BACKGROUND OF THE STUDY
Fluid and electrolyte balance is extremely vital for body physiology – its normal functioning and metabolism. About 70 % of body mass is water and along with it, a wide variety of electrolytes also harbour – especially Sodium, Chlorine, Potassium, Phosphorus and Calcium – that play pivotal role in sustaining the life process. Mainly the fluid balance nearly rests on Anti diuretic hormone from Posterior Pituitary gland and Aldosterone from the Adrenal Cortex. Fluid depletion can precipitate dehydration and in extremely low states, this can lead on to what we call as Hypovolemic shock. Fluid overload also has deleterious effects like Hypertension and Pulmonary edema. Fluid depletion is a rather serious and emergency situation, calling out for immediate interventions – a loss of as low as 15% of total body fluid can bring out deleterious effects.
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Usually the fluid balance can be maintained by the fluids which we take orally. But in a crisis situation and especially those necessitating rapid fluid replacement, like burns and massive hemorrhage calls out for a more reliable and quick acting, effective modality. This is where the IV therapy comes in handy. Here whatever IV supplements – fluid, blood, blood products or medications – being provided is directly reaching the blood stream, thereby making the response to it to occur very quickly and in a more efficient manner. Today, approximately 90 % of patients in acute care settings receive some form of IV therapy [Jenine Willin, 1999].
The history of IV therapy began with the discovery of circulation by Sir William Harvey in 1628. The first practical application of IV therapy was carried out by Dr. Thomas Latta, who used infusion of saline to treat diarrhoea. Normal Saline was used at first in early 1900’s and since then fluid and electrolyte knowledge grew and today more than 200 commercially prepared IV fluids are available. In 1935, slow drip method of continuous transfusion was published by two English physicians. In 1940, a nurse was assigned as I.V. Therapist at Mass General Hospital, with prerequisite to perform venipuncture successfully. In 1965, Dr. Stanley Dudrick of University of Penn tried giving nutrients intravenously to dogs & research led to today’s total parenteral nutrition. Metal needle was used prior to World War II. In 1945 plastic catheter was developed due to frequency of infiltrations. Glass containers used first individually packed/prepared by hospital pharmacy & later by major company as enclosed unit. Plastic containers were introduced in 1970’s. Today, IV Therapy has become a sub-specialty in nursing. National Intravenous Therapy Association. (N.I.T.A.) was established in 1985, for ensuring standards of practice. Approximately today, 90 % of patients in acute care settings receive some form of IV therapy ,[Jenine Willin, 1999].
The practice of IV therapy had become an important entity for nurses, that in 1981, Congress proclaimed January 25th as “National IV Nurses Day “. The IV Nurses Society [INS] is the professional organisation that establish standards of practice to promote excellence in IV nursing to ensure the highest quality, cost effective care for all individuals requiring IV therapy [INS, 2000].
Intravenous therapy or IV therapy is the giving of liquid substances directly into a vein. The word intravenous simply means “within a vein”. Therapies administered intravenously are often called specialty pharmaceuticals. It is commonly referred to as a drip because many systems of administration employ a drip chamber, which prevents air entering the blood stream (air embolism) and allows an estimate of flow rate. Compared with other routes of administration, the intravenous route is the fastest way to deliver fluids and medications throughout the body. Some medications, as well as blood transfusions and lethal injections, can only be given intravenously.
When considering the peripheral IV route, administration factors such as compliance, absorption and rate of medicine administration are also important. The peripheral IV route ensures the prescribed medicine concentration is achieved rapidly. It overcomes any nil-by-mouth or fasting requirements, and may also overcome a patient’s refusal to take oral medication. One hundred per cent bioavailability is achieved as the medicine is administered directly into the circulation and avoids the need for absorption; problems with malabsorption or medicine inactivation by the gut are also avoided. The risk of pain is also avoided; some medicines can be painful to the tissues and therefore cannot be given by the subcutaneous or intramuscular route (Dougherty and Lamb 1999). Once injected, there is no recall. The risks of speedshock, anaphylaxis, extravasation, infiltration and fluid overload with large-volume rapid infusions are factors to be considered, taking into account time, cost and increased risk of infection.
The benefits of the peripheral IV route outweigh the risks (CRAG 2003); however, this method requires registered medical and nursing staff to monitor the patient and the prescription regularly to ensure that the treatment continues to be the most appropriate and effective.
In 2002, the Nursing and Midwifery Council (NMC) released first professional document which was The code of professional conduct (NMC, 2002), which not only encouraged nurses to expand their practice, provided they had the necessary knowledge and skills and accepted responsibility for their actions, but also recognised the importance of involving patients/ clients in decisions affecting their care. The updated 2008 version of The Code (NMC, 2008b) emphasizes the need to deliver care based on the best available evidence, which strongly supports the need for robust standards of practice for infusion therapy. Knowledge and skills must be kept up to date and nurses must take part in appropriate learning and practice activities to maintain and develop their competence (NMC, 2008b).
The nurse inserting devices and/or providing infusion therapy should be competent in all clinical aspects of infusion therapy and have validated competency in clinical judgement and practice, and practice in accordance with the NMC’s Code: that is, they will maintain their knowledge and skills (Collins et al., 2006; NMC, 2007). Nurses undertaking the administration of infusion therapy and care and management of vascular access devices will have undergone theoretical and practical training in the following aspects (Lonsway, 2001).
It is mandatory to follow strict aseptic technique, while cannulating the patient and during management of IV therapy. Universal precautions are also to be kept in mind. The site to be cannulated should be ideally in the lower arm – preferably Cephalic vein. It is not recommended now to use alcohol or Betadine to clean the cannulation site, but only 2% Chlorhexidine in 70% alcohol. Regular sterile dry gauze dressing without any medication was also found to be beneficial. Heparin prophylaxis is also an important way of maintaining the IV cannula for more period (INS, 2006; Pratt et al., 2007; Dougherty & Watson 2008; NMC, 2008).
There are three peripheral IV routes: bolus injection, intermittent and continuous infusion, and each have inherent risks. The rationale for route choice is based on knowledge of the medicine and its therapeutic effect. The patient, circumstances and equipment need to be considered. Peripheral route choice requires competent practice and effective clinical judgement to reduce risk and ensure safe practice (NMC 2004a).
The most common sites for peripheral venous cannula are Superficial Dorsal, Meta carpal, Basilic and Cephalic veins in dorsal surface of hand & Cephalic, Basilic, Medial cubital and Radial veins in inner arm. Veins that should be ideally considered for peripheral cannulation are those found on the dorsal and ventral surfaces of the upper extremities including the metacarpal, cephalic and basilic (Griffiths, 2007; Dougherty, 2008; Scales, 2008).
Migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization of the catheter tip is the most common route of infection for peripherally inserted, short-term catheters (Mermel LA, McCormick RD, Springman SR, Maki DG., 1991). Contamination of the catheter hub contributes substantially to intraluminal colonization of long-term catheters. Occasionally, catheters might become hematogenously seeded from another focus of infection. Rarely, infusate contamination leads to CRBSI. Important pathogenic determinants of catheter-related infection are 1) the material of which the device is made and 2) the intrinsic virulence factors of the infecting organism.
Some catheter materials also have surface irregularities that enhance the microbial adherence of certain species (e.g., coagulase-negative staphylococci, Acinetobacter calcoaceticus, and Pseudomonas aeruginosa) (Locci R, Peters G, Pulverer G., 1981); catheters made of these materials are especially vulnerable to microbial colonization and subsequent infection. Additionally, certain catheter materials are more thrombogenic than others, a characteristic that also might predispose to catheter colonization and catheter-related infection (Stillman RM, Soliman F, Garcia L, Sawyer PN., 1977). This association has led to emphasis on preventing catheter-related thrombus as an additional mechanism for reducing CRBSI.
The adherence properties of a given microorganism also are important in the pathogenesis of catheter-related infection. For example, S. aureus can adhere to host proteins (e.g., fibronectin) commonly present on catheters (Herrmann M, Suchard SJ, Boxer LA, Waldvogel FA, Lew PD., 1991). Also, coagulase-negative staphylococci adhere to polymer surfaces more readily than do other pathogens (e.g., Escherichia coli or S. aureus). Additionally, certain strains of coagulase-negative staphylococci produce an extracellular polysaccharide often referred to as “slime” (Gray ED, Peters G, Verstegen M, Regelmann WE., 1984). In the presence of catheters, this slime potentiates the pathogenicity of coagulase-negative staphylococci by allowing them to withstand host defense mechanisms (e.g., acting as a barrier to engulfment and killing by polymorphonuclear leukocytes) or by making them less susceptible to antimicrobial agents (e.g., forming a matrix that binds antimicrobials before their contact with the organism cell wall). Certain Candida spp., in the presence of glucose-containing fluids, might produce slime similar to that of their bacterial counterparts, potentially explaining the increased proportion of BSIs caused by fungal pathogens among patients receiving parenteral nutrition fluids (Branchini ML, Pfaller MA, Rhine-Chalberg J, Frempong T, Isenberg HD., 1994).
The interior wall of a vein, the Tunica Intima, consists primarily of a single layer of tightly packed endothelial cells. Injury or irritation to this layer can trigger a cascade of inflammatory reactions. The cannula may injure the endothelium, or sometimes, clot develops proximal to cannula site. Any of these will cause release of Histamine, Bradykinin or Serotonin and other inflammatory mediators. They inturn initiate pain response, dilatation of vein, increased localised blood flow, increased capillary permeability etc, which cause the fluid and proteins to leak into interstitial space, causing edema and tenderness [Denise Macklin, 2003].
The common types of peripheral cannula associated complications are Phlebitis, Infiltation, Extravasation, Hematoma, Embolism, Blood stream infection etc. Phlebitis is the inflammation of the tunica intima of the vein. It is the most common of the lot, affecting between 27 % – 70 % of all patients receiving IV therapy. There are three types of phlebitis: mechanical, chemical and infective (Macklin, 2003). Kathryn Burke (2000) describes Thrombophlebitis as a common complication of IV therapy, estimated to occur in around 1.3 million patients annually.
Infiltration should be defined as the inadvertent administration of non-vesicant medication or solution into the surrounding tissue instead of into the intended vascular pathway (Fabian, 2000; INS, 2000; Hadaway, 2002; Lamb and Dougherty, 2008).
The rate of all catheter-related infections (including local infections and systemic infections) is difficult to determine. Although CRBSI is an ideal parameter because it represents the most serious form of catheter-related infection, the rate of such infection depends on how CRBSI is defined. Since 1970, CDC’s National Nosocomial Infection Surveillance System (NNIS) has been collecting data on the incidence and etiologies of hospital-acquired infections. CDC and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommend that the rate of catheter-associated BSIs be expressed as the number of catheter associated BSIs per 1,000 CVC days (CDC., 1999 ; JCAHO., 1994). This parameter is more useful than the rate expressed as the number of catheter-associated infections per 100 catheters (or percentage of catheters studied), because it accounts for BSIs over time and therefore adjusts risk for the number of days the catheter is in use.
The factors that increase the patient risk of developing cannula related complications include advanced age, female sex, malnutrition, increased gauge of catheter, sites which are on flexion areas or bony prominences and nature of drug.Slow infusion rates have greater potential to irritate veins compared to faster rates (AJN, 2003).
Types of organisms that most commonly cause hospital-acquired BSIs change over time. Pooled data from 1992 through 1999 indicate that coagulase-negative staphylococci, followed by enterococci, are now the most frequently isolated causes of hospital-acquired BSIs . Coagulase-negative staphylococci account for 37% (12) and S. aureus account for 12.6% of reported hospital-acquired BSIs . In 1999, enterococci accounted for 13.5% of BSIs, an increase from 8% reported to NNIS during 1986–1989. The percentage of enterococcal ICU isolates resistant to vancomycin also is increasing, escalating from 0.5% in 1989 to 25.9% in 1999. Candida spp. caused 8% of hospital-acquired BSIs reported to NNIS during 1986–1989, and during 1992–1999 (Pfaller MA, Jones RN, Messer SA, Edmond MB, Wenzel RP., 1998). Gram -negative bacilli accounted for 19% of catheter-associated BSIs during 1986–1989 (Schaberg DR, Culver DH, Gaynes., 1991) compared with 14% of catheter-associated BSIs during 1992-1999.
The management of IV therapy complication is according to the severity of complication. Common management for infiltration and thrombophlebitis are ice application, warm application, Heparin ointment, moist heat application, antiseptic or anti-inflammatory creams, analgesics and antibiotics.
Thrombopob is heparin jelly for topical application, which contains Heparin Na 19.5 grams and 95 % Ethanol 0.5 grams. It is a novel form of heparin therapy. Natural heparin inhibit thrombin formation and promote fibrinolysis. The microthrombin present close to skin are more rapidly absorbed. It also has a refreshing cooling effect on the skin. It dries up quickly and shows excellent tolerance to skin.
Ichthammol Glycerin (Ammonium Ichthosulphonate) belongs to a class of compounds containing acid sulphonates, designated by group name Sulphoichthyolic Acids. It is blackish brown liquid, viscous in nature, with strong pungent rheumatic odour. It is soluble in glycerin, water and partly in alcohol. IG paint provides more efficient and comfortable symptomatic relief in case of Thrombophlebitis and Infiltration, and is more cost effective, compared to use of Thrombophob (Anitha Nesa Thanka, 2004).
Topical vapocoolant sprays can produce immediate cannulation pain relief. Commonly used vapocoolants include ethyl chloride, fluorohydrocarbon, and alkane mixtures (butane, propane, and pentane). Alkane vapocoolant sprays are primarily used to provide rapid pain relief from acute muscular injuries. Rapid evaporation of the volatile liquid spray from the skin surface causes a drop in temperature and results in temporary interruption of pain sensation, possibly through desensitisation of pain receptors or activation of ion channels involved in pain transmission.Topical vapocoolant spray therefore offers a potentially convenient and effective anaesthetic for intravenous cannulation.
Another recent development is a topical anesthetic cream, EMLA, or eutectic mixture of local anesthetics, (2.5% lidocaine, 2.5% prilocaine), is approved for use in reducing the pain of pediatric procedures, including injection.
External Thermomechanical Stimulation is another developing, yet to be proved notion in the field of IV therapy pain management, where mechanoreceptor and noxious thermal inhibitory stimulation modulate pain conduction. It involves application of a vibrating cold device to proximal region of cannula.The combination of cold and vibration gives significant venipuncture pain relief without affecting cannulation success. Interventions are more helpful for those with greater preprocedural fear.
NEED FOR THE STUDY
The nurses practicing today are bound with a wide variety of duties and responsibilities and world looks out for more specialised, systematic approach, catering highly proficient skills and techniques. IV therapy evolved as a mere practice initially, and later turned out into one of the major responsibilities of a nurse, in her day to day practice and is an area which is continuously expanding, on the eve of extended and expanded roles of a nurse.
The current guidelines from Centre for Disease Control and Prevention state that even when no problem arise in association with cannula and site, the peripheral venous cannula should be replaced and sites rotated, every 96 hours.
The practice of not changing an IV cannula, because patient shows no signs of complication, like infiltration or phlebitis, should be avoided, especially in patients who are neutropenic, immunosupressed or malnourished, as these conditions can delay appearance of symptoms [CDC, 2002].
Unfortunately, as Speechley and Toovey  remarks, these complications are sometimes regarded as routine occurrence or a mere nuisance, but to overlook or underestimate potential risk of IV therapy literally means to lose the sole aim of therapy, which is to effectively replace fluid and electrolyte, without causing discomfort or further injury to patient.
Manjula J Ramani (2000) conducted study to assess the knowledge and practice of IV therapy among RN working in KLE Society Hospital, Belgaum. Result showed that 19 (41.3%) of RN had average knowledge with good practice and 8 (17.39%) had average knowledge but poor practice and 10.86 % had above average knowledge and good practice.
Neil E. Soifer and Steven Borzak (1998) performed a randomized, prospective, controlled study in a university-affiliated hospital to determine whether the use of an IV therapy team decreases peripheral venous catheter-related complications in adult medical patients. Patients were randomized to undergo peripheral catheter insertion and/or maintenance either by the IV team or by medical house staff. Patients with catheters started by the house staff and maintained by ward nursing staff more often had signs or symptoms of inflammation (21.7%) than did patients with catheters maintained by the IV team (7.9%) (P<.001). Study proved that an IV therapy team significantly reduced both local and bacteremic complications of peripheral IV catheters. Timely replacement of the catheter appeared to be the most important factor in reducing the occurrence of complications.
A cannulated patient can go on to develop any one of the four complications – Thrombophlebitis, Hematoma, Infiltration or Embolism. Among these, statistics show that Phlebitis and Infiltration are the most common ones.
The outcome of IV therapy on a patient is bassed on a lot of factors – size of cannula, site of cannulation, vein used, medicine instilled, frequency of use, maintenance of asepsis through hand hygiene, proper technique of drug administration, speed of drug instillation etc. Despite evolving of newer, biofreindly and compatible devices for IV cannulation, these factors still contribute to increase incidence of negative outcomes among patients on IV therapy.
Pain in the IV site is usually the primary warning that is expressed, which gives a cue about more serious problems to come. Since pain is subjective, it is important that the nurse assess and evaluate the patient condition for more reliable objective cues. The nurse should inspect and palpate IV site for edema, erythema, warmth, induration and thickening of vein, which can objectively indicate negative outcomes in relation to IV therapy. The extremity should be compared with the opposite side.
Nowadays, the recommended practices are breached to a great extent. Each and every scientifically based recommendations are just torn into pieces. Many of the hospitals are not keen to recruit qualified eligible staffs; but instead are satisfied with just 6-8 month trained unprofessionals. Such a practice is a huge blow not only in the IV therapy feid, but to the whole health care system.
It has been noticed and empirically proved that in most hospitals as the degree of rush and workload becomes heavy, the standard practices and basic techniques like handwashing arre tormoiled. All infusion related procedures require the use of aseptic technique, observation of standard precautions and product sterility (DH, 2005b; Rowley & Laird 2006; Pratt et al., 2007). In case of IV therapy, this action alone can single handedly bring negative outcomes to the patient.
Also, during his clinical experience, the researcher has came across numerous occasions, were he has seen that the standards of practice meant to be followed for IV therapy being breached. Researcher feels that, if those are aptly followed, the worth of the saying “Prevention is better than cure” would be evident, as he assumes that such a practice can considerably reduce the occurrence of negative outcome among patients on IV therapy. Execution of set standards and proper surveillance of patients can bring about the desired outcome to a great extent. For that purpose, the researcher wants to investigate, whether standard practices really can have an influence on the outcome of patients with IV therapy.
The purpose of setting standards is clear: to inform and educate staff about current best evidence and practice. Peripheral IV therapy theory should relate to local and/or national guidance or procedures. NES (2004) is focusing on educational and training standards in clinical skills, venepuncture, cannulation and peripheral IV therapy. Such standards ensure that staff are trained to an appropriate level, now and for future approved levels, and staff can transfer skills without the need to repeat training.
The NMC Code of Professional Conduct states that each registered nurse has a responsibility to deliver care based on current evidence, best practice and, when available, validated research (NMC 2004a). Policies and procedures should be documented and developed by experienced practitioners to reflect current issues in clinically effective care, and should be subject to annual review.
Statement of the problem:
A study to assess the effect of protocol based intravenous therapy techniques on the outcome of IV therapy among patients receiving continuous IV infusion and IV medications, in a selected hospital at Thirupur, Tamilnadu.
Aim of the study:
The aim of the study is to evaluate whether the application of protocol based IV therapy techniques make a difference in the outcome of IV therapy among patients receiving IV infusion and medications, compared to patients who receive IV therapy without the prescribed IV therapy techniques.
To assess and compare the daywise and overall degree of pain of the experimental and control group.
To assess and compare the daywise and overall manifestations of thrombophlebitis and infiltration related to IV therapy, among experimental and control group
To associate selected IV therapy related variables like cannula size, duration of therapy and medications used with the outcome of IV therapy, among the experimental and control group.
H1 – There will be a significant difference in the daywise and overall mean pain score, between experimental and control group receiving IV infusion and medications.
H2 – There will be a significant difference in the daywise and overall outcome score of Thrombophlebitis, between experimental and control group receiving IV infusion and medications.
H3 – There will be a significant difference in the daywise and overall outcome score of Infiltration, between experimental and control group receiving IV infusion and medications.
Effect – It refers to something that inevitably follows a cause; the power to bring about a result; the creation of a desired impression.
In this study, the effect refers to the anticipated outcome in response to IV therapy, which involves the non-occurrence of localised signs and symptoms like pain, edema, erythema, hardened vein, leaking, numbness, skin blanching, tightness and distal circulatory impairment.
Protocol Based – It refers to the techniques of carrying out a procedure, in a systematic way, with related scientific principles, as mentioned in the literature, published by experienced authors, which provides the basis for carrying out technical procedures safely on patients.
In this study, the protocol based technique of IV therapy includes:
Site selection and skin preparation
Site dressing and maintenance
Drug loading, administration and proper maintenance of infusion
Heparin lock prophylaxis
IV therapy – The administration of continuous IV infusion as well as intermittent bolus administration of medications, for various purposes like treatment and prophyllaxis.
Outcome – Refers to the observable and measurable localised signs and symptoms related to IV therapy, which includes :
Pain, measured by 0 – 10 Numerical Pain Intensity Scale.
Pain, edema, erythema and hardened vein, which can be measured using Thrombophlebitis Scale.
Skin blanching, translucency, leakage, cool to touch, edema, numbness, circulatory impairment and tightness of skin, assessed by Infiltration Scale.
IV therapy is a very common procedure among hospitalized patients, worldwide.
One needs to have adequate knowledge and skills to carry out IV technique safely on patients.
There can be variations in the technique due to various influencing factors such as level of education, experience, environmental factors etc.
Adhering to protocol based IV therapy techniques can considerably minimize the occurrence of negative outcomes.
The degree of pain which is going to be assessed is a subjective data, where the subject is expressing what he feels and this can vary individually and may not be accurate or can be biased.
The application of prescribed IV therapy techniques by researcher is limited to daytime alone. The researcher perceives this as a limitation and will try to maintain control by providing instructions to night shift staff and checking the activities.
The study is carried out in only in Tirupur, and that too confined to only one hospital.
The study takes into account data from only 40 samples.
This study is conducted within a period of one month. Since the time frame is too narrow, several vital factors related to the study may not be properly assessed.
A concept is the building block of a theory, describing mental image of a phenomena, which can be abstract or concrete.
A theory is a set of interrelated concepts, adapted for a scientific purpose; definitions and propositions, that present a systematic view of phenomena by specifying relations among variables, with the purpose of explaining and predicting the phenomena [ Kerlinger, 1986 ]
A conceptual framework is quite similar to the foundations of a house. Just like the foundation which supports the house, conceptual framework provides rationale for predictions about relationship among variables in the research study. Much like the framework of house, that rest on foundation, which will define the all over design of house, conceptual framework forms the base of observations, definition of concepts, research design, interpretation etc. Conceptual framework gives meaning to problem and study findings by summarizing existing knowledge in the field of enquiry and identifying linkages between the concepts.
For this study, the theoretical base used is TITLER EFFECTIVENESS MODEL . The study focus on evaluating effectiveness of applying protocol based IV therapy techniques on outcome of IV therapy.
This theory has been derived from Roger’s Diffusion model of Innovation (2004). It is a model which states how to inculcate novel ideas into existing practice. The way in which innovations and evidence based actions can be initially tested and finally incorporated into a system is dealt with clarity.
Titler’s model shows light into al those factors existing in the phenomena, which can have a say in the result of the actions. Here, it is stated as ‘ Factors/ influencing characteristics’. This model is ideal for experimental qualitative projects since it expresses the comparative picture between part receiving the new idea and one which is following traditional way. This is expressed as Experimental and Control groups. ‘Process’ is the level which shines light into the evidence based newly developed idea. It is this notion, for which the researcher will check the effectiveness.
The ‘ effectiveness’ can be assessed through analysing the outcome of both groups. This will prove whether the new innovation is effective and worthy of incorporating into the system or to be rejected.
This study focus on evaluating effectiveness of applying protocol based IV therapy techniques on outcome of IV therapy.
Independent variable – Protocol based IV therapy techniques
Intervening variables – Outcome of IV therapy, which involves localised signs and symptoms like pain, edema, erythema, hardened vein, leaking, numbness, skin blanching, tightness and distal circulatory impairment.
Several factors are linked together in determining the outcome of an IV therapy. In the study, the experimental group will be subjected to Protocol based IV therapy techniques, whereas the control group will undergo the routine procedures of IV therapy practiced in the settings.
The application of Protocol based IV therapy techniques to experimental group includes the following:
Site selection and skin asepsis
Site dressing and maintenance
Drug loading, administration and proper maintenance of infusion
Heparin lock prophyllaxis
Adhering to such protocol based techniques of IV therapy can reduce the localized signs and symptoms related to IV therapy. The factors incorporated into selected IV therapy techniques are those, which the researcher feels as having a vital role in the outcome of IV therapy.
FACTORS / INFLUENCING PROCESS EFFECTIVENESS
Outcome of IV Therapy showing reduction om manifestation of localized signs &
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