In This Issue of JWOCN
This issue of the Journal balances important updates and original data in each of the primary areas of our practice, with 2 professional practice articles focusing on your role as a clinical investigator and consumer of research. Your research spotlight describes techniques for reviewing the literature using electronic databases and citation management software. Dr Steele correctly points out that many WOC nurses began their career, using the traditional index card method when reviewing the literature, and I personally remember maintaining a massive (and poorly organized) collection of article reprints. You will want to read her article to update your knowledge about electronic options that render these approaches obsolete, while increasing our ability to truly keep up with and articulate current best evidence for WOC practice.
Denise Netta-Turner, Linda Bucher, Lois Dixon, and Norma Jean Layton summarize the challenges and obstacles that prompted them to close a potentially valuable research project comparing an anal pouch with a nasal trumpet for management of incontinence-associated dermatitis in the critical care setting. This must-read article provides an excellent summary of some of the most common obstacles facing WOC nurses when they act in the role of clinical researcher. However, it offers more than simply a description of "what went wrong." Instead, the authors provide invaluable strategies for ensuring success when you begin your first (or next) clinical investigation, especially if your practice is in the acute or critical care setting.
Joy Pittman, Susan M. Rawl, C. Max Schmidt, Marcia Grant, Clifford K. Yo, Christopher Wendel, and Robert S. Krouse report on factors that influence the risk for 3 common complications experienced by persons with ostomies: cutaneous irritation, pouch leakage, and difficulty adjusting to the ostomy. The strength of their findings is augmented by a robust sample size (N = 239), the geographic diversity of participants (Arizona, California, and Indiana), and the use of validated instruments. Read this article to gain a better understanding of demographic and clinical factors that influence the risk profile for experiencing these common complications of a fecal ostomy.
Leanne Richbourg, Jane Fellows, and Whitney D. Arroyave report on a national survey of pouch wear time. The value of their findings is also strengthened by a robust sample size (N = 551), the geographic diversity of respondents (84% of states represented), and the inclusion of persons living with fecal as well as urinary ostomies. Read their article to find the often-sought, but before now never definitively answered question, "What is the average pouch wear time among persons living with an ostomy?" As an honorary member of the Registered Nurse of Ontario's Best Practice Guideline Panel for Ostomy Care, I am acutely aware of the comparatively small evidence base guiding WOC nurse management of the person living with an ostomy. The wealth of original data contained in this issue's ostomy section truly defines the term "must read!!"
Some argue that the presence of a national health system in the United States will solve problems with access, while others argue that such a system will only exacerbate current problems of resource utilization. In this issue's Continence Care section, Neel Desai, Teresa Keane, Adrian Wagg, and Judith Wardle report on the provision of continence pads in Great Britain. Read their article for an insightful and original report of the strengths, limitations, and complexity associated with resource utilization of continence containment devices in a country with an extensive history of healthcare delivery using a nationalized system.
Finally, this issue's special focus, Diabetic Foot Care, is the topic of 3 features. Laura B. King describes establishment of a foot care clinic for patients with diabetes. This quality improvement project resulted in an overall reduction in the number of elective lower extremity amputations among the diabetic population served by her facility. You will want to read this timely article not only to take advantage of the contact hours but also to hear about an excellent example of the value gained when healthcare systems truly switch their focus from management of complications to their prevention. Given the evolving changes in prospective payment via the Centers for Medicare & Medicaid Services, this article represents precisely the type of innovative program that more and more facilities are seeking to establish, and the essential role a WOC nurse can play in a prevention-based program.
The Wound, Ostomy, and Continence Nursing Certification Board's Getting Ready for Certification feature is written by Diana Gallagher, who provides excellent information about the board's certification in foot and nail care, as well as 3 exemplary questions that both inform and assist nurses preparing to sit for this important credential.
In this issue's Challenges in Practice, Jerrie Larsen and Julia Overstreet describe 2 cases where they enabled patients to heal complex, full-thickness diabetic foot wounds and avoid possible lower extremity amputation, using standard wound healing interventions and pulsed radio-frequency energy. Read this article to gain more knowledge about the feasibility and application of this novel technique for prompting healing in complex and indolent wounds.
Evidence From Other Publications
WOUND CARE
Steed and coworkers1 provide a clinical practice guideline for the prevention of diabetic foot ulcers in the March-April 2008 issue of Wound Repair and Regeneration. This issue is notable for clinicians because it also contains clinical practice guidelines for prevention of lower extremity arterial ulcers,2 prevention of venous ulcers,3 and prevention of pressure ulcers.4 According to Barbul,5 these clinical practice guidelines are a follow-up to previously published treatment guidelines in each of these areas of management. Each of the guidelines is based on systematic reviews of MEDLINE, EMBASE, Cochrane Database of Systematic Reviews electronic databases, and Medicare/CMS consensus of usual treatment of chronic wound. Similar to the approach used by the WOC nursing, these guideline panels ranked the strength of evidence supporting specific interventions on a 3-tiered taxonomy where level I indicated strong evidentiary support from meta-analysis of multiple randomized clinical trials, level II indicated moderate supportive evidence from at least 1 randomized clinical trial augmented by clinical series or expert opinion articles, and level III evidence is limited to data that suggest proof of principle but insufficient to draw more definitive conclusions.
OSTOMY CARE
Does the presence of a peristomal prolapse influence quality of life (QOL) among persons living with an ostomy? Kald and colleagues6 administered the short health scale (an instrument designed to measure health-related general QOL) and the ostomy-QOL (a disease-specific measure of health-related QOL) to 70 persons with sigmoidostomies created an average of 8.1 years prior to the study. Peristomal bulging was noted in 66% of the subjects. Participants with peristomal bulging were more likely to report a lower health-related QOL affecting multiple dimensions of health-related quality life including symptom load, worry, and general sense of well-being. When data from the ostomy-QOL were analyzed, respondents with peristomal herniations or prolapse reported more symptoms of fatigue, less confidence in responses of family to their body habitus, and increased concerns about pouch leakage. Research about stomal and peristomal complications remains sparse, and clinical evidence about the efficacy of various preventive and management interventions even more scarce. Although this descriptive study does not provide direct evidence evaluating interventions to prevent or treat peristomal herniation or prolapse, it does provide additional insights into the negative influence of these complications on quality of life, and it reinforces the need for ongoing evaluation and monitoring of persons with an ostomy by a WOC nurse.
CONTINENCE CARE
Pessary placement remains a viable alternative for the conservative management of women with pelvic organ prolapse, including many who also experience stress urinary incontinence. To address both of these disorders, manufacturers have developed pessaries designed to both correct vaginal wall prolapse and alleviate stress urinary incontinence. Noblett and colleagues7 report on a study of 95 women with pelvic organ prolapse and stress urinary incontinence who were fitted with an incontinence dish pessary. Following pessary fitting, 84% experienced correction of urethral hypermobility assessed by a Q-tip test. Urodynamic testing was performed in 33 subjects. These studies revealed that maximum urethral closure pressure increased by a mean of 19.7 cm H2O, and stress urinary incontinence occurred in 40% after the pessary was fitted as compared to leakage in 90% before placement. Based on these data, the authors hypothesize that the incontinent dish pessary alleviates or corrects stress urinary incontinence by reducing urethral hypermobility and by increasing urethral closure pressures. The role of pessaries in the management of women with pelvic organ prolapse and incontinence continues to evolve. Its acceptance among gynecologists is limited by an inaccurate impression that pessaries are not effective for the management of stress urinary incontinence8 and its popularity among WOC nurses is limited by the perception that placement requires expert knowledge and advanced practice skills. This study is important because it provides evidence that incontinence dish pessaries are effective for the management of stress urinary incontinence in women with pelvic organ prolapse, and it provides insights into the mechanisms for its effect. As for its proper place in the scope of WOC nursing practice, I believe that placement does require considerable skill that is enhanced by experience. Fortunately, the level of skill and knowledge required for successful pessary fitting is no more than that required for the majority of routine pouching challenges successfully managed by WOC nurses on a daily basis.
References