Managing intravenous (IV) infusion related phlebitis in a tertiary

care private hospital of Karachi. A cross-sectional study using the

visual infusion phlebitis (VIP sore).

Introduction:

Phlebitis Overview

Peripheral venous catheter-associated phlebitis is caused by inflammation to the vein at a

cannula access site. It can have a mechanical, chemical or infectious cause. Good practice when
inserting a cannula, including appropriate choice of device and site, can help to prevent phlebitis.
Good infection control techniques are also vital in preventing the condition. There are two
phlebitis scoring systems, which should be used in routine practice to identify and treat early
signs of the Peripheral venous cannulation.( Higginson R, Parry A . Nursing Times. 2011 Sep 13)

Observation of the cannula is imperative in detecting early signs of phlebitis. To maintain high
standards of cannula care, nurse education is important, along with regular auditing of the
incidence of phlebitis. Careful consideration should be given to the size of cannula used and the
position in which it is sited. Use of Vialon cannulae may be preferable to Teflon. (Stonehouse J,
Butcher J Professional Nurse PMID: 9128650)

Background:

Peripheral intravascular catheterization (PIVC) is a common feature of acute hospitalization,

with the majority of patients requiring the intravenous administration of fluid or medication at

some time during their hospital stay. one of the complications of PIVC is phlebitis, diagnosed by

one or more signs or symptoms of pain, tenderness, swelling, indurations, erythema, and a

palpable, cord-like vein.

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A number of studies of risk factors for infusion phlebitis have been published recently.

According to these studies, risk factors for infusion phlebitis include the high concentrated

electrolytes which cause major complications of phlebitis, including skin burn. This study focus

on sodium bicarbonate related phlebitis.(Pakistan journal: 2018). Other many studies focus on

how to reduce patient costs related hospital stay. One of the study says PIVC phlebitis lead to

further long stay in hospital and cost of patients. Phlebitis is most common in pediatric

population because of difficult cannulation and thin veins so it’s need a necessary to early

identification of signs of phlebitis by nurses. (M suleman, w salehJournal of pediatric 2020).

One of the study conducted in India air force hospital which works on identify factors of

phlebitis related with age, cannula site, cannula size, insertion date, blood products, infusion set

and phlebitis score graded by using VIP score of phlebitis.(Journal of family medicine and

primary care (9), 2827, 2019).

Phlebitis present with sign of tenderness, swelling, pain, fever leading with infection, which

cause intravenous fluid, numbers of medication, mechanical reason.( Inpatients Sookhee Lee 1,

Kyunghee Kim 2, * and Ji-Su Kim 2019 )

Evidence suggests that nurses' knowledge of infusion phlebitis and its risks factors may influence

the risk for infusion phlebitis in hospitals .So our study, performed in tertiary care hospital

Karachi, investigated nurses' perception of the risk factors for infusion phlebitis.

Pico

P: - incidence of phlebitis due to poor daily inspection and vip score

I: - increased knowledge, using of transparent dressing , frequently inspection

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C: - lack of knowledge, not use of transparent dressing

O: - decreased prevalence of high incidence of phlebitis

Abstract :

The VIP score empowers healthcare workers so that iv catheters can be removed at the first

indication of phlebitis. Phlebitis from peripheral intravenous infusions is an important potential

source of patient morbidity. The introduction of the visual infusion phlebitis (VIP) score tool for

assessment of the early signs of phlebitis, along with prompt removal of peripheral intravenous

cannula, has been very successful in reducing the incidence rate. However, achieving this goal

depends on strict compliance with guidelines for cannula insertion, documentation, and

assessment using the VIP tool. (Ray‐Barruel, G., Polit, D. F., Murfield, J. E., & Rickard, C. M. (2014)

This study aimed to increase the use of vip scoring tool to 100% on an ccu during a 2 moths of

period in order to maximize its utility in phlebitis prevention. Plan-do-study-act (PDSA) cycles

were carried out; in first cycle we were observed the practices of nurses and assess the

knowledge by taking pre test .In 2nd cycle our aimed to improve nurse’s awareness of VIP

scoring. To achieve 2nd cycle we give presentations, teaching and providing vip tool chart on

bedside.

Pre-intervention, showed only 3% staff were in excellent category and 43 % staff were in good

category ,this proportion rose to around 80% of staff were in excellent category by the end of

the second PDSA cycle .( Lee, Y., & Lee, E. (2019).

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CARE CURE AND CORE THEORY BY LYDIA HALL

According to the theory, the core is the person or patient to whom nursing care is directed and

needed.

The cure, on the other hand is the attention given to patients by the medical professionals. The

model explains that the cure circle is shared by the nurse with other health professionals. These

are the interventions or actions geared on treating or “curing” the patient from whatever illness

or disease he may be suffering from.

The care circle explains the role of nurses, and focused on performing that noble task of

nurturing the patients, meaning the component of this model is the “motherly” care provided by

nurses, which may include imited to provision of comfort measures, provision of patient teaching

activities and helping the patient meet their needs where help is needed.

Literatures Review:

[Phlebitis is the inflammation of a vein, usually in the legs. It most commonly occurs in

superficial veins. Phlebitis often occurs in conjunction with thrombosis and is then called

thrombophlebitis or superficial thrombophlebitis. Unlike deep vein thrombosis, the probability

that superficial thrombophlebitis will cause a clot to break up and be transported in pieces to the

lung is very low.] ( Sengupta, M. (2019).

A study was conducted in Rawalpindi, Pakistan (Jamal, et al 2018) on 170 subjects; researcher

found the incidence of thrombophlebitis found in this study was 53.5%. The most common grade

found was Grade 2 (52.7%) followed by Grade 1 (35.1%) and 3(12.1%). Increased incidence of

thrombophlebitis in this study was found in younger age group (16-40years), females admitted in

medical units, large sized catheters inserted on hands, hypertensive and hyperlipidemia patients

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and significant associations were Diabetes Mellitus (P=0.004), Smoking (P=0.004) and

Catheterization without Gloves (P= 0.003). Park, I., Jeong, M. H., Park, C. J., il Park, W., Park, D. W., &

Joh, J. H. (2019).

A research was conducted (Qatar, 2017) in Lahore, Pakistan on 240 nurses, the study results

depict nurses have good knowledge regarding IV cannula protocols. The results show that

nurses are not practicing appropriately. Similarly, nurses offering pathetic practices in

maintaining aseptic technique while performing this procedure. However, nurses’ knowledge and

practice about care and maintenance of IV cannulation is good but still the practices are not

according the standard protocols. In addition, health care providers are accountable for safe and

quality care delivery to the patients, so they should be well resourced and enough trained nursing

staff. Furthermore, public hospital administration should emphasize on training of the nurses to

fulfill the practices protocols, so that the quality care can be provided. Qamar, Z., Afzal, M., Kousar,

R., Waqas, A., & Gilani, S. A. (2017).

Phlebitis can be divided into types mechanical, when movement of the cannula inside the vein

causes friction and inflammation, or when the cannula is too wide for the vein, chemical

phlebitis, caused by the drug or fluid infused through the catheter, where factors such as pH and

osmolality can be present and bacterial phlebitis related to peripheral Intravenous catheters were

reported. We could not find only one factor associated. Most of the cases occurred after 2 days of

the function. The main difference between phlebitis and infiltration is the cause of their

occurrence. While both can be IV catheter-related complications, phlebitis has a wider range of

causal factors that may be responsible for the condition- like chemical and bacterial infections.

However, infiltration is exclusively caused by a dislodged IV catheter]. Paans, W., Onrust, M.,

Nijsten, M. W., & Dieperink, W. (2019).

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VIP score, The Visual Infusion Phlebitis score is an essential tool that facilitates the timely

removal of short peripheral intravenous catheters at the earliest signs of infusion phlebitis. It is

important that every short peripheral intravenous catheter should be monitored at least daily.

Introduction to the Visual Infusion Phlebitis (VIP) score. The Visual Infusion Phlebitis score is a

equalize approach to monitoring peripheral IV catheter sites. The fact that it encourages site

observation means that it also has an impact on other peripheral IV catheter problems such as

dislodgement, infiltration and infection]. Anggraeni, R., Suryati, Y., & Nurjanah, N. (2021).

The VIP score empowers healthcare workers so that IV catheters can be removed at the first

indication of phlebitis. The Visual Infusion Phlebitis score is accepted as the international tool

for the early recognition of infusion phlebitis and appropriate removal of the vascular access

device] Diwakar, K., Kumar, S., Srivastava, P., Uddin, M. W., & Mishra, S. (2021).

The VIP score was developed to reduce the incidence and impact of infusion phlebitis. However,

the added benefits of site monitoring include early recognition of other issues such as infiltration

or “Phlebitis should be documented using a standard scale infection. for measuring degrees or

severity of phlebitis” . Sengupta, M. (2019).

To Compare the incidence of phlebitis before and after the implementation of a new standardized

protocol that includes the scale VIP as phlebitis diagnostic tool .VIP score popularity is

increasing because of their many advantages compared to . For instance, VIP score are easier to

set up, they cause less pain in insertion area, and their extraction has lesser risks. Thus, they are a

safe and effective alternative.

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A descriptive cross-sectional study conducted in tertiary care hospital in Dhaka city, Bangladesh.

The study aim was to explore the level of knowledge and practice on intravenous cannulation

among staff nurses of selected at tertiary care hospitals in the Dhaka city, Bangladesh. The

sample size was 290, the results of the study show half of the nurses were not knowledgeable on

every aspect of IV cannulation. In the clinical area, nurses should be kept sufficient knowledge.

The staff nurse need to involve in identify the care of patient with IV cannulation and safe

practices. Otherwise patient will be sufferer as well as country. Hossain, A. M., Hasan, M. I. A., &

Haque, M. M. (2016).

Awareness program regarding our project in

CCU/ MICU/ SICU units
In Our 3rd Week Of Our Evidence Base Project, We Started The Awareness Session On Vip
Score Of Phlebitis But Before Vip Score We Teach And Educate Staff About The All Material
Related To Our Goals , Which Includes

 Phlebitis
 Machinal And Chemical Phlebitis
 Sign, Symptoms of Phlebitis
 Complication Of Phlebitis
 Iv Size and Gauges,
 Flow Rate
 Color Coding
 Selection Of Vain
 Vip Score
 Founder Of Vip Score
 Vip Score Chart
 Assessment Need

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This awareness session phase is provided to assist with the integration of the VIP score into

clinical practice. The VIP score empowers healthcare workers so that iv catheters can be

removed at the first indication of phlebitis. The VIP score is recommended by the department of

health (uk), ins (us) and rcn (uk). If you implement the VIP score you will be joining thousands

of health care workers around the globe who use the VIP score to improve iv standards.

AWARENESS SESSION ON TYPES OF IV CANNULA -

IV CANNULA SIZES FLOW RATES AND COLOR
CODES, VEIN SELECTION AND COMPLICATIONS:
Cannula — or flexible tubes that can be inserted into a patient's body — are used for different
purposes, resulting in cannula sizes that range from 14-26 gauge. Intravenous cannula is used to
administer medications and other fluids to patients and to remove blood for sampling. The
purpose, the condition of the patient and the urgency at which intravenous fluid must be
delivered determine which cannula sizes must be used. The smaller the gauge, the larger the
diameter of the cannula and the faster the flow of fluid. Different cannula sizes are indicated by
different colors, making them easier to differentiate, especially in emergency situations in which
size might be critical.( Zyhier, S. (2018)

Always select the smallest gauge peripheral catheter that will accommodate the prescribed
therapy and patient need. Peripheral catheters larger than 20G are more likely to cause phlebitis.
Do not use peripheral veins for continuous infusions of vesicants, parenteral nutrition or
infuscate with an osmolarity of 900 mOsm/L.1 External catheter diameters, length and water
flow rates are variable among each brand of catheter, with the dimensions and flow rates listed
below being approximate. Fluid flow rates in actual patient use, are influenced by the type and
viscosity of fluid, fluid temperature, height of the container and the use of needleless

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connectors.2 There are numerous factors that could also affect fluid flow rates, once the catheter
is inserted into a patient.( Denex International (2014).

Peripheral IV Catheter Chart

External Water
Gauge Length Recommended
Color Diameter Flow Rate
Size (mm)* Uses
(mm)* (mL/min)*

Trauma, Rapid
~240
14G 2.1 mm 45 mm blood transfusion,
mL/min
Surgery1
Orange

Rapid fluid
~180 replacement,
16G 1.8 mm 45 mm
mL/min Trauma, Rapid
blood transfusion1
Gray

Rapid fluid
~90 replacement,
18G 1.3 mm 32 mm
mL/min Trauma, Rapid
blood transfusion1

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 Green

Most infusions,
Rapid fluid
~60
20G 1.1 mm 32 mm replacement,
mL/min
Trauma, Routine
blood transfusion1
Pink

Most infusions,
Neonate,
~36
22G 0.9 mm 25 mm Pediatric, Older
mL/min
adults, Routine
blood transfusion1
Blue

Most infusions,
Neonate,
Pediatric, Older
~20 adults, Routine
24G 0.7 mm 19 mm
mL/min blood transfusion,
Neonate or
Yellow Pediatric blood
transfusion1

~13 Pediatrics,
26G 0.6 mm 19 mm
mL/min Neonate1

Purple

Choosing a vein

1. Inspect the patient’s arm for an appropriate cannulation site:

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 You should select a site that is the least restrictive for the patient such as the posterior forearm
or dorsum of the hand. In an emergency situation, any large peripheral vein may be used.
 Avoid areas near the elbow and wrist joints (to reduce the likelihood of dislodgement as a
result of the patient’s movement).
 Areas of broken, bruised or erythematous skin should be avoided.

 Areas in which two veins join should be avoided where possible, as valves are often present.

2. Position the patient’s arm in a comfortable extended position that provides adequate access to

the planned cannulation site.

3. Apply the tourniquet approximately 4-5 finger-widths above the planned cannulation site.

4. Palpate the vein you have identified to assess if it is suitable:

 Tapping the vein and asking the patient to repeatedly clench their fist can make the vein easier
to visualize and palpate.
 An ideal vein feels ‘springy’. A vein that feels hard is likely sclerosed, thromboses or phlebitis
(inflamed) and should be avoided.

5. Once you have identified a suitable vein you may need to temporarily release the tourniquet,
as it should not be left on for more than 1-2 minutes at a time.

6. Clean the site with an alcohol swab for 30 seconds and then allow to dry completely for 30
seconds:

 You should start cleaning from the center of the cannulation site and work outwards to cover

an area of 5cm or more.

 DO NOT touch the cleaned site afterwards at any point, otherwise, the cleaning procedure will

need to be repeated prior to cannulation.( Infusion Therapy Standards of Practice Jan/Feb (2016).

Few IV Cannula Complications We Must Know :

Complications of picking up I.V. cannula may incorporate penetration, hematoma, an air

embolism, phlebitis, extravascular tranquilize organization, and intra -arterial infusion. Intra-

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arterial infusion is more uncommon, however as undermining. (Simin, D., Milutinović, D.,
Turkulov, V., & Brkić, S. (2019).

Penetration:

Penetration is the imbuement of liquid as well as prescription outside the intravascular space,

into the encompassing delicate tissue. For the most part brought on by poor position of a needle

or angiocath outside of the vessel lumen. Clinically, you will see swelling of the delicate tissue

encompassing the IV, and the skin will feel cool, firm, and pale. Little measures of IV liquid will

have little outcome, however certain meds even in little sums can be exceptionally lethal to the

encompassing delicate tissue.( MILLAM, D. A. (1988).

Hematoma:

TA hematoma happens when there is spillage of blood from the vessel into the encompassing

delicate tissue. This can happen when an IV Angio catheter goes through more than one mass of

a vessel or if weight is not connected to the IV site when the catheter is evacuated. A hematoma

can be controlled with direct weight and will resolve through the span of 2 weeks. (Makafi, S. A.

M., & Marfega, M. A. C. M. (2017).

Air Embolism:

Air embolism happens subsequently of an extensive volume of air entering the patient's vein through

the I.V. organization set. The I.V. tubing holds around 13 CCs of air, and a patient can for the most part

endure up to 1 CC for every kilogram of weight of air; little kids are at more serious hazard. Air

embolisms are effortlessly forestalled by ensuring that all the air pockets are out of the I.V. tubing;

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luckily, it is a to a great degree uncommon entanglement. By Katherine Brind'Amour, PhD, MS (August

15, 2018).

AWEARNESS SESSION ON PHELBITIS AND VIP

SCORE

What is infusion phlebitis?

Infusion phlebitis originates from two main sources. One is mechanical the other is chemical. By

far the most prevalent cause of infusion phlebitis is chemical in origin. Early recognition of

phlebitis will help to maintain patient safety and comfort. Consideration of blood flow past the

tip of the catheter must be viewed in association with the chemical composition of the drug to be

infused. Urbanetto JS, Peixoto CG, May TA. Rev Latino-AM Nursing. (2016).

SIGN AND SYMPTOMS OF PHILBITIS

 A long, thin red area or “streaking” along the skin

 Warm, hard or tender skin

 A section of rope- or cord-like lumps you can feel under the skin

 Redness or irritation that follows a vein

 Itchy or swollen skin

 Throbbing or burning at the site of red or tender skin

 Lumps or a swollen spot on your skin

 Worsening of symptoms when you get out of bed, flex the nearest joints, or have your leg
lowered rather than elevated

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  Low-grade fever

 Swelling, pain or skin irritation caused by infection

INTRODUCTION OF VIP SCORE

The Visual Infusion Phlebitis score is a standardized approach to monitoring peripheral IV

catheter sites.

The fact that it encourages site observation means that it also has an impact on other peripheral

IV catheter problems such as dislodgement, infiltration and infection.

The innovation of this tool is the recognition of the visual nature of peripheral IV problems and

the subsequent benefits of a visual tool to identify these issues early.

As health care workers we have a duty of care to monitor the condition of a patients IV site.

Failure to monitor IV sites is seen as failure in duty of care.

The VIP score is internationally acknowledged as a proven standardized tool for the monitoring

of peripheral IV catheter sites. ( Urbanetto, J. de S., Muniz, F. de O. M., Silva, R. M. da, Freitas, A.P. C.

de, Oliveira, A. P. R. de, & Santos, J. de C. R. Dos. (2017).

The VIP (Visual Infusion Phlebitis) score monitoring tool was developed over 20

years ago by nurse Andrew Jackson. The tool helps nurses determine appropriate

assessment, discontinuation of peripheral intravenous catheters based on the

presence and severity of symptoms :

VIP SCORE CHART

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 IV site appears healthy 0 > No signs of phlebitis OBSERVE
CANNULA
One of the following is evident: 1 > Possible first signs OBSERVE
• Slight pain near IV site or CANNULA
• Slight redness near IV site

Two of the following are 2 > Early stage of phlebitis RESITE

evident: Pain at IV site CANNULA
• Erythema
• Swelling

All of the following signs are evident: 3 > Mid-stage RESITE

• Pain along path of cannula CANNULA
• Erythema of phlebitis CONSIDER
• Induration TREATMENT

4 > Advanced stage RESITE

All of the following signs are evident
and extensive: CANNULA
• Pain along path of cannula of phlebitis or start CONSIDER
• Erythema TREATMENT
• Induration of thrombophlebitis
• Palpable venous cord

All of the following signs are evident 5 > Advanced stage of INITIATE
and extensive: TREATMENT
• Pain along path of cannula Thrombophlebitis
• Erythema
• Induration
• Palpable venous cord
• Pyrexia

Assessment:

All patients with an intravenous access device in place must have the IV site checked at least
daily for signs of infusion phlebitis. The subsequent score AND action(s) taken (if any) must be
documented. The cannula site must also be observed when:

• Bolus injections are administered

• IV flow rates are checked or altered

• Solution containers are changed the incidence of infusion phlebitis varies. The following
‘Good Practice Points’ may assist in reducing the incidence of infusion phlebitis:

1 Observe cannula site at least daily

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2 Secure cannula with a proven intravenous dressing

3 Replace loose, contaminated dressings

4 Cannula must be inserted away from the joints whenever possible

5 Aseptic techniques must be followed

6 Consider your policy position on resisting of the cannula

7 Plan and document continuing care

8 Use the smallest gauge cannula most suitable for the patient’s needs

9 Replace the cannula at the first indication of infusion phlebitis (Stage 2 on the VIP score

CONCLUSION: -
Hospital is a busy environment nursing staff need to be aware that the systems they work in are

in need of constant refinement to optimize working conditions and minimize the potential for

harm. In pre test evaluation nurses were not knowledgeable on every aspect of IV cannulization

and VIP score for phlebitis. In the clinical area, nurses should be kept sufficient knowledge.

Otherwise, patient will be sufferer as well their families and hospital resources. So, the

introduction of VIP score at ICU MICU and CCU has clearly had a significantly beneficial effect

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as shown in comparison between pre and post test. Training sessions on implementation and use

of VIP score by the staff nurses and senior nurses in the hospital is really going to benefit the

patients in prevention and control of infusion related phlebitis.

Strength:

 The strengths of our study include: ensuring systematic observations thanks to the use of

a validated tool like Andrew Jackson’s VIP Score.

 Strong background knowledge by research teacher.

 Institution support

 Teachers and preceptor cooperation

 Team work

 Availability of resources

 One last strength was the high level of interest and collaboration the nursing team showed

in our research project.

Implementation Strategy:
 Introduction to VIP score.

 Awareness program regarding Our project in CCU/MICU/SICU units.

 Awareness session on types of IV cannula, IV cannula size, flow rate, and color codes,
vein selection and complications.

 Awareness session on phlebitis and VIP score.

 Assessments.

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Inclusions Criteria:
 Staff who have at least one year clinical experience.
 RN with PNC.
 COVID vaccinated staff preferred.
 Those staff members who don’t have any clinical condition or disease.
 Participants who are physically, mentally and socially well are preferred.

Exclusions Criteria:
 Those who have colored eyes may be they are color blind.
 Student Nurses Were Not Allowed To Participate In This Study

 WHO ARE NOT VACCINATED FOR COVID 19

Sample Size And Technique:

 50 staffs from ccu micu sicu are available.

 Data collected by questionnaire which we develop on this topic.

 After pre- test, face to face interaction with staff.

 On duty teaching session on daily bases for at least 15 minutes.

 Show charts related to cannula color and size.

Limitations of this project:

 Study with job

 Time constraints

 Social distance

 Difficulty in group activities

First trial

RECOMMENDATIONS AFTER PROJECT:

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  Don’t stop this VIP score application.

 After applying in CCU we recommend that, spread this knowledge among other staff
working in Indus Hospital.

 As we learn a lot from this activity, we encourage staff for conduct more teaching
sessions that promote nursing care.

 Upgrade yourself with latest guidelines.

 Always practice your nursing on evidence base in the light of new literature.

PURPOSE OF THE STUDY

Based on internal findings and the successful use of a standardized visual assessment scale, the authors
proposed a study to implement and evaluate a standardized assessment scale as the diagnostic
determination for changing PIV sites, to determine the incidence of PIV phlebitis over time and to assess
for any increase in the rate of bloodstream infections.

A PIV catheter was considered phlebitic if the VIP score was 2 or greater. The research questions were as
follows:

What is the incidence of PIV phlebitis at 24, 48, 72, 96 hours, and longer than 96 hours?

Is there a difference in phlebitis rates between PIV catheters indwelling up to 96 hours as compared
with those indwelling for longer than 96 hours?

What is the incidence of PIV phlebitis in patients who have had 1 or more PIV catheters restarted?

What is the relationship of the infusate or medications with the incidence of PIV phlebitis?

What is the relationship of dwell time with bloodstream infections?

Is the VIP scale a valid and reliable scale for use in daily clinical practice? (Gallant, Paulette BSN, RNC;
Schultz, Alyce A. PhD, RN, FAAN , November 2006)

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References :

 Scovell, S., Eidt, J. F., Mills, J. L., & Collins, K.A. (2022). Superficial vein thrombosis and phlebitis of the

lower extremity veins. In UpToDate. Retrieved July 10, 2022, from

https://www.uptodate.com/contents/superficial-vein-thrombosis-and-phlebitis-of-the-lower-extremity-

veins.

 Sengupta, M. (2019). Use of visual infusion phlebitis (VIP) score to care and control intravenous (IV)

infusion related phlebitis. International Journal of Integrative Medical Sciences, 6(5), 836-838.

 Qamar, Z., Afzal, M., Kousar, R., Waqas, A., & Gilani, S. A. (2017). Assess nurses knowledge and

practices towards care and maintenance of peripheral intravenous cannulation in Services Hospital Lahore,

Pakistan. Saudi Journal of Medical and Pharmaceutical Sciences, 3(6B), 608-614.

 Park, I., Jeong, M. H., Park, C. J., il Park, W., Park, D. W., & Joh, J. H. (2019). Clinical features and

management of “phlebitis-like abnormal reaction” after cyanoacrylate closure for the treatment of

incompetent saphenous veins. Annals of vascular surgery, 55, 239-245.

 Paans, W., Onrust, M., Nijsten, M. W., & Dieperink, W. (2019). Use of infrared thermography in the

detection of superficial phlebitis in adult intensive care unit patients: A prospective single-center

observational study.

 Anggraeni, R., Suryati, Y., & Nurjanah, N. (2021). The Effect of Aloe vera Compress in Reducing the

Degree of Phlebitis among Hospitalized Children in Indonesia. Iranian Journal of Neonatology IJN, 12(3),

1-6.

 Diwakar, K., Kumar, S., Srivastava, P., Uddin, M. W., & Mishra, S. (2021). Reduction in the incidence of

infusion-related phlebitis in a pediatric critical care unit of Eastern India: A quality improvement

initiative. Medical Journal Armed Forces India.

 Sengupta, M. (2019). Use of visual infusion phlebitis (VIP) score to care and control intravenous (IV)

infusion related phlebitis. International Journal of Integrative Medical Sciences, 6(5), 836-838.

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 Hossain, A. M., Hasan, M. I. A., & Haque, M. M. (2016). Assessment of the level of knowledge and

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