according to their demographic variables. In experimental group-I, 11 (36.67%) and experimental
group II 12 (40%) of them were in 50-59 years. In experimental group-I 16 (53.3%) of them were females and experimental group-II 19 (63.3%) of them were males. In experimental group-I 24 (80%) and experimental group-II 20 (66.6%) of them had intravenous cannula size 20 gauge. In experimental group-I and experimental group-II 18 (60%) of them were with intravenous cannulation on second day. In experimental group-I 15 (50%) and experimental group II 16 (53.3%) of them had cephalic vein as the site of intravenous cannula. In experimental group-I and experimental group II 30 (100%) of them had antibiotics as type of medication. In experimental group-I 9 (30%) and experimental group II 15 (50%) of them had musculoskeletal disorder.
Section – B
Comparison of patency of Peripheral intravenous cannula after intervention in experimental group I and II
0 10 20 30 40 50 60 70 80 90 100
Phlebitis scale Infiltration scale
43.3% 50%
16.6%
23.3%
PATENCY OF PERIPHERAL INTRAVENOUS CANNULA IN EXPERIMENTAL GROUP-I AND EXPERIMENTAL GROUP-II
Experimental group-I Experimental group-II
Figure -4.1: Percentage distribution of patients receiving intravenous medications according to their patency in experimental group I & II
The above figure on percentage distribution of patients receiving intravenous medications in experimental group I and II related to patency of peripheral intravenous cannula. In experimental group I 13 (43.3%) of patients and experimental group II 5 (16.6%) of patients had first grade clinical symptoms during third day in phlebitis scale. In experimental group I 15(50%) of patients and experimental group- II 7(23.3%) of patients had first grade clinical symptoms during third day in infiltration scale.
Percentage of patients
Table -4.2:
Comparison of mean, standard deviation and mean percentage of normal saline lock and heparin lock on the patency of peripheral intravenous cannula among patients receiving intravenous medications in experimental group-I and II.
n=60 Experimental group I Experimental group II
Scores
Mean SD Mean
% Mean SD Mean
%
Difference in mean percentage Phlebitis 0.43 0.50 10.75 0.17 0.38 4.25 6.5%
Infiltration 0.50 0.51 12.5 0.23 0.43 5.75 6.75%
Table -4.2 reveals the phlebitis and infiltration scores of patients who have received normal saline lock and heparin lock. In experimental group-I, phlebitis and infiltration mean scores were 0.43 ? 0.50 and 0.50?0.51 respectively, Whereas in experimental group-II phlebitis and infiltration mean scores were 0.17? 0.38 and 0.23?0.43 respectively. The mean percentage for phlebitis in experimental group-I and experimental group-II was 10.75% and 4.25% respectively, whereas the mean percentage for infiltration in experimental group-I and experimental group-II was 12.5% and 5.75%. In phlebitis and infiltration the difference in mean percentage shows 6.5% and 6.75% respectively.
Section – C Hypotheses Testing
Table -4.3:
Comparison of the effectiveness of normal saline and heparin lock on the patency of peripheral intravenous cannula among patients receiving intravenous medications in experimental group-I and II.
n=60 Experimental group I Experimental group II
Scores
Mean SD CV % Mean SD CV %
‘Z’ value
Phlebitis 0.43 0.50 1.16 0.17 0.38 2.24 2.36*
Infiltration 0.50 0.51 1.02 0.23 0.43 1.87 2.25*
* Significant at p<0.05. Table value =1.96
Table -4.3 reveals the phlebitis and infiltration scores of patients who have received normal saline lock and heparin lock. In experimental group-I, phlebitis and infiltration mean scores were 0.43 ? 0.50 and 0.50?0.51 respectively, whereas in experimental group-II phlebitis and infiltration mean scores were 0.17 ? 0.38 and 0.23?0.43 respectively. Coefficient of variation for phlebitis and infiltration scores of patients received heparin lock is consistent than normal saline lock. The calculated
‘Z’ value (2.36, 2.25) was greater than tabulated ‘Z’ value (1.96) at 5% of significance and hypothesis H1 is retained. It reveals that heparin lock was effective than normal saline lock.
Table –4.4:
Association between patency of peripheral intravenous cannula among patients receiving intravenous medication in experimental group-I and II with their selected demographic variables
Experimental group –I (n=30) Experimental group –II (n=30 ) Phlebitis Infiltration Phlebitis Infiltration S.No Demographic variables
df ?2 df ?2
Table
value df ?2
Table
value df ?2
Table value
1. Age in years 4 8.541 4 3.637 9.488 4 3.429 9.488 4 2.915 9.488
2. Sex 1 0.475 1 0.536 3.841 1 0.718 3.841 1 0.258 3.841
3. Size of intravenous cannula 1 0.136 1 0.000 3.841 1 1.920 3.841 1 0.373 3.841 4. Presence of intravenous
cannula
2 0.134 2 0.132 5.991 2 0.39 5.991 2 1.1 5.991
5. Site of intravenous cannula 2 1.707 2 1.886 5.991 2 0.107 5.991 2 0.053 5.991
6. Diagnosis 6 5.848 6 3.611 12.592 6 2.709 12.592 6 1.890 12.592
Not Significant at p < 0.05 level
There is no association between the patency of intravenous cannula with their demographic variables such as age, sex, size of intravenous cannula, presence of intravenous cannula, site of intravenous cannula and diagnosis in both experimental I and II at p < 0.05 level. Hence H2 is rejected.
Summary
This chapter dealt with data analysis and interpretation in the form of statistical values based on the objectives. Percentage distribution of patients receiving intravenous medications based on their selected demographic variables. Z test was used to compare the effectiveness of normal saline lock and heparin lock on the patency of peripheral intravenous cannula among patients receiving intravenous medication. The chi-square analysis was used to find out the association between the patency of peripheral intravenous cannula among patients receiving intravenous medication in experimental group-I and II with their selected demographic variables.
CHAPTER-V
Discussion
CHAPTER-V DISCUSSION
The primary purpose of this study was to compare the effectiveness of normal saline lock versus heparin lock on the patency of intravenous cannula and to find out the association between patency of peripheral intravenous cannula among patients receiving intravenous medications with their selected demographical variables.
Description of demographic variables
? In experimental group-I 11(36.67%) and experimental group-II 12(40%) of them were in 50-59 years.
? In experimental group-I 16(53.3%) of them were females and experimental group-II 19 (63.3%) of them were males.
? In experimental group-I 24(80%) and experimental group-II 20 (66.6%) of them had size of intravenous cannula 20 gauge.
? In experimental group-I and experimental group-II 18(60%) of them were with intravenous cannulation on second day.
? In experimental group-I 15(50%) and experimental group-II 16(53.3%) of them had cephalic vein was the site of intravenous cannula.
? In experimental group-I and experimental group-II 30(100%) of them had antibiotics as type of medication.
? In experimental group-I 9(30%) and experimental group-II 15(50%) of them had musculo skeletal disorder
Patency of peripheral intravenous cannula after normal saline lock and heparin lock among patients receiving intravenous medication in experimental group-I and group-II
In experimental group-I 13(43.3%) and experimental group-II 5(16.6%) had first grade clinical symptoms during third day in phlebitis scale. In experimental group-I 15(50%) and experimental group-II 7(23.3%) had first grade clinical symptoms during third day in infiltration scale.
Compare of the effectiveness of normal saline lock versus heparin lock on the patency of peripheral intravenous cannula among patients receiving intravenous medication between experimental group-I and group-II
In experimental group-I, phlebitis and infiltration mean scores 0.43 ? 0.50 and 0.50?0.51 whereas in experimental group-II phlebitis and infiltration mean scores 0.17 ? 0.38 and 0.23?0.43. Coefficient of variation for phlebitis and infiltration scores of patients received heparin lock is consistent than normal saline lock. The calculated
‘Z’ value (2.36, 2.25) was greater than tabulated ‘Z’ value (1.96) at 5% of significance and hypothesis H1 is retained. It reveals that heparin lock was effective than normal saline lock.
The study supported by Tripathi, et.al, (2008 ) conducted to evaluate the factors affecting complications and patency of intravenous cannula at Lady Hardinge Medical College, New Delhi. The samples composed of 88 patients. The results showed that there was a statistically significant increase in the duration of patency
Association of the patency of peripheral intravenous cannula among patients receiving intravenous medications between experimental group I and group II with their selected demographic variables.
The present study reveals that in experimental group I and II there was no association between the patency of peripheral intravenous cannula among patients receiving intravenous medications with their selected demographic variables.
Summary
The discussion was made in this chapter based on the objectives of the study and it was related with similar studies conducted by other investigators.
CHAPTER - VI
Summary, Conclusion, Implications &
Recommendations
CHAPTER VI
SUMMARY, CONCLUSION, IMPLICATION AND RECOMMENDATIONS
Summary
A quasi experimental design was adopted to compare the effectiveness of normal saline lock versus heparin lock on the patency of peripheral intravenous cannula among patients receiving intravenous medications. The study was conducted from 05.07.2010 to 31.07.2010 Sri Gokulam Hospital and Vinayaka Mission Hospital, Salem. A observational tool was used for data collection, it consisted of two parts Section-A deals with the demographic characteristics of patients, Section– B consist of observational tool (phlebitis scale and infiltration scale) used to assess the patency of the peripheral intravenous cannula.
The Major Findin gs of the Study
? In experimental group-I, 11 (36.67%) and experimental group-II, 12 (40%) of them were in 50-59 years.
? In experimental group-I 16(53.3%) of them were females and experimental group-II, 19 (63.3%) of them were males.
? In experimental group-I 24 (80%) and experimental group II, 20 (66.6%) of them had size of intravenous cannula 20 gauge.
? In experimental group-I and experimental group- II 18(60%) of them were with intravenous cannulation on second day.
? In experimental group-I 15(50%) and experimental group-II 16(53.3%) of them had cephalic vein as the site of intravenous cannula.
? In experimental group-I and experimental group-II 30(100%) of them had antibiotics as type of medication.
? In experimental group-I 9(30%) and experimental group-II, 15(50%) of them had musculo skeletal disorder.
? In experimental group-I 13(43.3%) and experimental group-II, 5(16.6%) had first grade clinical symptoms during third day in phlebitis scale. In experimental group-I, 15(50%) and experimental group II, 7(23.3%) had first grade clinical symptoms during third day in infiltration scale.
? In experimental group-I, phlebitis and infiltration mean scores were 0.43 ? 0.50 and 0.50?0.51 respectively whereas in experimental group-II phlebitis and infiltration mean scores 0.17 ? 0.38 and 0.23?0.43 respectively.
Coefficient of variation for phlebitis and infiltration scores of patients received heparin lock consistent than normal saline lock. The calculated ‘Z’ value (2.36, 2.25) was greater than tabulated ‘Z’ value (1.96) at 5% of significance and hypothesis H1 is retained. It reveals that heparin lock was effective than normal saline lock.
? There was no association between the patency of intravenous cannula with their demographic variables such as age, sex, size of intravenous cannula, presence of intrave nous cannula, site of intravenous cannula and diagnosis in both experimental group I and II at p <0.05 level.
Conclusion
This comparative study to evaluate the effectiveness of normal saline lock versus heparin lock on the patency of peripheral intravenous cannula among patients receiving intravenous medications in selected Hospitals, Salem. The finding of the
intravenous cannula, presence of intravenous cannula, site of intravenous cannula and diagnosis in both experimental group I and II at p <0.05 level.
Implications Nursing practice
? Nurse can use heparin lock to maintain the patency of peripheral intravenous cannula.
? Infection control committee should teach the hospital staff about different techniques of maintaining the patency of peripheral intravenous cannula.
? Heparin lock can be used for maintaining the patency of peripheral intravenous cannula.
? Awareness can be created among student nurses on heparin lock to maintain the patency of peripheral intravenous cannula.
Nursing education
? Nurse educator can prepare a standard protocol on maintaining patency of peripheral intravenous cannula.
? In service education can be conducted to improve the practice of nurses on maintaining patency of peripheral intravenous cannula.
? A skills training programme can be arranged for Nur ses in maintaining patency of peripheral intravenous cannula.
? Nurse educator can encourage the student nurses to apply evidenced based practices to maintain the patency of peripheral intravenous cannula.
Nursing administration
? Nursing administration should initiate policies and plans for intravenous administration.
? Plan in-service education periodically for the nurses about intravenous therapy.
? Nurse administrator can arrange refreshment courses for new health team member to re-orient about the skills in doing intravenous procedure.
Nursing research
? Research studies can be conducted with the more samples on a long term basis adopting a controlled double blind randomized design.
? Findings of this study can be utilized for conducting further observational study on patency of peripheral intravenous cannula.
? An observational study can be conducted to determine intravenous complications
? A study can be conducted to know the effectiveness of protocol based intravenous care.
Recommendations
? A comparative study can be conducted with different flushing solutions to maintain the patency of peripheral intravenous cannula.
? Similar studies can be conducted with the more samples on a long term basis.
? A study can be conducted at various settings to identify the factors influencing the intravenous cannula related complication.
? Protocol can be prepared for administering intravenous heparin lock.
BIBLIOGRAPHY
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Unpublished Thesis
? Molly Thomas, (1999) conducted a study to evaluate the effectiveness of In- service education to nursing personnel in initiation and maintenance of peripheral intravenous lines, Master of Science in Nursing, Dr.M.G.R.University, Chennai.
? Remya, (2009) conducted a study to evaluate the effectiveness of self instructional module on practices of intravenous infusion therapy on children among nurses, Master of Science in Nursing, Dr. M.G.R.University, Chennai.
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ANNEXURES
ANNEXURE - A
Letter Seeking Permission to Conduct a Research Study
Letter Seeking Permission to Conduct a Research Study
ANNEXURE – B
TOOL FOR DATA COLLECTION SECTION – I: DEMOGRAPHIC DATA Instruction:
The investigator observe and questions wherever necessary and place a tick mark (?) against the correct option given below.
Sample No.
Date:
1) Age (in years)
a. 20 – 29 ?
b. 30 – 39 ?
c. 40 – 49 ?
d. 50 – 59 ?
e. 60 – 69 ?
2) Sex
a. Male ?
b. Female ?
3) Size of the intravenous cannula
a. 16 gauge ?
b. 18 gauge ?
c. 20 gauge ?
d. 22 gauge ?
4) Presence of intravenous cannula
a. Day one ?
b. Day two ?
c. Day three ?
d. More than three days ?
