In This Issue of JWOCN

This inaugural issue for 2011 opens with a professional practice article that cuts across management issues relevant to wound, ostomy, and continence practice. Ivy Razmus provides an excellent review of the profound but seldom discussed congenital anomalies gastroschisis and omphalocele. Whether you typically care for adults, children, or both you should read this article because it reviews current knowledge of the early management and long-term consequences of these profound abdominal wall defects.

Your Wound Care section opens with an article from Kelli Bergstrom about the evaluation and management of fungating wounds. You will want to read this essential article to review and update your knowledge about assessing and managing these especially challenging wounds. Kelli's article also qualifies as must read because of the insights provided about the substantial emotional and psychosocial support that both patients and their families so disparately need when faced with a fungating wound.

Young Sung and Kyung Park from Korea report findings of an original study that identified factors affecting pressure ulcer healing. Their article qualifies as must read because it provides novel insights into both logistic and systemic factors influencing pressure ulcer healing in acute and critically ill patients.

Julia Paul, Journal Consulting Editor Barbara Pieper, and Thomas Templin investigated the symptom of itch and its relationship to venous disease and venous leg ulcers. This fascinating research report easily qualifies as must read because it explores existing knowledge, and provides novel data guaranteed to enhance your understanding of the symptom of itch, the true nature of its relationship to pain, and how itch affects patients with chronic venous disease and venous leg ulcers.

Jane Johnson, Darcie Peterson, Betty Campbell, Regina Richardson, and Dana Rutledge report on an evaluation of a low air loss bed for prevention of hospital acquired pressure ulcers. You will want to read the results of this prospective comparison cohort study to gain further insights into the researchers' experience when comparing units that incorporated a low air loss bed as part of a comprehensive hospital-acquired pressure ulcer prevention program versus units that used alternate pressure redistribution surfaces as part of the same facility wide prevention program.

Your Ostomy Care section opens with the latest research report from Thom Nichols focusing on social connectivity during the first 2 years following ostomy surgery. You will want to read this article to gain further insight into the complex and significant impact of social connectivity or social isolation on life satisfaction, body image, and adjustment to life with an ostomy.

Your Continence Care section opens with an original research report by Jill Cutright who evaluates the impact of a bladder scanner on indwelling catheter insertion and recatheterization in an acute care facility. You will want to read this interesting and highly pragmatic article to gain insights into the role and utility of the increasingly portable bladder scanner devices on a program to prevent catheter-associated urinary tract infections by minimizing indwelling catheterization.

Bonnie Westra, Kay Savik, Cristina Oancea, Lynn Choromanski, John Holmes, and Donna Bliss evaluated which support system characteristics and interventions predicted improvement in urinary and fecal incontinence in home health patients. You will want to read this article to gain insight into the proportion of patients seen by home health care nurses who experienced improvements in urinary or fecal incontinence, and to appreciate the complexity required to restore fecal or urinary incontinence in this complex and challenging population.

Susan Fletcher presents this issue's Challenges in Practice, a case study of an older man referred to the Veteran's Administration Preservation-Amputation Care and Treatment Service. You will want to read this article to gain insight into the possible role of combination therapy using compression and pulsed radio frequency energy for management of a nonhealing venous leg ulcer, and to enhance your insight into the potential for this type of patient service to preserve limbs from amputations and lives from a potentially mortal blow.

This issue's Getting Ready for Certification feature serves 2 purposes. It provides several questions, along with a discussion of the correct answer and distracters focusing on general principles of wound care. In addition, it provides an insider's perspective that is rich in practical advice on how to prepare for, and successfully survive the examination process.

Finally, I am pleased to report that this issue's Spotlight on Research by Lynn Eberly and Susan Telke is part 1 of a series of 6 Spotlights that will discuss how statistics are used to report research findings. You will want to read this article to gain a new perspective into the logical reasoning that statisticians use and how you as a clinician can gain insights into how research findings can meaningfully influence clinical practice.

Evidence from Other Publications

What is the real cost of healing a Stage IV pressure ulcer? Clinical experts frequently speculate on or estimate the answer, but a review of the literature reveals few studies that have directly measured the economic cost of these often catastrophic wounds. However, given its administrative classification as a "never condition", more precise knowledge of the true cost of healing a stage IV pressure ulcer is essential as WOC nurses seek justification for the cost of preventive interventions such as pressure redistribution surfaces and heel protection devices. In a recent issue of the American Journal of Surgery, Brem and colleagues2 reviewed the medical records of 19 patients with hospital acquired (n = 11) or community acquired (n = 8) stage IV pressure ulcers managed by a single university-based acute care facility. Far different from "estimated costs" or total costs (applied to all pressure ulcer stages), the investigators reported that the average cost of treating a stage IV ulcer was a whopping $129,248 for a hospital-acquired wound and $124,327 for a community-acquired pressure ulcer. While additional studies are needed to measure the average national costs, the findings of this study strongly suggest that the cost of a stage IV pressure ulcer is even higher than previous estimates and provide even more justification for shifting resources from treatment to a far more cost-effective and humane alternative: prevention.

In a recent issue of the Journal, Li and Rew3 reported on sexual problems and body image in women with colorectal cancer. As noted in this important review, sexual dysfunction affects both female and male colorectal cancer survivors. Unfortunately, research in this area is limited. In a recent issue of Sexual Medicine, Ellis and colleagues4 evaluated responses from 229 men who had undergone surgery for colorectal cancer. They found that that 75% have erectile dysfunction based on results of the International Index of Erectile Function, a validated instrument, and only 33% reported having sexual intercourse in the previous 6 months. The presence of an ostomy was identified as an independent risk factor for erectile dysfunction. The findings of this study serve as a sobering reminder that sexual dysfunction is prevalent among male survivors of colorectal cancer, and that we must address this with all of our patients if we wish to enable them to truly achieve a maximal recovery from this devastating disease.

Orthotopic neobladder surgery is an increasingly popular alternative for treating men with bladder cancer. While the majority of patients are able to empty their reconstructed bladders adequately via a combination of bolus contraction and abdominal straining, a minority cannot. Ji and colleagues5 reviewed the results of 231 patients who underwent construction of an orthotopic neobladder and found that 16% has clinically relevant urinary retention. Urodynamic evaluation revealed that the majority had bladder outlet obstruction, with anastomotic stricture being the most common. Relief of the obstruction using minimally invasive techniques enabled most to achieve adequate bladder emptying via spontaneous micturition, a primary goal of the surgery. Contrary to expectations, the results of this study suggest that most patients who experience clinically relevant urinary retention following construction of an orthotopic neobladder should undergo urodynamic testing to determine whether they have an obstructive lesion amenable to surgical manipulation. This finding is relevant to the WOC nurse because it provides a basis for referral of patients experiencing difficulty emptying their neobladders to a continence specialist rather than assuming that emptying difficulties are caused by the inability to generate sufficient intravesical pressures for spontaneous emptying, as was traditionally thought.

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