Comprehensive Child and Adolescent Nursing

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Warm Water Compress as an Alternative for

Decreasing the Degree of Phlebitis

Fitri Annisa, Nani Nurhaeni & Dessie Wanda

To cite this article: Fitri Annisa, Nani Nurhaeni & Dessie Wanda (2017) Warm Water Compress
as an Alternative for Decreasing the Degree of Phlebitis, Comprehensive Child and Adolescent
Nursing, 40:sup1, 107-113, DOI: 10.1080/24694193.2017.1386978

To link to this article: https://doi.org/10.1080/24694193.2017.1386978

Published online: 22 Nov 2017.

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 COMPREHENSIVE CHILD AND ADOLESCENT NURSING
2017, VOL. 40, NO. S1, 107–113
https://doi.org/10.1080/24694193.2017.1386978

Warm Water Compress as an Alternative for Decreasing

the Degree of Phlebitis
Fitri Annisa, Nani Nurhaeni, and Dessie Wanda
Faculty of Nursing, Universitas Indonesia, Jalan Bahder Djohan Campus, Depok, Indonesia

ABSTRACT KEYWORDS
Intravenous fluid therapy is an invasive procedure which may Infusion; intravenous
therapy; phlebitis
increase the risk of patient complications. One of the most
common of these is phlebitis, which may cause discomfort
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and tissue damage. Therefore, a nursing intervention is needed

to effectively treat phlebitis. The purpose of this study was to
investigate the effectiveness of applying a warm compression
intervention to reduce the degree of phlebitis. A quasi-experi-
mental pre-test and post-test design was used, with a non-
equivalent control group. The total sample size was 32 patients
with degrees of phlebitis ranging from 1 to 4. The total sample
was divided into 2 interventional groups: those patients that
were given 0.9% NaCl compresses and those given warm water
compresses. The results showed that both compresses were
effective in reducing the degree of phlebitis, with similar p
values (p = .000). However, there was no difference in the
average reduction score between the two groups (p = .18).
Therefore, a warm water compress is valuable in the treatment
of phlebitis, and could decrease the degree of phlebitis both
effectively and inexpensively.

Introduction
During the first year of life, a child may experience a phase of being
susceptible to illness with a higher risk of hospitalization in a health care
facility (Bowden & Greenberg, 2010). Hospitalization can cause stress in a
child because they feel a loss of control, fear of separation from their parents,
and trauma due to invasive procedure related pain (Hockenberry & Wilson,
2014). One type of pain often causing trauma in children is the insertion of
an intravenous cannula (Nilsson, Finnström, Kokinsky, & Enskär, 2009).
The insertion of an intravenous cannula is the most common invasive
procedure performed in hospitals, with 70–80% of hospitalized patients
requiring one (Pasalioglu & Kaya, 2014). Moreover, approximately 150 mil-
lion hospitalized children receive intravenous therapy (Schultz & Gallant,
2005). Intravenous cannulas are required for the administration of fluid and
electrolyte therapy, nutrition, and blood transfusion products (Waitt, Waitt,

CONTACT Nani Nurhaeni nani-n@ui.ac.id Faculty of Nursing, Universitas Indonesia, Jalan Bahder Djohan
Campus, Depok 16424, Indonesia
© 2017 Taylor & Francis
 108 F. ANNISA ET AL.

& Pirmohamed, 2004). The health care workers who usually insert the
intravenous cannulas are the nurses.
Infusion therapy is an invasive procedure which may cause risks to the
patient, such as phlebitis, infiltration, extravasation, and bacteremia (Arias-
Fernández, Suérez-Mier, Martínez-Ortega, & Lana, 2016), and other pro-
blems, like discomfort, intravenous cannula reinsertion, compartment syn-
drome, and tissue damage. Therefore, any possible complications should be
prevented to reduce the risk of the other problems becoming more compli-
cated (Park, Jeong, & Jun, 2016).
Phlebitis is possibly the most common complication of intravenous ther-
apy, with more than 50% of children with an intravenous cannula for
96 hours experiencing phlebitis or infiltration (Tripathi, Kaushik, & Singh,
2008). Phlebitis is an inflammation that occurs in the veins causing irritation,
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with signs of redness, pain, and edema around the insertion site (Hankins &
Society, 2001).
Much effort has been made to reduce the discomfort often associated with
phlebitis and to accelerate the healing process, like applying warm or cold
compresses to the site of the phlebitis (Anjum, 2007; Gauttam & Vati, 2016).
The compress is used because it can provide a moist environment at the
inflammation area, which could possibly accelerate the wound healing pro-
cess (Bryant & Nix, 2015). Moreover, a warm compress could provide
comfort for the painful areas, while a cold compress could stimulate vaso-
constriction, which may reduce the edema (Gauttam & Vati, 2016).
Several studies conducted in India evaluated the degree of phlebitis in 30
samples, and found that warm and cold compresses exhibited similar effec-
tivity in decreasing the degree of phlebitis (Anjum, 2007; Gauttam & Vati,
2016). Another study stated that either a warm or cold compress could
decrease the phlebitis indicators, such as erythema, swelling (edema) and
pain (Gauttam & Vati, 2016). This study showed that both the warm and
cold compresses had similar effectivity in decreasing the degree of phlebitis.
At the top referral hospital in Indonesia, phlebitis is currently being
treated with 0.9% NaCl compresses, which are used continuously until the
degree of phlebitis drops to zero. The application of 0.9% NaCl on wounds
can stimulate an anti-inflammatory response and relieve pain, redness and
edema (Bashir & Afzal, 2010). In addition, the 0.9% NaCl has a relatively low
temperature because it is maintained at room temperature; therefore, it can
promote vasoconstriction in the vascular system (Gorji, Nesami, Ayyasi,
Ghafari, & Yazdani, 2014).
Although 0.9% NaCl can be effective for reducing the degree of phlebitis, it
does have a certain expense associated with it. The price of one container
(500 ml) of 0.9% NaCl may be relatively cheap; however, this price multiplies
with the high prevalence of phlebitis, becoming much more expensive when
compared to using warm compresses. Therefore, there should be other
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 109

alternatives that could achieve a similar effectiveness (or greater effective-

ness) in decreasing phlebitis. One possible alternative is the use of a warm
compress.

Methods
This study employed a quasi-experimental pre-test–post-test design, with a
non-equivalent control group, in which there were two groups involved. The
samples were selected using a consecutive sampling technique and included
32 children (age range 1 month to 17 years) divided into two groups: 16 in
the control group and 16 in the intervention group. The comparable variable
in this study was the decreasing degree of phlebitis in those patients being
given warm compresses and those being given 0.9% NaCl compresses. The
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expected outcome was to show that the warm compresses could significantly
decrease the degree of phlebitis. This study was approved by the ethics
committee of the Faculty of Nursing of the Universitas Indonesia and
hospital.
The phlebitis severity was measured using the degree of phlebitis table,
which was adopted from the Infusion Nurses Society. After the first phlebitis
measurement, the researcher discussed the intervention that would be per-
formed with the patient’s parents. In addition, the researcher provided an
explanation of the checklist and gave it to the parents. The checklist was used
while the patient’s family was applying the compresses to the site of the
phlebitis, and consisted of the compress application times. The patient was
treated with a warm water or 0.9% NaCl compress for 15–20 minutes, three
to four times each day. The evaluation of the degree of phlebitis was done at
24 hours and 48 hours after the compress was applied.

Results
The implementation showed that phlebitis occurred quite often (43.8%) in
the ≤ 1-year-old children, who were classified as the infant group (Table 1).
In addition, it was found that phlebitis was more common in the under-
weight nutritional status children (56.3%). The use of both electrolyte
(53.1%) and non-electrolyte (46.9%) solutions for intravenous therapy can
cause phlebitis. Moreover, those patients taking antibiotic medications were
more susceptible to phlebitis (87.5%).
The data analysis in Table 2 shows that there were differing degrees of
phlebitis before and after applying the 0.9% NaCl compress (p < .00). In
addition, the negative rank score shown in Table 2 (n = 16) might indicate
that decreasing degrees of phlebitis were found in all of the respondents on
the first day of the intervention. Moreover, Table 3 shows that there were
differing degrees of phlebitis before and after applying the warm compresses
 110 F. ANNISA ET AL.

Table 1. Patients’ characteristics.

Variable N %
Age
Infant 14 43.8
Toddler 7 21.9
Preschool 5 15.6
School 3 9.4
Adolescence 3 9.4
Nutritional Status
Underweight 18 56.3
Normal 9 28.1
Overweight 5 15.6
Intravenous Therapy Solution
Non-electrolyte 15 46.9
Electrolyte 17 53.1
Antibiotic Medication
No 4 12.5
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Yes 28 87.5

Table 2. Comparison of the average decrease in phlebitis before and after the intervention in the
normal saline compress group.
Rank
Variable Day 1 n Day 2 n p value
Degree of Phlebitis Negative rank 16 Negative rank 8 .000
Positive rank 0 Positive rank 0
Ties 0 Ties 8
Total 16 16

Table 3. Comparison of the average decrease in phlebitis before and after the intervention in the
warm water compress group.
Rank
Variable Day 1 n Day 2 n p value
Degree of Phlebitis Negative rank 16 Negative rank 4 .000
Positive rank 0 Positive rank 0
Ties 0 Ties 12
Total 16 16

Table 4. Comparison of the average decrease in phlebitis between the normal saline and warm
water compress groups.
Variable n Mean Rank p value
Type of Compress .108
Normal Saline 16 14.69
Warm Water 16 18.31

on the phlebitic sites (p = .00). The negative rank score shown in Table 3
(n = 16) implied that a decreasing degree of phlebitis was evident in all of the
respondents on the first day of the intervention. Finally, Table 4 shows that
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 111

there was no difference (p = .108) in the decrease in the degree of phlebitis

between the two groups of compresses (0.9% NaCl and warm water).

Discussion
The results of this research showed that both the 0.9% NaCl and warm water
compresses were effective for decreasing the degree of phlebitis, but there was
no significant difference between these two interventions. Thus, either the
0.9% NaCl or warm water compress could be used successfully. This finding
supports another study investigating the effectiveness of warm and cold
compresses in reducing the degree of phlebitis (Anjum, 2007; Gauttam &
Vati, 2016). This study argued that both warm and cold water compress were
effective.
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A warm compress could be advantageous for inflamed wounds in phlebitis

cases. The warm temperature could stimulate vasodilatation, which may
induce more optimal blood circulation. This can, in turn, promote a faster
wound healing process because the blood can more easily provide the nutri-
tion and oxygen needed for proper wound healing (Hankins & Society,
2001). In addition, the warm temperature of the water could improve the
patient’s comfort. One study of non-pharmacological interventions for pain
argued that warm water can improve comfort in patients feeling pain
(Kulisch, Bender, Németh, & Szekeres, 2009). A warm environment can be
provided using several methods, including warm water compresses, which
might be effective in reducing the redness, pain and edema associated with
phlebitis.
Importantly, the results of this study have shown that the application of a
warm water compress for the treatment of phlebitis did not evoke any
additional harm to the patients, such as the additional risk of infection.
The use of water has been rejected previously in wound care because it is
not sterile, but this argument has been disproven by several studies employ-
ing tap water for wound care (Salami et al., 2006; Valente, Forti, Freundlich,
Zandieh, & Crain, 2003). Several studies have argued that using tap water for
wound care might exhibit a similar effectivity as that when using 0.9% NaCl,
without any side effects. The studies even explained that using tap water for
wound care could assist in the tissue epithelization process, which could
accelerate wound healing.
Although a prescription is needed to acquire 0.9% NaCl, there are no
limitations in acquiring water, and everyone has access anytime because it
is provided with the hospital facilities. The warm water can be provided in
the hospital, and the patient’s parents can use it independently. The
temperature of the warm water should be maintained for 15 minutes,
but this can be achieved by motivating the parents to be compliant with
the interventional procedure, and informing them about the additional
 112 F. ANNISA ET AL.

complications of phlebitis. Overall, the application of a warm water com-

press in phlebitis cases may highly be achievable with collaboration
between the nurse and parents.
When considering the expense, using warm water compresses could be the
most affordable alternative for reducing the severity of phlebitis in the
hospital. Warm water compresses can also be applied at home, after the
patient is discharged; thus, they could be the cheapest way to effectively
overcome phlebitis.

Conclusion
Warm water compresses are one treatment alternative for phlebitis, aside
from using 0.9% NaCl or other medical therapies. The results of this study
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could be reinvestigated with a larger sample size, and warm water compresses
could possibly be added to the hospital standard operational procedure to
help cope with phlebitis cases.

Acknowledgments
The authors are deeply indebted to the study subjects and their parents, as well as the clinical
supervisors and head of the children’s infection ward of the hospital who helped with this study.

Declaration of interest
The authors report no conflicts of interest.

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