In This Issue of JWOCN

This issue of the Journal covers a variety of novel topics, including a description of the clinical and professional aspects of certified foot and nail care, and the first of a 3-article installment reviewing the pathophysiology, clinical manifestations, assessment, and management of common forms of moisture-associated skin damage. Added to this are cutting-edge articles focusing on benchmarking pressure ulcer prevalence and its impact on quality improvement policies in a local facility, clinical reliability of a wound measurement device, use of disposable absorbent products for fecal incontinence and you have all of the elements of a must-read issue of the premiere journal for wound, ostomy and continence nursing.

Annette Etnyre, Perla Zarate-Abbott, Laura Roehrick, and Sheri Farmer open this issue's Wound Care Section with a description of the evolving role that Certified Foot and Nail Care nurses play in promoting foot health and preventing potentially devastating outcomes such as amputation in high-risk persons. You will want to read this novel and valuable article to expand your knowledge of this emerging aspect of WOC nursing, and to learn more about certification in foot and nail care offered by the WOCNCB.

Sharon House, Tracey Giles, and John Whitcomb report a study of pressure ulcer prevalence and its impact on the prevention policies implemented in their local facility. This article qualifies as a must-read feature of this issue's Journal because it does more than simply report results of a national survey; rather, it describes how the benchmarking data established in this larger study influenced pressure ulcer prevention policies in their facility and has the potential to influence policies in your facility as well.

Despite its apparent clinical relevance, accurate measurement of wound size remains a significant clinical challenge, especially when the wound is irregularly shaped, or of variable depth. Catherine Hammond and Mark Nixon report on the reliability of a handheld device for measuring the surface area and depth of wounds. You will want to read this article to determine whether this device might be useful in your clinical practice.

WOC nurses are familiar with the damage to the skin associated with prolonged exposure to pressure and shear, vascular insufficiency, and peripheral neuropathies, but our awareness of the skin damage related to various forms of moisture continues to evolve. A consensus panel, including Joyce Black, Mona Beharestani, Donna Bliss, Janice Colwell, Margaret Goldberg, Karen Kennedy-Evans, Susan Logan, Catherine Ratliff, and others, reports the first of a series of 3 articles focusing on the etiology and pathophysiology of moisture-associated skin damage and its most common clinical manifestations. You will want to read this article to increase your knowledge of this clinically relevant cause of skin damage and its various clinical manifestations.

This issue's Ostomy Care Section opens with a report of a descriptive study of demographic and clinical characteristics of new ostomy patients in a level 1 trauma health system in the Midwestern United States written by Joyce Pittman. You will want to read this study report because it not only describes this robust patient population; it also compares these characteristics based on ostomy type, destination of the patient following hospital discharge, and pertinent demographic and clinical characteristics.

Mitsuko Kodama, Makoto Kume, Hideaki Miyazawa, Seiji Satoh, Yuzo Yamamoto, Tomoko Ito, and Yoshihiro Asanuma report on pigmentary changes in the peristomal skin of patients with advanced stage colorectal cancer undergoing chemotherapy using S-1. WOC nurses practicing in areas of the world who use this chemotherapeutic agent, which combines tegaful, gimestat, and potassium oxanate, will be especially interesting in this study that describes a common and distressing side effect of the chemotherapeutic agent.

This issue's Continence Care Section reports a study by Donna Bliss, Jaclyn Lewis, Keegan Hasselman, Kay Savik, Ann Lowry, and Robin Whitebird that describes use of absorbent products in community-dwelling persons with fecal incontinence. The article qualifies as a must read because it explores an area that has been largely unstudied until now, how do community patients adapt products principally designed for urinary incontinence to the management of fecal incontinence and how do they rank the strength and limitations of these products for managing this prevalent and devastating problem.

Amy Clegg, Thresa Brown, Dawn Engels, Phyllis Griffin, and David Simonds summarize their experiences adapting a telemedicine technology designed for critical care to remote wound care consultations. You will want to read this cutting-edge Clinical Challenges feature article to appreciate how they adapted this real-time telemedicine technology to remote wound care consultations and to gain ideas as to how you might incorporate similar technology into your practice.

Every WOC nurse or RN candidate for a WOCNCB examination will want to read Donna Thompson's tips on preparing for, and surviving, a certification or recertification examination. Combined with the practice questions and answers provided in this popular and valuable feature of the Journal, this issue's Getting Ready for Certification provides an essential resource for any nurse who faces the need for certification. You will also want to go online at http://journals.lww.com/jwocnonline/pages/default.aspx to review previous Getting Ready Certification features under the "Collections" tab that provide a rich source for review questions as well as a number of features available only to subscribers to the Journal of Wound, Ostomy and Continence Nursing.

Your WOC Nurse Consult focuses on a case of a woman with painful, necrotic wounds of the lower extremities. You will want to read this feature from Wound Care Section Editor Dorothy Doughty to sharpen your critical thinking skills as you diagnose the etiology of these wounds and consider options in management.

This issue's Research Spotlight feature contains the third in a series of 6 articles focusing on statistical analysis. Susan Telke and Lynn Eberly explain how statisticians establish associations between 2 variables or among multiple variables. You will want to read this valuable article to understand what is meant by a statistical association and how this relationship differs from cause and effect.

Evidence From Other Publications

Earlier I described this issue's Clinical Challenges article that summarized the authors' experiences with adoption of a real-time telemedicine technology for remote wound care consultations. In a recent issue of Wound Repair and Regeneration, Bowling and colleagues1 measured intra- and interrater reliability of an asynchronous telemedicine technique for remote assessment of diabetic foot ulcers. The technology generates a 3-dimensional, color calibrated image of a diabetic foot ulcer, and the periwound skin that can be manipulated to allow comprehensive visual inspection and measurement. Reliability was initially evaluated by asking 5 clinicians to evaluate 3 different wounds. The researchers then asked 2 clinicians to evaluate 20 diabetic foot ulcers from 2 wound care centers; this assessment included an evaluation of wound and periwound characteristics such as slough or necrotic tissue, evidence of infection or gangrene of the ulcer. Similar to the experiences of Clegg, Brown, Engels, Griffin, and Simonds, Bowling's group found that telemedicine technology provides an accurate assessment that is comparable to results obtained from direct consultation. The experiences of both groups strongly suggest that telemedicine technology has advanced to the point that it provides a cost efficient and effective alternative for remote assessment and management of chronic wounds.

Ostomy Care

Low anterior resection for colorectal cancer is preferred whenever feasible because it has the potential to avoid creation of a permanent intestinal ostomy. However, WOC nurses also recognize that this surgical approach must be employed in carefully selected patients and that some who undergo low anterior resection will ultimately require a permanent ostomy. Lindgreen and coinvestigators2 reported long-term follow-up of a multisite randomized controlled trial that originally enrolled 234 patients undergoing low anterior resection. Subjects were randomly allocated to low anterior resection with a defunctioning stoma (n = 116) or resection with no defunctioning stoma (n = 118). The median period of observation for these patients was 72 months (range, 42-108 months), providing a reasonable overview of long-term results. Patients who were randomly allocated to a no defunctioning stoma had a higher likelihood of ultimately requiring a permanent ostomy than did subjects who had a defunctioning stoma, but the difference was not statistically significant. Nineteen percent of patients underwent creation of a permanent ostomy, including 20 who received a loop ileostomy and 25 who underwent surgery for an end sigmoid colostomy. The main outcomes leading to creation of a permanent ostomy were unsatisfactory anorectal function, metastatic disease, or deterioration in the patient's general health and functional status. The likelihood of a permanent ostomy among patients with symptomatic anastomotic leaks was 56%, as compared to 11% in patients with asymptomatic leaks (P < .01). Age also acted as an independent predictor of a permanent ostomy. The results of this study suggest that the likelihood of requiring a permanent ostomy is significant among patients initially managed by low anterior resection, especially when the patient is older and experiences a symptomatic anastomotic leak.

Continence Care

WOC nurses have long been aware of the possible link between physical or sexual abuse, physical or emotional trauma, and bowel elimination symptoms or disorders. While I typically limit this section to reports of original data or a systematic review of current evidence, I include this integrative summary of current knowledge about functional gastrointestinal disorders and sexual or physical trauma or abuse written by Drossman.3 The author identifies multiple studies (including his own research) that found a strong association between sexual or physical abuse and functional gastrointestinal disorders such as irritable bowel syndrome and pelvic pain. In addition, he discusses our evolving understanding of the pathophysiological connections between abuse or trauma and gastrointestinal function, which proposes that a variety of genetic, environmental, and physical factors influence an individual's subsequent risk for functional disorders of the bowel. He notes that abuse is hypothesized to amplify the impact of the severity and experience of these symptoms resulting in adverse outcomes reflected in psychosocial measures such as symptom bother and physical outcomes such as increased microscopic and inflammation of the bowel. This article is also useful for WOC nursing practice because it provides practical advice concerning who should be screened for a history of abuse, and pointers for obtaining a referral to an appropriate mental health provider.

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