In This Issue of JWOCN

This issue of the Journal includes multiple articles that evaluate some of the most common and clinically relevant assessments and interventions that comprise our daily practice. In the current era when clinical practice guidelines and best practice statements are increasingly common, it might seem that questions concerning the effectiveness of various interventions or assessments have been largely resolved. However, the debate over health care reform has focused on the issue of how we identify and evaluate existing evidence and how we deal with pragmatic considerations such as cost-effectiveness, comparative effectiveness, and feasibility. This issue of the Journal contains precisely the type of cutting-edge articles to help you navigate the increasingly complex waters of comparative effectiveness, the accuracy of assessments, and how we balance the demands of demonstrating efficacy, while maintaining a focus on effectiveness in a real-world setting.

Debra S. Netsch and Jean A. Kluesner open this issue's Spotlight on Research with insights for evaluating clinical practice guidelines. While the number of guidelines has grown dramatically, the quality of these documents is uneven, and adopting a guideline for practice requires critical appraisal skills. You will want to read this article to learn about the fundamental steps of this appraisal process. Sharpening these skills will enhance your value as a resource to your facility or any other facilities or health systems that you consult with.

Your Wound Care section opens with an evaluation of the accuracy of toe pressures measured by a portable plethysmograph device. Phyllis Bonham, Teresa Kelechi, Martina Mueller, and Jacob Robison compared toe pressures obtained by a nurse using a portable device to the gold standard for this measurement, pressures obtained by a registered vascular technologist using standard laboratory equipment. You will want to read this article to determine whether this highly portable device provides reasonable accuracy for measuring toe pressures as part of an assessment for lower extremity arterial disease (LEAD) or whether patients should be referred to a vascular laboratory for this important evaluation.

The shifting focus of pressure ulcer care from management to prevention has clearly led to increasing awareness of the effect of preventive interventions such as pressure offloading, regular turning, and repositioning. However, less is known about nurses' specific knowledge about prevention of stage I pressure ulcers and suspected deep tissue injuries. Arzu Karabag Aydin and Ayise Karadag evaluated 243 nurses' knowledge and practice related to prevention of these common forms of pressure-associated skin damage. You will want to read this article to gain further insights into the limits of nurses' knowledge of pressure ulcer prevention in the 21st century.

Most WOC nurses will agree that we have knowledge of the essential elements of pressure ulcer prevention, but their application in the local facility remains a challenge. While there is no "one size fits all" answer, readers consistently tell us that real-life examples provide some of the most valuable insights for establishing and maintaining an effective prevention program. Judith Young, Mary Ernsting, Amira Kehoe, and Kathleen Holmes describe the results of a clinician-led task force for preventing hospital-acquired pressure ulcers. This article qualifies as must-read information for any WOC nurse seeking an effective method to integrate research into practice and promote shared professional accountability to ensure facility-wide reduction in the incidence of hospital- acquired pressure ulcers.

Your Ostomy Care section opens with a powerful reminder of the increasing significance of the Society's Center for Clinical Investigation (CCI) Small Grant Program. Grant funds administered by the CCI have proved their value to WOC nursing practice again and again. In this latest final report from a CCI-funded team, Catherine R. Ratliff and colleagues practicing in central Virginia report results of a study of the incidence of peristomal complications within 2 months following creation of a new fecal or urinary ostomy. You will want to read this article to improve your knowledge of the nature and frequency of peristomal complications experienced during the first 2 postoperative months, and to see a practical application of the taxonomy for stomal and peristomal complications validated by Colwell and Beitz,1 who also received grant funds from the Society's CCI.

Colostomy irrigation has generated debate; some WOC nurses readily incorporate this technique into their practice, while others feel less comfortable recommending irrigation owing to concerns about potential long-term effects on bowel function. Eva Carlsson, Meta Gylin, Laila Nilsson, Katarina Svensson, Ingrid Alverslid, and Eva Persson employed a mixed qualitative and quantitative approach to determine the extent to which Swedish WOC nurses incorporate colostomy irrigation in their practice and the counseling provided to patients who use this management technique. You will want to read this important article to both compare your practice to those of your colleagues in Sweden and evaluate the experiences of colostomy patients who regularly incorporate this practice into their ostomy management.

While it is known that women often experience altered perceptions of body image and sexual dysfunction following colorectal cancer surgery, few interventions have been designed to specifically meet the needs of this group. Chia-Chun Li and Lynn Rew use a feminist perspective to explore differences in gender role, body image, and its effect on sexual function in women undergoing surgical treatment for colorectal cancer, including creation of an ostomy. You will want to read this article to broaden your understanding of body image and sexual function in women with an ostomy due to colorectal cancer and to evaluate the need for further research designed to both assess and effectively support these women as they struggle to reintegrate body image and sexual function.

Your Continence Care section opens with an issue that is increasingly recognized as essential to all aspects of WOC nursing, assessment of moisture-associated skin damage. Kathleen Borchert, Donna Z. Bliss, Kay Savik, and David M. Radosevich describe the development and validation of the Incontinence Associated Dermatitis Instrument. This badly needed tool allows nurses to both describe essential IAD characteristics and rate its severity. This article qualifies as must-read information in order to determine whether you will want to integrate this instrument into both your practice and practice within your facility in order to ensure that nonexpert colleagues are able to more accurately differentiate IAD from pressure ulcers or lesions caused by a mixture of moisture and pressure.

A small but growing body of evidence suggests that urinary incontinence, diabetes mellitus, and congestive heart failure are often associated. Shelley Y. Hawkins, Jeongok Park, and Mary H. Palmer evaluated interests of heart failure patients with and without diabetes mellitus concerning urinary incontinence. You will want to read this article to increase your understanding of the potential associations between these chronic conditions, how diabetes and heart failure impact urinary incontinence management, and how this knowledge can be translated into early counseling and education about incontinence prevention and management.

This issue's Challenges in Practice section discusses a form of combination therapy frequently featured in the Journal. Mary Arnold-Long Richard Johnson, and LuAnn Reed present 4 cases where they found that the effectiveness of negative pressure wound therapy was enhanced by adding a collagen alginate to their topical dressing regimen. You will want to read this interesting article to determine whether you will want to incorporate this innovative technique into your management of patients with wounds involving significant tissue destruction.

This issue's WOC Nurse Consult describes the evaluation of urinary retention in an older, community-dwelling man. You will want to read this highly valued feature of the Journal to sharpen your critical thinking skills related to the assessment and management of urinary retention, including the proper use of a short-term indwelling urinary catheter.

This issue's Getting Ready for Certification focuses on pediatric ostomy surgery. Recent data demonstrate that a growing number of readers incorporate this regular feature of the Journal as part of their preparation for initial certification or recertification by examination. Go to jwocnonline.com and you will also find that our Web Page Section Editor, Lee Ann Krapfl, has pulled together a collection of previous Certification Review features. This collection is one of many features available at http://jwocnonline.com designed to supplement and enhance the cutting-edge information you have come to expect in your premier journal for wound, ostomy and continence care.

Evidence From Other Publications

Wound Care

I believe that the longer you practice in any given specialty, the more likely you are to find that even the most apparently distant specialties share multiple links. Extracorporeal shock wave therapy rose to prominence in the 1970s in urology as a treatment for urinary calculi. More recently, an Austrian group reported improved healing rates in a group of 102 patients with 104 chronic cutaneous wounds.2 In a recent issue of Clinical Rehabilitation, Larking and coinvestigators3 reported results of a small, randomized, controlled trial comparing extracorporeal show wave therapy versus placebo for chronic pressure ulcers. Only 9 patients participated in the trial, so the study must be viewed as a pilot trial rather than a definitive comparison. Nevertheless, the study design specifically addressed 3 legitimate threats to external validity: the Hawthorne effect (would patients do something different because of the study), the Pygmalion effect (would staff do something different because of the study findings), and the differential effect (does shock wave therapy that create the therapeutic effect or is it some unintended component of the intervention such as contact with the shock wave therapy device). While the initial results of this study are not definitive, study findings are important because they demonstrate the feasibility of performing a more definitive trial and the potential for extracorporeal show wave therapy for the treatment of pressure ulcers in selected patients.

Clinical experts have long recognized that shearing forces may be more destructive than interface pressure alone in the etiology of a pressure ulcer. In an article appearing in the 2010 Journal of Tissue Viability, Oomens and coworkers4 question the current focus on tissue interface pressure as a proxy for measuring the potential for a support surface to result in pressure ulceration in vulnerable persons. As an alternative to this outcome measure, the authors propose adaptation of devices capable of measuring the maximum shear strain and strain energy density created when a patient is placed on specific surface. Based on animal model data, they argue that it is feasible to identify a more meaningful threshold value that could be used to more accurately predict the potential for pressure ulceration in susceptible patients. While this article summarizes existing data rather than presenting new data validating this potential measurement, I recommend reviewing it to improve your understanding of biomechanical aspects of pressure measurement and its relationship to pressure ulcer etiology.

Ostomy Care

Surgeons and radiation oncologists have long compared, and often debated, the efficacy of radiation versus surgery and the prevalence and severity of short- and long-term complications associated with each procedure. Bruheim and coworkers5 compared long-term side effects in a group of 199 patients undergoing treatment for rectal cancer to 336 patients who did not require radiation therapy. Inclusion criteria include radiation treatments administered either prior to or following surgical resection resulting in a cumulative dose of 46 to 50 Gy. Self-reported effects on bowel and bladder function and global quality of life were assessed by telephone interview. Patients who underwent radiation therapy and did not undergo creation of an ostomy reported more bothersome bowel elimination symptoms and more fecal incontinence than those who underwent ostomy surgery. Patients undergoing radiation therapy were also more likely to report bothersome lower urinary tract symptoms, including urinary incontinence, than were those managed without radiation therapy. For most WOC nurses, these data tend to be confirmatory of clinical experience rather than unexpected. Nevertheless, they do serve as a reminder that radiation therapy has significant long-term effects on bowel and bladder function that affect both patients with and without an ostomy. These data also provide yet another reminder that we are all continence nurses; just as we are all wound care nurses and all ostomy nurses.

Continence Care

Clinician-directed pelvic floor muscle training (PFMT) has been shown to be effective for managing stress, urge, and mixed urinary incontinence, but treatment does require considerable time and effort for both patient and nurse. In a recent issue of Neurourology & Urodynamics, Hendriks and coinvestigators6 evaluate predictors of treatment failure in a group of 267 women undergoing PFMT for recurring stress urinary incontinence. Predictors for failure included severe urinary incontinence with frequent and high-volume urine loss with physical exertion, moderately severe to severe pelvic organ prolapse (POP-Q stage > 2), obesity (body mass index > 30), poor physical health, and high psychological distress. Many studies focus on predictors for success of certain interventions, but this study is noteworthy because it identifies factors that may reduce the likelihood of clinician-directed PFMT. While no WOC nurse will use these results to exclude any patient from a PFMT program, they are useful in counseling patients about anticipated duration of therapy and reinforce the need to establish reasonable goals for evaluating treatment outcome before engaging in this worthwhile and challenging intervention.

REFERENCES