In This Issue of JWOCN

This issue includes several articles that address persistent and clinically relevant gaps in our evidence, while several others illuminate persistent but largely unacknowledged evidentiary gaps. This combination of novel evidence mixed with sober assessments of knowledge deficits renders the entire issue a must read for every WOC nurse. Dimitri Beeckman, Tom DeFloor, Lisette Schoonhoven, and Katrien Vanderwee open this issue's Wound Care section with their study comparing a premoistened disposable washcloth that combines a no-rinse cleanser, moisturizing agents, and dimethicone-based skin protectant to the standard skin care regimen for Belgian nursing home residents (washing with a pH neutral soap and water). This randomized controlled trial easily qualifies as must read because it provides long overdue evidence concerning a persistent and controversial question about defined skin care regimens: is a 1-step skin care regimen using a premoistened cloth as effective as soap and water for preventing and treating incontinence-associated dermatitis?

Mary Mahoney, Barbara Rozenboom, Dorothy Doughty, and Hayden Smith report results of a survey that uncovers an underreported gap in our knowledge base. They asked WOC nurses to identify the etiology of 9 wounds as primarily caused by moisture, pressure, or a skin tear. The answers they found are both surprising and provocative. Read on to find out what they have to say and to explore steps to resolve this persistent issue.

Viviane Fernandes de Carvalho, Andre Oliveira Paggiaro, Cesar Issac, Julio Gringlas, and Marcus Castro Ferreira compared 3 different topical management strategies, saline-soaked rayon gauze dressings, transparent, polyurethane thin-film dressings, and bovine collagen calcium alginate dressings covered by a thin-film dressing in 34 burn patients with partial-thickness skin grafts. This article qualifies as must-read because it enhances the evidence concerning the effect of each of these approaches to topical therapy on reepithelialization following creation of a partial-thickness skin graft and the associated pain these patients so often experience.

Carolyn Crumley reports results of her doctor of nursing practice capstone project that evaluated a patient education intervention based on the Health Belief Model for management of post-thrombotic syndrome. This article is a must read for any WOC nurse who faces the challenge of encouraging adherence to what may be the most important preventive measures for preventing complications of deep vein thrombosis of the lower extremity, regular use of elastic graduated compression stockings.

Suspected deep tissue injury is an important new category in the revised pressure ulcer staging system promulgated by the National Pressure Advisory Panel in 2007. Leanne Richbourg, June Smith, and Susan Dunzweiler report the results of a prospective, observational study of 37 subjects with 42 suspected deep tissue injuries managed by participating members of the North Carolina WOC Nurse's Group. You will want to read this article both to increase your knowledge of the clinical manifestations and varying trajectories of suspected deep tissue injuries and to enhance your appreciation of the significant gaps in our understanding of this new and understudied category of pressure ulcers.

This issue's Continence Care section focuses on cultural aspects of continence care and includes articles that explore help-seeking behaviors in Korean American women, and responses to urinary incontinence following radical prostatectomy in Brazilian men. Youngmi Kang, Linda Phillips, and Kyunghee Lim report a cross-sectional study of 149 Korean American women living in the Southwestern United States. You will want to read this article to increase your knowledge of the impact of cultural factors on continence-seeking behaviors in this group of minority women. Maria Lopes, Rosangela Higa, Silvia Cordeiro, Nuri Estape, Carlos Ancona, and Egberto Turato report life experiences of Brazilian men with urinary incontinence and erectile dysfunction following radical prostatectomy. You will want to read this article in order to better understand how the combination of urinary incontinence and erectile dysfunction creates conflicts related to perceptions of masculinity and self-worth.

In this issue's Challenges in Practice, Catherine Milne, Darlene Saucier, Chenel Trevellini, and Juliet Smith report their experiences managing 11 patients with peristomal skin damage with topical cyanoacrylate. You will want to read this innovative approach to managing this difficult and prevalent complication of fecal and urinary ostomies, peristomal moisture-associated skin damage resulting in erythema, erosion, exudates, and poor adherence of the skin barrier wafer.

Knowledge is a key ingredient for success with any licensure or certification examination, including those offered by the WOCNCB. However, we must also acknowledge the significant role that test-taking skills and controlled anxiety play during this distressing process. In this issue's Getting Ready for Certification feature, Heidi Cross, Bonnie Hermesman, and June Smith describe the RACE technique for test taking. Do you incorporate this technique in your preparation for your certification examination? Are you aware of what the acronym RACE represents? Read this informative feature of your Journal and find out!

This issue's Research Spotlight completes a 6-article series focusing on statistical analysis of research findings that comprise the evidence base for WOC nursing written by professional statisticians Susan Telke and Lynn Eberly. You will want to read their informative and highly useful description of the roles that the Kaplan-Meier curve, hazard ratio, and Cox proportional hazard ratio play in clinical research supporting WOC nursing practice and to truly find out what is meant by survival when it is applied to an outcome rather than mortality.

Evidence From Other Publications

Wound Care

Venous leg ulcers present multiple challenges to the wound care specialist, including difficulties ensuring healing and the high risk for recurrence. Abbade and colleagues1 report a descriptive study of 90 patients with venous leg ulcers affecting 103 lower extremities. Most were female (68.9%) and Caucasian (84.4%); their mean age was 56 years. Age >= 60 years (OR 4.0, 95% CI: 1.1-16.3) and lipodermatosclerosis (OR 8.7, 95% CI: 1.8-41.1) were associated with an increased risk for poor healing. However, the factor with the strongest association with poor healing, by far, was a history of a previous venous leg ulcer (OR 19.9, 95% CI: 2.68-858.8). Factors associated with an increased risk for recurrent venous leg ulcers included time since the previous venous leg occurred and severity of underlying venous incompetence. While the large confidence intervals noted above indicate the clinically relevant imprecision in measurement in this comparatively small sample group; results strongly suggest that underlying chronic venous disease renders patients at very high risk for development of venous leg ulcers that heal slowly and are likely to recur. These findings reinforce the need for an aggressive prevention program including appropriate compression therapy coordinated by a WOC nurse.

Ostomy Care

Despite advances in radiation and chemotherapy, radical cystectomy with urinary diversion remains the cornerstone of treatment for patients with invasive bladder cancer. Significant short-term complications, including mortality, occur with this complex procedure, especially in adults aged 80 years and over.2 However, less is known about the long-term complications (5 years or greater following surgery) experienced by this population. Shimko and coinvestigators3 retrospectively reviewed the records of 1057 patients with invasive bladder cancer treated with radical cystectomy and creation of an ileal or colonic conduit over an 18-year period. Eight hundred forty-four (79%) died at a median of 4.1 years following surgery. The median follow-up for the remaining 213 patients as 15.5 years; this cohort included 97 patients who survived more than 20 years after ostomy creation. Physical complications included bowel obstruction in 20.3% (7% required surgical repair). In addition, 19% developed renal insufficiency (defined as a serum creatinine > 2.0 mg/dL or 20 g/L) and 12% developed pyelonephritis. Stomal complications were reported in 15.4%; the most common were parastomal hernia in 13.9% and stomal stenosis in 2.1%. The incidence of peristomal skin complications was not reported. While data from such retrospective reviews must be viewed with considerable caution, these findings suggest that a significant number of patients who undergo radical cystectomy with creation of a permanent ileal or colonic conduit will survive for more than 5 years. These patients are at risk for a variety of long-term complications that impact the stoma, the conduit, and the ureteral-conduit anastomoses. Both the frequency and nature of these complications provide compelling evidence that patients living with ostomies should remain under the care of a certified WOC nurse.

Continence Care

Bariatric patients are well known to WOC nurses because of their skin care and continence needs. A variety of aggressive treatments are increasingly used to manage morbid obesity, including a growing number of bariatric surgical techniques. In a 2010 study, Roberson and colleagues4 reported a cross-sectional survey of 404 adults managed by bariatric surgery. They queried the presence of both fecal and urinary incontinence prior to and following bariatric surgery. Urinary incontinence was extremely prevalent among women (72%), but 39% reported significant improvement in their continence following surgery and weight loss. In contrast, the reported prevalence of urinary incontinence among men was 21%, less than among female bariatric patients, but far more than reported prevalence rates in the general population (2%-11%).5 A significant proportion of both women and men reported fecal incontinence. Nearly half of the female (48%) and 42% of male respondents reported incontinence associated with liquid stools. In addition, 30% of men and 21% of women reported incontinence of formed stools. Unlike urinary incontinence, fecal soiling tended to get worse following bariatric surgery. The findings of this study are significant for WOC nursing because they dramatically reinforce what daily practice already suggests, morbid obesity is a powerful risk factor for urinary and fecal incontinence. Although additional research is needed before definitive conclusions can be drawn, this study also suggests that bariatric surgery tends to alleviate the perceived frequency and severity of urinary incontinence while paradoxically exacerbating the perceived frequency and severity of fecal incontinence, especially when the person experiences diarrhea.

References