In This Issue of JWOCN
This issue of the Journal summarizes existing evidence and premieres new data essential to your care of patients with wounds, ostomies or continence disorders. Contained within this issue is the latest information pertaining to the ongoing controversy over whether certain pressure ulcers are truly avoidable, a comparison of 2 negative pressure wound therapy technologies, and 3 features focusing on factors linked with pressure ulcer risk, including cumulative and subscale scores from the Braden Scale for Pressure Sore Risk. This issue of the journal also contains 2 features, a case report and cutting-edge review, and a WOC Consult feature challenge that will test your knowledge and critical thinking skills about the care of peristomal complications. We also present a detailed review of the clinical implications of the latest knowledge about incontinence-associated dermatitis (IAD), followed by an original research report that provides the first published data on the epidemiology of IAD in a long-term acute care facility. You have come to expect that each issue of the Journal provide the latest knowledge and evidence relevant to your practice, and thanks to the hard work of the authors who contributed to this issue, we are able to deliver just that.
The lead article for this issue focuses on a professional practice issue pertinent to every WOC nurse. Barbara Pieper and Janice Colwell present a professional practice article that serves as an exciting and informative summary of issues related to preparation of advanced practice nurses at the doctoral level. This tour de force discussion qualifies as must-read for any WOC nurse who is considering education as an advanced practice nurse, as well as master's prepared nurse practitioner and clinical nurse specialists considering doctoral education as a strategy for career advancement and enrichment.
The Wound Care section opens with a study comparing 2 technologies (foam vs gauze) used to deliver negative pressure wound therapy. You will want to read this original research report, authored by Nancy Albert, Ronald Rock, Molly Sammon, James Bena, Shannon Morrisson, Angela Ciccero, Irene Kato and Judith Landis-Erdman to determine the effect of these technological systems on wound healing rates, pain, direct cost, and staff time.
The Wound Care section continues with a report from Joyce Black, Christin Berke, and Gail Urzendowski on the results of a comparison cohort study that examined pressure ulcer incidence using a low air loss with microclimate management bed versus an integrated power pressure redistribution bed in a 12-bed cardiovascular intensive care unit. You will want to read this article to find out whether outcomes differed between these beds, and to determine how the findings of this important comparative study may influence bed choice in your facility.
The Wound Care section also features with 3 articles focusing on hospital-acquired pressure ulcer risk and associated factors. Karen E. Bry, Diannalyn Buescher, and Mary Sandrik report results of a descriptive study describing comorbid conditions and Braden Scale scores in 82 patients who developed at least 1 facility-acquired pressure ulcer during their hospital course. You will want to read this article to gain insight into the number and character of comorbid conditions found in these patients, their scores on the Braden Scale for Pressure Sore Risk, and the number of preventive interventions in use when these nosocomial ulcers developed. Ann Tescher, Megan Branda, T.J. O-Byrne, and James Naessens report findings from a study examining records of more than 12,000 patients in order to identify risk factors associated with development of hospital-acquired pressure ulcers. You will want to read the findings from this robust study to gain new insights into the influence of cumulative and subscale scores from the Braden Scale on pressure ulcer development and to identify other factors associated with an increased likelihood for developing a hospital-acquired pressure ulcer. This research report is followed by a View from Here authored by Molly Gadd, which discusses the use of the Braden Scale subscale scores for pressure ulcer prevention. You will want to read this provocative and well-reasoned feature to enhance your insights into the clinical implications of subscale scores from the Braden Scale for Pressure Sore Risk when planning an individualized program for prevention of facility-acquired pressure ulcers.
Frank Hoentjen, Janice Colwell, and Stephen Hanauer review a case of a male patient with peristomal complications including ileal stricture, stoma retraction, and enterocutaneous fistula. You will want to read this complex and riveting case report and literature review to enhance your knowledge of peristomal complications associated with Crohn's disease following proctocolectomy and creation of an intestinal ostomy. This case report and literature review is followed by a WOC Consult authored by Connie Kelly, which focuses on another peristomal complication in a 47-year-old woman. Read the case description and answer Connie's questions to find out the nature of this complication and its management.
This issue's Continence Care section contains 2 articles that discuss issues that cut across every WOC nurse's practice caring for patients with wounds or continence issues. Dorothy Doughty, Joan Junkin, Peter Kurz, Joan Selekof, Mandy Fader, Donna Z. Bliss, Dimitri Beeckman, Susan Logan, and colleagues conclude their 2-article series from a consensus conference evaluating progress and challenges linked to differential assessment, prevention, and treatment of IAD. You will want to read this article and complete the attached CE to enhance your understanding of clinical and economic issues related to IAD and review the recommendations for practice promulgated by this international panel of clinicians and researchers.
Mary Long, Lu Reed, Kari Dunning, and Jun Ying report findings from a study supported by a grant from the WOCN Center for Clinical Investigation, which measured the prevalence and incidence of IAD and pressure ulcers in a long-term acute care facility. You will want to carefully read this article that is the first to report both IAD and pressure epidemiology in this emerging health care setting.
This issue's Clinical Challenges, authored by Joanna M. Stafiej and Maria T. Szewczyk, reports initial experiences using a collagen sponge filled with gentamicin in an aged and bedridden patient with 5 full-thickness pressure ulcers. This article qualifies as must read for every WOC nurse involved in the management of higher-stage, nonhealing pressure ulcers in frail, elderly patients who are often not candidates for surgical debridement.
This issue's WOCNCB Getting Ready for Certification feature includes sample questions in all 3 areas of our practice. You will want to read this exciting feature from the Certification Board because these questions, while varied in clinical focus, provide the first examples of the types of questions candidates can expect to encounter when taking the new advanced practice certification examinations.
Evidence From Other Publications
In addition to other forms of skin damage, WOC nurses are often involved in establishing or updating protocols and policies designed to prevent and treat skin tears. This task is especially challenging for WOC nurses because of the paucity of clinical evidence related to assessment, classification, prevention, and treatment. In a recent issue of the International Journal of Evidence Based Healthcare, Lopez and colleagues1 report results of a before-after project using the Joanna Briggs Institute Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRIP)tools. The researchers applied these tools to implementation of a best practice guideline for skin tears in multiple acute care and rehabilitation units for aged persons. The researchers evaluated the prevalence of skin tears in a group of 96 patients (aged 78.2 +/- 10.92 years; mean +/- SD) in acute care and rehabilitation wards of 2 public hospitals in the Australian Capital Territory. Baseline evaluation revealed a skin tear prevalence rate of 19.8% and a facility-acquired prevalence of 10%. The units then implemented best practice guidelines for preventing and treating skin tears, appointed unit-based champions to coordinate efforts, and educated staff about this often-overlooked hospital-acquired wound. Following implementation of the program, the prevalence of facility-acquired skin tears declined from 10% to 0.15%. I recommend reviewing this interesting article in order to enhance your knowledge of skin tears and to determine whether the PACES and GRIP tools might be useful in your facility as you continue to act as both a direct provider of care and change agent for integrating the latest evidence into practice, and ensuring these changes are translated into meaningful nursing practice and patient outcomes.
Ostomy Care
Stomal and peristomal complications are a prevalent and important component of ostomy nursing. However, research exploring the epidemiology of peristomal complications is limited. Ripoche and coworkers2 reported results of a robust study of 782 persons living with an ostomy (mean time since ostomy surgery, 10.5 years) randomly selected from the electronic database of the French Federation of Ostomy Patients. The reported prevalence of parastomal hernia was 25.6%, and 76% reported bothersome symptoms they associated with their parastomal hernia. The most common symptoms were pain reported by 35%, pouching difficulties and leakage in 28%, and irritation of the peristomal skin in 24%. Persons living with colostomies were more likely to report parastomal herniation than were individuals with ileostomies. More than half (56%) reported undergoing surgical repair, but 52% reported recurrent herniation within 6 months. Multivariate analysis found that age greater than 60 years and presence of peristomal complications immediately following stoma surgery were associated with an increased risk for parastomal hernia. While these data are limited because they exclusively rely on self-report and patient recall, they strongly suggest that parastomal hernias are prevalent, associated with bothersome symptoms in most patients, and respond poorly to surgical repair. Additional research focused on a goal that is central to WOC nursing practice, prevention of this bothersome complication, is urgently needed.
Continence Care
Pharmacotherapy of overactive bladder and urge incontinence currently relies on a number of classic and novel drugs including oral and transdermal oxybutynin, tolterodine, fesoterodine, darifenacin, solifenacin, and trospium.3 All of these agents belong to the same class of drugs (the antimuscarinics) and all act by blocking one or both of the predominant muscarinic receptors in the bladder wall, M2 and M3. While these drugs have proven effective and comparatively safe, they are associated with anticholinergic adverse side effects including constipation and dry mouth. More recent evidence also suggests that aged persons with parkinsonism and dementia may be at an increased risk for functional and cognitive adverse side effects from antimuscarinic administration, and their use is increasingly discouraged in patients receiving acetylcholinesterase reuptake inhibitors such as donepezil (Aricept).4 In a recent issue of Drugs of Today, Gras5 reports on outcomes of phase III clinical trials of mirabegron, a beta-3 agonist designed to inhibit the overactive detrusor contractions associated with the characteristic symptoms of overactive bladder syndrome. The drug has been approved for use by the Japanese regulatory body for prescriptive medications, and it is undergoing review by the US Food and Drug Administration as well as the EMEA (European Medicines Agency) for approval. I counsel monitoring the progress of this investigational agent closely since it has the potential to significantly expand our pharmacologic armamentarium of drugs used for the treatment of overactive bladder syndrome, should it be approved for use in North America, Europe and Australia as it has been in Japan.
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