http://doi.org/10.33698/NRF0130– Maninder Deep Kaur ,Sukhpal Kaur ,Firuza D Patel
Abstract :Peripheral intravenous catheter insertion is a common nursing procedure often required for the administration of chemotherapy, antibiotics, blood products, fluids, and other medical therapies. Insertion of intravenous cannula can be extremely difficult, particularly in individuals receiving repeated courses of chemotherapy. The current study attempts to provide information about the effect of moist heat therapy on the visibility and palpability of peripheral veins. Using purposive sampling technique, 60 subjects were selected who were scheduled for IV cannulation for the purpose of chemotherapy administration and whose veins were not visible and palpable. Moist heat was applied at the forearm, hands and wrist for 10 minutes prior to IV cannulation. Following the intervention vein assessment was done by using Vein Assessment Scale. Permission to conduct the study was sought from Ethics Review Committee of the institute. Mean age (yrs) ± SD of the subjects was 47 ± 12.46yrs with range of 20-75. 65% subjects were females. 27% were suffering from cervical cancer. Mean duration of getting chemotherapy treatment was 4.07±3.86 months with range of 1 to 24 months. 40% subjects had clearly visible and palpable veins after the intervention. Intervention was significantly more effective in the patients with shorter duration of chemotherapy (p<0.05).
Key words :
Moist heat therapy, peripheral veins, chemotherapy, visibility & palpability of veins.
Correspondence at : Maninderdeep Kaur
Lecturer
Sri Guru Ram Dass College of Nursing, Mehta Road, Amritsar
Introduction
Chemotherapy is the use of cytotoxic drugs in the treatment of cancer. It is one of cancer treatment modalitiesthat provide cure, control, or palliation. Most of the chemotherapeutic drugs are delivered intravenously. The main purpose is to deliver a very high dose of chemotherapy to tumor sites1. Chemotherapeutic drugs are vesicants and irritants which cause skin reactions like tenderness, warmth, redness and itching along the vein or at the injection site. The veins may get damage, which causes the cannulation difficult.2,3 Commonly used veins for chemotherapy administration are cephalic, median and basilic veins of forearms and dorsal veins of dorsum of hands4. The vein needs be palpable before cannulation. Bruised or inflamed areas should be avoided. Venipuncture sites must be changed on planned basis every 48 hours to reduce the possibility of phlebitis and infiltration.4- 6 Cancer patients need repeated courses of chemotherapy. Insertion of intravenous (IV) cannula often is a source of patient anxiety and discomfor t.7,8 About 20% of adults experience a mild to moderate fear of needles and have anxiety leading to bradycardia and hypotension9. Thus, because of the vesicant nature of chemotherapy drugs and the fear of IV insertion, the cancer patients often pose a problem for cannulation. Sometimes multiple attempts may occur, which can further lead to distress and anxiety in the patient.
Application of heat at the IV 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 blood flow to the injured part. 10 There is increase in the cutaneous blood flow by 70% during the periods of heating. This increase in cutaneous blood flow is attributed initially to withdrawal of sympathetic vasoconstrictor activity and increase in sympathetic vasodilator activity.11,12 The various warming methods include immersion of patient’s hand and arm in warm water and then wrapping the arm with a moist towel, application of dry heat chemical warm pack and use of a microwaved wheat-filled bag.13 Others procedures 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 arm down.14,15
Fink et al16 examined the effect of dry versus moist heat application on the improvement of IV inser tion rates. They concluded that dry heat was 2.7 times more likely than moist heat to result in successful IV insertion on the first attempt. The type of heat did not have any effect on the patients’ anxiety level. Lenhardt et al found that local warming using dry versus no heat prior to intravenous peripheral cannulation facilitated IV insertion and decreased the number of attempts of cannulation.17
Though the beneficial effects of heat on the visualization and insertion of IV cannula have been reported, but there is scarcity of information on the effect of moist heat on the accessibility of peripheral veins. Thus the current study was under taken with an objective to assess the effect of moist heat therapy on the visibility and palpability of peripheral veins for cannulation.
Materials & Methods
The study was conducted in Radiotherapy ward and Day care centre of Nehru hospital PGIMER, Chandigarh. In these areas patients are admitted on daily basis for the purpose of administration of chemotherapy. Purposive sampling technique was adopted. Sixty patients whose veins neither visible and nor palpable were included in the study. Only one vein of one patient was taken as sample. Veins of forearm, hand or wrist were taken.
An interview schedule was used to gather the data regarding age, gender, marital status and educational status of the subjects. Cycles and duration of getting chemotherapy was also noted. Protocol on moist heat therapy was developed. A 5 point scale (1– 5) was used to assess the visibility and palpability of the veins. Maximum attainable score was 5. Score 1 was given when the vein was neither visible nor palpable, score 2 was given when vein was visible but not palpable, score 3 was given when vein was barely visible and palpable, score 4 was given when vein was visible and palpable and score 5 was given when the vein was clearly visible and easily palpable. (Lenhardt 2002)17. The content validity of the tools was established by circulating the tools amongst the experts in the related fields.
In the selected subjects the status of visibility of vein was assessed. Then moist heat was applied on the vein by applying a small towel diped in lukewarn water (39.5ºC). The moist heat was applied for 5 minutes continuously. Then towel was teken out again dipped in lukewarm water & reapplied for another five minutes. Total for 10 minutes heat was applied.
After 10 minutes the towel was removed and skin was dried by using a dry towel and visibility of vein was reassessed. On one patient the heat therapy was applied only once. All the precautions were taken regarding the application of heat therapy. Investigator closely monitored the subject during the intervention in order not to cause any untoward effects. SPSS 16 was used to analyze the data. Both descriptive and inferential statistics was applied. The various statistical measures used were such as measures of central tendency, measures of dispersion, percentage, and non- parametric tests i.e. Fissure exact test. A written permission was taken from Head of Department of Radiotherapy of Nehru hospital, PGIMER, Chandigarh. Written consent was obtained from the patient in his/her own language. Study was approved by the Ethics Review Committee of the institute.
Results
The subjects were in the range of 20 to 75 years of age with the mean age of 47±12.46 yrs. 33.3% of the study subjects were between 51- 60 yrs, followed by 25% in the age group of 41-50 yrs. More than half of the subjects were females (65%). 91.7% were married. 66.7% were not working (house wives, unemployed) and 43.3% were undergraduates (Table 1).
Table 1: Socio demographic characteristics of subjects N=60
Variable n (%)
Mean duration of getting chemotherapy treatment was 4.07±3.86 months with the range from 1-24 months. 66.7% were getting chemotherapy from 1- 3 months. 20%
Age(yrs)*
<30 6(10.0)
31-40 12(20.0)
41-50 15(25.0)
51-60 20(33.3)
subjects had completed the treatment of 4-6 months. Only 5% subjects were getting chemotherapy treatment from more than 10 months
Table 2 : Distribution of subjects as per duration of getting chemotherapy N=60
>60 7(11.7)
Duration of getting
Gender
Male 21(35.0)
Female 39(65.0)
Marital Status
Married 55(91.7)
Unmarried 5( 8.3)
Occupation
Working 20(33.3)
Not working 40(66.7)
Education
Illiterate 15(25.0)
Just literate 9(15.0)
Undergraduate 26(43.3)
Graduate & above 10(16.7)
*Mean age (yrs)±SD 47±12.46 Range 20-75 yrs
Distribution of subjects as per duration of getting chemotherapy
Table 2 depicts the duration of getting chemotherapy among the study subjects.
chemotherapy (months) n (%)
1-3 40(66.7)
4-6 12(20.0)
7-9 5 ( 8.3)
>10 3 ( 5.0)
Mean ±SD 4.07±3.86 Range 1-24
Effect of the intervention on the vein status -Prior to intervention none of the patients had visible and palpable veins. Then therapy was used for 10 minutes i.e., application of small towel dipped in lukewarm water (39.5ºC) on the vein for 10 minutes after removing the towel the status and vein was assessed. After the intervention 40% subjects had clearly visible and easily palpable peripheral veins (score 5). One third (33.3%) had the score of 4 i.e. visible and palpable veins. In 11.7% subjects the veins were visible but not palpable after the intervention. (Table 3)
Table 3 : Effect of the intervention on the vein status N=60
| Score | Peripheral veins status | Prior to intervention n (%) | After Intervention n (%) |
| 1 | Neither visible nor palpable | 60 (100) | ——– |
| 2 | Visible but not palpable | ——– | 7(11.7) |
| 3 | Barely visible and palpable | ——– | 9(15.0) |
| 4 | Visible and palpable | ——– | 20(33.3) |
| 5 | Clearly visible and easily palpable | ——– | 24(40.0) |
Effect of intervention on status of vein as per the duration of chemotherapy
Table 4 shows the vein status of the subjects according to the duration of getting chemotherapy. After administering the moist heat therapy 28.3% subjects who were getting chemotherapy treatment from last 3 months, their veins were clearly visible and easily palpable. This percentage decreased to 10% and 1.7%, in the subjects who were getting chemotherapy from last 4-6 and 7 months respectively. Numbers of patients with visible and palpable veins were significantly more with shorter duration of chemotherapy as per fisher test (F= 16.10, p= 0.004)
Table 4: Effect of intervention on the vein status according to the duration of chemotherapy N=60
Effect of intervention on the vein status
| Duration of chemotherapy | visible but not palpable | barely visible and palpable | visible and palpable | clearly visible or easily palpable |
| (months) | n(%) | n(%) | n(%) | n(%) |
| 1-3 | 1(1.7) | 7(11.7) | 15(25) | 17(28.3) |
| 4-6 | 1(1.7) | 1(1.7) | 4(6.7) | 6(10) |
| More than 7 | 5(8.3) | 1(1.7) | 1(1.7) | 1(1.7) |
Fisher test value 16.10, df=6, p=0.004
Discussion
Inser tion of IV cannula is the most common invasive procedure in the hospitalized patients. Usually the insertion is easy and causes only mild distress in the patients. But, sometimes it may be difficult especially in cancer patients requiring repeated courses of chemotherapy. Nurses use various techniques including heat to improve the visualization of veins to enhance the success rates of IV insertion.
In the current study effect of moist heat application was observed on the visibility and palpability of the veins for the insertion of IV cannula. Moist 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, ar terioles and venules. The increased metabolism leads to release of carbon dioxide, lactates and promotes movements of waste products from the affected area.18 Status of veins was assessed by using 5 point scale in which score 1 was given when veins neither visible nor palpable and score 5 was given when the veins were clearly visible and easily palpable. Before the intervention 100% of the subjects had mean vein status score of 0.
The moist heat therapy in the current study was effective in improving the status of veins, though different percentage of subjects had different vein status score. Following the intervention 40% had vein status score of 5 i.e. their veins were clearly visible and easily palpable. Keeping the patient warm for the success of IV insertion has also been suggested by Rosenthal. 9 Wagner et al19 had fur ther suppor ted the fact that warming the arm of the patients for IV cannula inser tion had a positive effect on patients’ thermal control and wellbeing.
The results are supported by the finding of another study16 which was carried out to determine the effect of dry versus moist heat application on the IV insertion rate. Participants were randomly assigned to dry or moist heat. In moist heat group the mean pre warming vein status was 3±1.4 and the mean status was 3.8±1.2 after the warming. In case of dry heat group the mean pre warming vein status was 3.4±1.3 and the post warming vein status was 4±1.2 16. Nurses’ rating of vein status improved from pre to post insertion, regardless of the modality used. No significant differences were observed between the groups in pre and post warming temperatures on the vein status. Lenhardt et al17 conducted single- blinded, randomized controlled and crossover trial to see the effect of dry verses no heat on peripheral venous cannulation. Fifteen minutes of warming significantly increased vein scores. (>3).
It was found that intervention was effective in the patients with shorter duration of chemotherapy treatment. This could be explained by the fact that chemotherapeutic drugs are vesicants and irritating which causes tenderness, warmth or redness on the skin. It was observed that as the cycle and duration of chemotherapy increases the vein visibility and palpability was decreasing due to the effect of chemotherapeutic drugs. Although the comfort level was not assessed in current study but no incidence of discomfort was reported by the study subjects. All subjects were comfortable with moist heat.
It was concluded that there is significant effect on the visibility and palpability of peripheral veins with the application of moist heat at the site prior to peripheral intravenous cannulation. Heat therapy was safe and easy to administer. The cost of the procedure was not calculated. Only warm water and towels were used for the intervention. It may be considered as an option in hospital and day care centres for the visibility and palpability of the veins. Further studies may be carried out to see the effect of moist heat on the number of IV attempts, time taken to achieve IV cannulation, patient’s anxiety and comfort level.
References
- Langhorme Oncology Nursing. 5thed.USA: Elsevier; 2007: 362.
- Vesicants chemotherapy extravasations pdf [Online] 1989 Available from: URL:http:// www.cincinnatichildrens.org/9065455. Accessed on 26.09.10
- Chemocare vesicants [online]. Avialable from: URL: http://www.Chemocare.com. Accessed on 03.2011.
- Millam AD. On the road to successful intravenous Nursing health module 2003 May; 35(1):1-14.
- Brady M, Chadwick G, Ferguson F, Mckendrick S, Preston J, Richardson Guidelines for safe handling & administration of cytotoxic chemotherapy. NHS Greater Glasgow. 2nd ed; 2003 April.
- Donna M, Shirtey Developing a venous assessment tool in IV chemotherapy administration. Br J Nurs 1999; 17(3):158-64.
- Bartfield JM, Janikas JS, Lee RS. Heart rate response to intravenous catheter placement Acad Emerg Med 2003 Sept; 10(9):1005-8.
- Soysal S, Topacoglu H, Karcioglu O, Serinken M, Koyuncu N, Sarikaya Factors affecting pain in intravenous catheter placement. International Journal of Clinical Practice 2005; 59 93): 276-280.
- Rosenthal K. Tailor your IV insertion technique for special Nursing 2005 May: 35(5):36-41.
- Perry S, Tepperman The therapeutic use of heat and cold. 1986 May;32: 1110-14.
- David A, Roscoe EM, Samuel TJ, Yuonne B, Agenor Changes in blood flow oxygen uptake and tissue temperature produced by the topical application of wet heat. Arch Phys Med Rehabil 1961:305-17.
- Roberge Venodilatation technique to enhance venipuncture and intravenous cannulation. J Emerg Med 2004; 27(1):69-73.
- Beer Local warming does help when inserting cannulas. BMJ 2002; 325(7371):1038.
- Mbamalu D, Banerjee Methods of obtaining peripheral venous access in difficult situation. Postgrad Med J 1999; 75(886):459- 62.
- Norwood Policies and procedures for infusion nurse. J Infus nurs 2006 July 44(7):11.
- Fink MR, Hjorte E, Wenger B, Cook FP, Cunningham M, Orf A et The impact of dry versus moist heat on peripheral catheter insertion in hematologic oncology patient. Oncol Nurs Forum 2009 July 36(4): 1-11.
- Lenhardt R, Seybold T, Kimberger O, Stosier B, Sessler Local warming and insertion of peripheral venous cannulation single blinded prospective randomized controlled trial and single blinded randomized crossover trail. BMJ 2002 Aug 24; 325:409-10
- Theratherm moist heating pad [online] 2005 [cited 2010 April 7]. Available from: URL: http://www.knee Accessed on 7.03.2011.
- Wagner D, Byrne M, Kolcaba Effects of comfort warming on preoperative patients. AORN Journal 2006 Sept; 84(3):13.