A STUDY TO EVALUATE EFFECTIVENESS OF COLD APPLICATION AND MAGNESIUM SULPHATE APPLICATION ON SUPERFICIAL THROMBOPHLEBITIS AMONG PATIENTS RECEIVING INTRAVENOUS

THERAPY IN SELECTED HOSPITALS, AMRITSAR.

A Synopsis Submitted for the partial fulfillment of the requirement for the degree of

MASTER OF SCIENCE IN NURSING (Medical Surgical Nursing)

Of Baba Farid University of Health Sciences, Faridkot, Punjab

2012
Navjot Kaur

Mai Bhago College of Nursing, Tarn-Taran

A STUDY TO EVALUATE EFFECTIVENESS OF COLD APPLICATION AND MAGNESIUM SULPHATE APPLICATION ON SUPERFICIAL THROMBOPHLEBITIS AMONG PATIENTS RECEIVING INTRAVENOUS THERAPY IN SELECTED HOSPITALS, AMRITSAR.

A Synopsis Submitted for the partial fulfillment of the requirement for the degree of

MASTER OF SCIENCE IN NURSING (Medical Surgical Nursing)

Of Baba Farid University of Health Sciences, Faridkot, Punjab

2012
Navjot Kaur Name and Signature Of Supervisor Name and Signature of Co-Supervisor

Mr. Sekar P.

Ms. Jicy Shaji

Mai Bhago College of Nursing, Tarn-Taran

ABSTRACT OF PLAN OF THESIS Title A study to evaluate effectiveness of cold application and magnesium sulphate application on superficial thrombophlebitis among patients receiving intravenous therapy in selected hospitals Amritsar For the degree of Name candidate Supervisor Mr. Sekar P. Lecturer ( deptt. Of Medical Surgical Nursing) Mai Bhago College of Nursing, Tarn-Taran Institution University Mai Bhago College of Nursing, Tarn-Taran Baba Farid University of Health Sciences, Faridkot of MSc (Nursing) Medical Surgical Nursing the Navjot Kaur

Superficial thrombophlebitis is defined as inflammation of superficial vein.The use of intravenous devices is an integral part of patient care in hospitals. These devices are used for the administration of fluid, nutrients, medications, blood products and to monitor the hemodynamic status of a patient. Infusion phlebitis, defined as the inflammation of a cannulated vein, is a common cause of pain and discomfort in these patients. Studies over the past 2 decades have shown that 20 to 70% of patients receiving peripheral IV therapy develop phlebitis. Some recent trends in hospital care include the application of

magnesium sulphate (Epsom salt) for reducing the oedema. Magnesium sulphate reduces striated muscle contractions and blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction. Cold application is a simple and inexpensive therapy which is an effective nonpharmacologic intervention for thrombophlebitis. Applying cold may help numb tissues and relieve muscle spasms. Ice chips is used in reducing the inflammation, Ice reduces swelling by decreasing blood flow of blood to an area and increase the platelet aggregation. The study is quasi experimental in nature. The study will be conducted on 60 samples, 30 in magnesium sulphate group and 30 in cold applications group. A standardized Visual infusion
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phlebitis scale will be used to collect data. The data will be analyzed by using descriptive and inferential statistics.

Index of content Chapter Title no. 1. Background of the study Introduction Need of the study Research problem Aim of the study Objectives Operational definitions Hypotheses / assumptions Delimitations 2. 3. Review of literature Methodology Research design Research setting Target population Sample and sampling technique Inclusion and Exclusion criteria Selection and Development of tool Description of tool Validity of tool Reliability of tool Pilot study Data collection procedure Ethical considerations Plan of data analysis References 13 13 13 13 13 14 14 14 14 14 14 15 15 16,17 1-4 4,5 5 5 6 6 7 7 8-12 Page no.

Chapter-I Background of the study Introduction:

An ounce of prevention is worth a pound of cure Health is a dynamic process and it is always changing. All have times of good health, times of sickness, and maybe even times of serious illness. As lifestyles change, so does the level of health. Health is the level of functional and (or) metabolic efficiency of a living being. It is the general condition of a person in the mind, body and spirit, usually meaning to be free from illness, injury or pain.1 An impairment of the normal state of a human being that interrupts or modifies its vital functions is known as disease. Disease is a main reason for the people to seek medical help and admit in hospitals. According to American hospital association, hospitals are licensed institutions with at least six beds whose primary function is to provide diagnostic and therapeutic client services for medical conditions.2 The use of intravenous devices is an integral part of patient care in hospitals. These devices are used for the administration of fluid, nutrients, medications, blood products and to monitor the hemodynamic status of a patient. In modern medical practice, up to 80% of hospitalized patients receive intravenous therapy at some point during their admission.3-4 A number of factors increase the risk of infection from intravascular devices. For example, infection rates are higher among patients in large hospitals who may be especially ill, those with burns or surgical wounds or those who are malnourished or immune compromised. In addition, the rates are higher for certain devices, the type of fluid being infused and the length of time the catheter is left in place.5 Serious complications related to peripheral IVs are uncommon, but problems do occur, especially with prolonged use. That is why there are guidelines in different
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hospitals about the recommended duration that a peripheral IV should be in place. As with any side effect or complication of health care procedures, early detection, and good communication between the patient and healthcare provider are important.6 Infusion phlebitis, defined as the inflammation of a cannulated vein, is a common cause of pain and discomfort in these patients. Studies over the past 2 decades have shown that 20 to 70% of patients receiving peripheral IV therapy develop phlebitis According to statistics; about 80% of the patients with intravenous therapy develop varying degrees of infusion phlebitis in China alone.7

The incidence of superficial venous thrombosis is highly dependent on the population studied as well as the means by which it is documented. It is generally believed that incidence rates from epidemiological studies are underestimates since autopsy studies indicate that up to 50% of venous thromboembolism are not recognized ante mortem. Community based studies of hospitalized patients have suggested an annual incidence of 56 per 100,000 while population based studies of healthy volunteers have produced estimates of 122 per 100,000. Studies confirmed thrombophlebitis in Sweden has suggested a somewhat higher incidence of 160 cases of new or recurrent disease per 100,000 population per year. Extrapolated to the population of the United States, this represents 116,000 to over 250,000 new cases of clinically recognized infusion phlebitis per year.8 Phlebology is the medical discipline that involves the diagnosis and treatment of disorders of venous origin. The American Medical Association has added Phlebology to their list of self-designated practice specialties. A medical specialist in Phlebology is termed a phlebologist. Phlebitis means inflammation of a vein. Thrombophlebitis is the term used when a blood clot in the vein causes the inflammation. Thrombophlebitis usually occurs in leg veins, but it may occur in arms. The thrombus in the vein causes pain and irritation and may block the blood flow in the veins. Blood clots (thrombi) can form which may break off and travel to the lungs. This is a potentially life threatening condition called Pulmonary embolism.9

Some recent trends in hospital care include the application of magnesium sulphate (Epsom salt) for reducing the oedema. Magnesium is the second most plentiful cation of the intracellular fluids. It is essential for the activity of many enzyme systems and plays an important role with regard to neurochemical transmission and muscular excitability. Magnesium sulphate reduces striated muscle contractions and blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction. Additionally, Magnesium inhibits Ca2+ influx through

dihydropyridine-sensitive, voltage-dependent channels. This accounts for much of its relaxant action on vascular smooth muscle.10 Cold application is a simple and inexpensive therapy which has been accepted for decades as an effective nonpharmacologic intervention for thrombophlebitis. Applying cold may help numb tissues and relieve muscle spasms. Ice chips is used in reducing the inflammation, Ice reduces swelling by decreasing blood flow of blood to an area and increase the platelet aggregation. While some blood flow is required to bring the healing cells to the injured area, the body always overdoes it and sends too much blood, that's why we can reduce blood flow without too much concern Ice also numbs the area, thereby reducing pain. The nursing interventions should be meaningful and affordable by the client in terms of this aspect this study is relevant to the profession.11 Need for study: It is estimated that 150 million peripheral intravenous devices are placed each year in North America alone. One of the most common complications of peripheral intravenous catheter is phlebitis that may occur in up to 75-80 % of hospitalized patients. It remains a significant problem in clinical practice and causes patient discomfort, catheter replacement, prolonged hospital stay and healthcare costs. Maintenance of the patency of these catheters and prevention of phlebitis is an important problem. It is estimated that 200,000 cases of catheter related infections are occurring worldwide each year. Superficial Thrombophlebitis which occurs in about 75% of all patients receiving intravenous therapy, deep vein Thrombophlebitis occurs at least 5% of surgical patients.12

In hospitalized individuals, the incidence of venous thrombosis varies considerably, from 20% to 80%, and the incidence of Deep vein thrombosis is estimated to be about 80 cases per 100,000 populations annually. Superficial Thrombophlebitis is very common in hospitalized patients, but frequency is not known precisely because many cases go unreported and untreated. Deep vein thrombosis frequency also is not known precisely because of misdiagnoses.13 If Thrombophlebitis is in a vein just under the skin (superficial vein), complications are rare. However, if the clot occurs in a deep vein the client may develop a serious medical condition known as deep vein thrombosis. If that happens, the risk of serious complications is greater. Complications may include: pulmonary embolism and heart attack or shock. A study conducted to evaluate superficial thrombophlebitis and the incidence of cancer in primary care patients. the results conclude that only single exposure to superficial thrombophlebitis does not cause cancer, but frequent exposure may cause malignancies after 2-3 years of exposure.14 Student researcher during clinical practices had experienced that there is higher incidence of superficial thrombophlebitis among patients who are receiving continuous intravenous therapy. Some degree of erythema is a frequent occurrence around drip

infusion sites, so much so that it may easily be disregarded. The complaints of

patients who are troubled by the pain and irritation often pass unheard. Sometimes

the vein thromboses, the drip stops, and the patient are suffering from a full-blown thrombophlebitis. This complication, although not so frequent nor apparently so
severe as in former times, is a very familiar problem; but the pathophysiology

remains poorly understood and hence the management is often unsatisfactory.

Thus, in extensive review of literature, investigator came across so many studies regarding infusion phlebitis. So investigator felt need to conduct study to find out which is the most effective method in relation to rapidity of subside the signs and symptoms, and practicability in patients with superficial thrombophlebitis. The cost effective care

also one of the main concepts of quality of nursing care. The cost effective management is necessarily carried out to reduce oedema and anxiety related to care.

Research problem A study to evaluate effectiveness of cold application and magnesium sulphate application on superficial thrombophlebitis among patients receiving intravenous therapy in selected hospitals Amritsar. Aim of the study: To evaluate the effectiveness of two interventional strategies on treatment of superficial thrombophlebitis. Objectives: Assess the pre test degree of superficial thrombophlebitis among clients receiving IV therapy Assess the post test superficial thrombophlebitis scores among clients receiving IV therapy. Assess the effectiveness of cold application on superficial thrombophlebitis. Assess the effectiveness of magnesium sulphate on superficial

thrombophlebitis. Compare the effectiveness of cold application and magnesium sulphate on thrombophlebitis. Find the association between post test superficial thrombophlebitis scores in cold applications group with selected demographic variables. Find the association between post test superficial thrombophlebitis scores in magnesium sulphate group with selected demographic variables. Operational definitions:

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1. Effectiveness: The degree to which level of superficial thrombophlebitis is reduced after the cold applications and magnesium sulphate. It is measured by visual infusion phlebitis scale. 2. Cold Application: It is application of ice chips externally over the site 3 times a day for 3 days to reduce sign and symptoms of superficial thrombophlebitis 3. Magnesium sulphate: It refers to the application of magnesium sulphate over the site 3 times a day for 3 days to reduce superficial thrombophlebitis. Magnesium sulphate is crystal like substance which helps to reduce the redness, edema and swelling. 4. Superficial Thrombophlebitis: Inflammation of superficial vein followed by formation of clot at the site of intravenous line. 5. Intravenous Therapy: Administration of fluids and drugs into veins through the use of hypodermic needle, peripheral cannula, and intravenous catheter, etc Hypothesis: H 1: There will be significant association between selected clinical variables and pre-test superficial thrombophlebitis score. H
2

-There will be a significant effect of cold application on superficial

thrombophlebitis. H
3

-There will be a significant effect of magnesium sulphate application on superficial

thrombophlebitis. H
4

-There will be a significant difference among cold application and magnesium-

sulphate application in reducing the signs and symptoms of superficial thrombophlebitis. Delimitations: Study is limited to the patients who are receiving continuous IV therapy. Study is limited to hospitals of only one district of Punjab. Study is concise to small sample size.

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Chapter-II Review of Literature A literature review is summary of previous research on a topic which can be either a part of a large report of a research project, a thesis or bibliographic essay that is published separately in scholarly journal. The purpose of literature review is to convey the reader what knowledge and ideas have been established on topic and what are the strength and weaknesses. It allows the reader to bring up to date reading the state of research in the field and familiarizes the reader with any contrasting perspectives and view point on the topic. There are many reasons for beginning a literature review before starting a research paper. a) Studies Related to superficial thrombophlebitis among clients with I V Cannulation. b) Studies Related to magnesium sulphate and other topical drug therapies. c) Studies Related to hot and cold applications.

a) Studies Related To superficial thrombophlebitis among clients with I V Cannulation. A prospective, randomized, controlled unblinded study was conducted to assess the effectiveness of elective re-siting of intravenous cannula decrease peripheral thrombophlebitis. Forty-two patients admitted for major abdominal surgery were included in the study. The patients were allocated to either the study or the control group using block randomizationrestricted randomization method. Cannula in the study group were changed and re-sited electively every 48 hours. All the patients were examined every 24 hours for signs and symptoms of peripheral thrombophlebitis at the current and previous sites of infusion. The incidence of peripheral thrombophlebitis was 100% (21/21) in the control group and only 9.5% (2/21) in the study group (p<0.0001). The severity of peripheral thrombophlebitis was also less in the study group compared with
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that in the control group. Day-wise correlation of the incidence of peripheral thrombophlebitis showed that 82.6% of the episodes of peripheral thrombophlebitis occurred on day 3.15 A study was conducted to compare the rates of phlebitis of peripheral intravenous lines left in place for 72 hours versus rates of those left in place 96 hours. Design was a prospective, nonrandomized study. Setting was a university teaching hospital with 375 beds. Results were a total of 2503 peripheral lines were evaluable. The overall phlebitis rate was 6.8%. It was estimated that in 1 month approximately 300 intravenous lines potentially could be prolonged beyond 72 hours; 215 lines were changed at 72 hours despite no signs of inflammation, 61 lines were kept till 96 hours, and 19 lines were kept beyond 96 hours. Conclusion of the study was Phlebitis rate for our peripheral intravenous catheters at 96 hours was not significantly different from that at 72 hours.16 A Randomized Controlled Trial on factors Affecting Complications and Patency of peripheral IVs.This sample was composed of 88 patients, from neonates to 12-yearolds, on whom a total of 377 catheters were started. Intravenous cannulations were randomized for heparin flushes (1:100 dilutions) and splints. Prospective data was collected regarding duration of patency and complications. Both univariate and multivariate analysis were done. There was a statistically significant increase in the duration of patency with the use of heparin flushes and splints. Shorter patency duration and increased complications were associated with younger age, wrist and scalp insertions, and 24-gauge catheters.17 A study was conducted on two groups of patients received one of two intravenous catheters, a 20-gauge Criticon (C group;n=96) or a 20-gauge Vitaflon Plus (V group;n=100).The incidence of early complications (erythema, swelling, tissue hardness, pain) was comparable in both groups. The survival distribution curves for all complications and swelling >2 cm were significantly longer in the V group. The incidence of complications following cannulation was high in both groups. The period from catheter insertion to the clinical onset of phlebitis was prolonged in both groups if antiphlebitogenous fluids were used. The incidence of late complications (phlebitis, displacement of the cannulae, etc.) and damage to the catheters was more frequent in the C group. 18
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A study was done on Relevance and complications of intravenous infusion. Objective of the study was Insertion of peripheral venous catheters (PVCs) is current practice within the hospital environment and particularly in the emergency department (ED). During the study 2515 patients over 16 years of age attended the unit. Overall, 390 PVCs were followed until the time of their removal. Mean duration of IV infusion was 28 h. Among these 390 patients, 62 (15.9%) developed complications, of which 54 (13.6%) had thrombophlebitis and 9 (2.3%) developed local infection. Conclusion of the study was Insertion of PVC is common practice especially in EDs.19

b) Studies Related to magnesium sulphate and other topical drug therapies.

A quasi-experimental study was conducted to assess the effectiveness of the therapeutic effect of tanshinone, magnesium sulphate and hirudoid in the treatment of infusion phlebitis on 150 in patients with infusion phlebitis. Patients were randomly divided into tanshinone group (n=50), hirudoid group (n=50) and magnesium sulphate group (n=50). The therapeutic effect was assessed after 5 days treatment. The results shows the excellence rate of 64% in tanshinone group, 36% in hirudoid group and 18% in magnesium sulphate group, the differences was statically significant at level of p= 0.05. The efficacy rate was 94% in tanshinone group, 80% in hirudoid group and 60% in magnesium sulphate group, the differences was statically significant at level of p=0.001.20 A quasi experimental study was conducted to assess the effectiveness of cold application, heparinoid application and magnesium-sulphate application on superficial thrombophlebitis among patients in selected hospitals of Indore. Three-group pre test and post test design was adopted for the study. 45 patients were selected using purposive sampling and they were randomly assigned into three groups. A superficial thrombophlebitis scale and pain intensity distress scale was used for data collection. Following the pre-test, intervention with cold application was given to 1st experimental group (C), for a period of twenty minute, 2nd experimental group (H) was intervened with heparinoid application using thrombophobe ointment by gentle massage and similarly in 3rd experimental group (M), magnesium-sulphate dressing was done by dipping the gauze
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in the magnesium sulphate glycerine solution and applied on superficial thrombophlebitis three times a day for three days. The finding of the study indicated that the computedt value of cold application group ('t'14 =14.33), heparinoid application group ('t14' =11.90) and magnesium sulphate application group ('t'14 =20.82) were statistically significant, which suggested that all three interventions were effective in reducing the signs and symptoms of superficial thrombophlebitis. The computed 'F' ratio of all the three groups ('F'2.42 =10.10) showed that three types of application differ significantly. However, the mean difference of magnesium sulphate group (18.34) was higher than the cold application (13.33) and heparinoid application (12.8) group. This study concluded that magnesium sulphate application is most effective intervention in reducing the superficial thrombophlebitis.21 An interventional study was conducted in Mangalore on effectiveness of ice packs versus thrombophobe gel for reducing intra venous infiltration in patients admitted in paediatric wards. The study was conducted on 40 samples (20 for thrombophobe gel group and 20 for ice cube group) selected using purposive sampling technique. The infiltration was assessed by using modified infiltration scale. The results showed that before the treatment, majority (65%) of patients had grade two infiltrations after the treatment with thrombophobe and 100% of patients infiltration had reduced to grade one infiltration. In group two majorities (80%) had grade two infiltrations after the treatment with ice cube 100% had grade one infiltration. The study concluded that both thrombophobe gel and ice pack are effective in reducing intravenous infiltration among paediatric patients.22 A study was conducted on Anti-coagulant ointment in the prevention of postinfusion thrombophlebitis. 169 cases were included (84 experimental, 85 control) to study the effect of topical anticoagulant ointment. The finding was the Topical anticoagulant ointment was effective in decreasing the incidence of thrombophlebitis if the duration of infusion was up to 12 hours or less, the use of anticoagulant ointment reduced the average number of days of recovery especially in moderate to severe grades of thrombophlebitis. 23 A study was conducted on Topical heparin for the treatment of acute superficial phlebitis secondary to indwelling intravenous catheter A double-blind, randomized,
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placebo-controlled trial. Objective of the study was to assess the clinical efficacy of a topical gel containing 1000 IU.g1 of heparin, applied three times daily for a maximal period of 7 days to patients with acute superficial phlebitis secondary to indwelling intravenous catheter. Result of the study was, after treatment for 7 days superficial phlebitis healed in 27 of the 61 patients (44.3%) who received topical heparin, and in 17 of the 65 patients (26.1%) receiving placebo, giving a relative risk of 1.69 (1.032.78). Conclusion of the study was the topical heparin is safe and effective for the treatment of superficial phlebitis secondary to indwelling intravenous catheter.24 A study was conducted on Topically Applied Heparins for the Treatment of peripheral Vascular Disorders. A total of 1055 patients participated in a total of 20 studies that compared topical heparin formulations with placebo, no treatment, subcutaneous heparin or with each other in the treatment of superficial thrombophlebitis. In head-to-head studies comparing different topical heparin formulations, all preparations appeared effective. Conclusion of the study was topical heparin preparations may be useful for relieving the signs and symptoms of vascular disorders while improving microcirculation.25 c) Studies Related To hot and cold applications. A study was conducted on Effect of warm and cold applications on the resolution of IV infiltrations. Differences in pain intensity, surface area measurements of indurations and erythema, and interstitial fluid volume when warm versus cold applications were randomly made to an intentional intravenous infiltrate of 5 mL of a designated solution were examined. Three solutions were used: 0.5 saline (154 mOsm), normal saline (308 mOsm), and 3% saline (1027 mOsm). The sample was 18 healthy adults between 20 and 45 years. Pain intensity did not differ by treatment but a significant difference was found by solution, with 3% saline producing the greatest difference. Erythema was absent with all solutions. Study reveals that there is no significant difference between the cold and warm application in resolution of IV infiltrations.26 A study was conducted on local warming and insertion of peripheral venous cannulas it is a single blinded prospective randomised controlled trial and single blinded randomised crossover trial. Objective of the study was to determine whether local warming of the lower arm and hand facilitates peripheral venous cannulation. Setting was
16

Neurosurgical unit and haematology ward of university hospital participants were 100 neurosurgical patients and 40 patients with leukaemia who required chemotherapy. Intervention was given was Neurosurgical patients' hands and forearms were covered for 15 minutes with a carbon fibre heating mitt. Results were In neurosurgical patients, it took 36 seconds (95% confidence interval 31 to 40 seconds) to insert a cannula in the active warming group and 62 (50 to 74) seconds in the passive insulation group (P=0.002). The crossover study in patients with leukaemia showed that insertion time was reduced by 20 seconds (8 to 32, P=0.013) with active warming and that failure rates at first attempt were 6% with warming and 30% with passive insulation (P<0.001). Conclusion of the study was Local warming facilitates the insertion of peripheral venous cannulas, reducing both time and number of attempts required. This may decrease the time staff spend inserting cannulas, reduce supply costs, and improve patient satisfaction.27

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Methodology flow chart Research design Quasi-experimental two groups pre test post test design

Research setting Medical and surgical wards of selected hospitals of Amritsar, Punjab

Target population Clients with infusion phlebitis

Sample size The sample size for the study will be consisting of 100

Sampling technique The purposive sampling technique

Research tool Standardized infusion phlebitis scale

Data collection procedure Samples will be selected purposively and randomly. Pre test and post test will be conducted by using visual infusion phlebitis scale. Selected interventions magnesium sulphate and cold applications will be provided to the group.

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Data analysis Descriptive and inferential statistics, unpaired t test and chi square test will be used for analysis. Chapter-III Methodology Research design A quasi experimental two group pre test post test design will be adopted for the study to evaluate the effectiveness of magnesium sulphate and cold applications on superficial thrombophlebitis. Research setting This study will be conducted in Medical and surgical wards of selected hospitals of Amritsar, Punjab. Target population The population of the study will be the clients who developed superficial thrombophlebitis and having intravenous line and admitted in Medical wards of hospitals of Amritsar, Punjab. Sample and sampling technique: The sample size for the study will be consisting of 60 samples those who fulfil the inclusion criteria, 30 in magnesium sulphate group and 30 in cold application group. The purposive sampling technique will be adopted for sampling and samples will be divided into two groups randomly. Inclusion and exclusion criteria: Inclusion criteria

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Clients with peripheral intravenous cannula induced phlebitis who are willing to participate in the study. Clients who are available during the period of data collection. Clients who are hospitalized in medical and surgical wards.

Exclusion criteria Clients with phlebitis who are having skin disorders. Clients having open wounds. Clients having associated vascular disorders like DVT, varicose veins etc. Clients having hypersensitivity to magnesium sulphate

Selection and development of tool: A standardized visual Infusion Phlebitis Scale will be selected. Description of tool: TOOL-1 Demographic questionnaire will be used to assess the demographic data of the clients such as age, gender, occupation, diagnosis, purposes of intravenous

infusion, site of intravenous cannula, number of prick during the intravenous cannulation procedure, size of peripheral intravenous cannula, types of medication infused, period of hospital stay, and duration of peripheral intravenous cannula. TOOL-II Visual infusion phlebitis scale will be used to assess the severity of peripheral intravenous cannula induced phlebitis. Validity of tool: Content validity will be determined by experts opinion.

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Pilot study: It will be conducted to find the reliability and feasibility of tool by taking 10 samples.

Data collection procedure: Formal permission will be obtained from the concerned authority. Samples will be selected purposively and randomly assigned into magnesium sulphate and cold application group. Pre test will be conducted by using standard visual infusion phlebitis scale. Selected interventions magnesium sulphate and cold application will be provided to the respective groups. Post test will be conducted for the by using the same tool after seven days of interventions. Ethical considerations: Approval of research/ethical clearance will be taken from research committee of Mai Bhago College of Nursing, Tarn-Taran. The formal permission will be taken from concerned authorities of selected hospitals. The written informed consent from each sample will be obtained.

Plan of data analysis The plan of data analysis is as follow:The data obtained will be analysed in terms of the objective of the study using descriptive and inferential statistics. The plan of data analysis is as follows. Frequency and percentage distribution will be used to analyse the socio demographic variables and severity of peripheral intravenous cannula induced phlebitis.

21

 Mean, mean percentage and standard deviation will be used to assess pre test and post test severity of peripheral intravenous cannula induced phlebitis. unpaired t test will be used to compare pre test and post test severity of peripheral intravenous cannula induced phlebitis of magnesium sulphate group and cold applications group Chi-square test will be used to determine association between pre test severities of peripheral intravenous cannula induced phlebitis and selected socio demographic variables.

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