In This Issue of JWOCN

The first issue of 2012 blends clinical articles with reports of original research and syntheses of existing evidence that you have come to expect from the Journal of Wound, Ostomy and Continence Nursing. This issue's Wound Care section opens with a study focusing on development and validation of an online wound care algorithm program. This article by Janice M. Beitz and Lia van Rijswijk qualifies as must read for any WOC nurse interested in the proper use of an algorithm for clinical decision making, or questioning the potential for interactive online educational programming in the clearly underserved area of wound care.

WOC nurses have long been advocates of evidence-based care. Nevertheless, despite frequent use of the terms "evidence" and "evidence-based practice," our understanding of their precise meaning and their application to clinical practice continues to evolve. Lia van Rijswijk and colleague summarize key concepts of evidence and evidence-based practice, including efficacy, effectiveness, safety, and cost. You will want to read this article to both review your understanding of evidence-based practice and update your knowledge of the concept of comparative effectiveness research and its contribution to clinical decision making in wound care practice in the 21st century.

This issue's WOC Consult also focuses on wound care. Phyllis Bonham, an internationally recognized expert on lower extremity arterial disease (LEAD), provides a concise and cogent description of the use of ankle brachial index testing and calculation for evaluation of LEAD. Her discussion of this clinically relevant discussion qualifies as must read because it reminds us of the essential elements of a valid and reliable assessment of the ankle brachial index based on selection of proper equipment as well as proper preparation of the both the patient and immediate environment.

What defines an ostomy as temporary? What percentage of ostomies originally created as temporary, ultimately wind up as permanent? What is the optimal time period between creation of a temporary ostomy and its reversal? Claire Taylor and Sarah Varma address these questions in an article that combines a literature review examining time to closure of temporary ostomies, and the incidence and reasons for delayed closure with original data of a group of 27 patients who underwent closure of a temporary ostomy.

In 2007, the Journal published what is now one of the most widely cited articles on the topic of incontinence-associated dermatitis.1 While our knowledge of the etiology, epidemiology, and pathophysiology of this common form of moisture-associated skin damage is modest, and evidence for its prevention and treatment is limited, both have expanded significantly within the past decade. This issue's Continence Care section opens with an updated, comprehensive review of incontinence-associated dermatitis by a Consensus Panel that includes Dimitri Beeckman, Donna Bliss, Mandy Fader, Susan Logan, Joan Junkin, Joan Selekof, Dorothy Doughty, and others. This article qualifies as must-read information for every WOC nurse who manages patients with urinary or fecal incontinence.

Caring for a patient with a long-term indwelling catheter presents multiple challenges, including selection and maintenance of the urinary drainage bag, for the WOC nurse. Joan Ostaszkiewicz and Jan Paterson report results of a survey of continence nurses about advice given to patients about use and cleaning of urinary drainage bags. You will want to read the results of this article to gain greater knowledge of similarities and differences in advice given by continence nurse colleagues in Australia, Western Europe, and North America when counseling patients with long-term indwelling urinary catheters.

Tulay Basak, Senay Uzun, and Filiz Arslan evaluated incontinence characteristics, quality of life, and risk factors in a group of women attending a urology outpatient clinic in Ankara, Turkey. You will want to read this article to gain further insights into the relationship between urinary incontinence and quality of life in women and to compare incontinence type and risk factors in community-dwelling Turkish women to women experiencing incontinence in your practice.

Maria Helena Baena de Moraes Lopes, Rosangela Higa, Silvia Nogueira Cordeiro, Nuri Aparecida Rodrigues Estape, Carlos Arturo Levi D'Ancona, and Egberto Ribeiro Turato report a study of life experiences in Brazilian men with urinary incontinence and erectile dysfunction following radical prostatectomy. You will want to read this study to gain further insight into the profound impact of these disorders on men's perceptions of masculinity and self-esteem.

Have you ever wondered what is really meant by the term "validated instrument?" Continence Section editor Sandra Engberg and co-author Lut Berben describe the processes used to demonstrate the most common forms of reliability and validity used by nurse researchers. You will want to read this valuable resource to both demystify common misconceptions about the true meaning of the term "valid instrument" and update your understanding of this ongoing process when applied to the use of standardized instruments in daily clinical practice or the research setting.

In this issue's "Getting Ready for Certification" update, Diana Gallagher and Donna Thompson provide a succinct description of the WOC certification examination's coverage of fecal incontinence along with 3 practice questions. You will want to read this valuable feature to both update your knowledge of fecal incontinence identification and management and remind yourself that we are truly all continence nurses, just as we are all ostomy and wound care nurses. In addition, you will want to go online at http://journals.lww.com/jwocnonline/pages/default.aspx to view the entire collection of Getting Ready for Certification features written by WOCNCB Board members and collected by Web page section editor, Lee Ann Krapfl.

Necrotizing fasciitis is a devastating, and all too often deadly, infection that requires multidisciplinary care including close supervision by wound care nurses. In this issue's Challenges in Practice feature, Elizabeth Geiger Jones and Ahmed El-Zawahry describe 3 cases of men with Fournier's gangrene (necrotizing fasciitis involving the genitalia and perineal area) who were managed with initial surgical debridement followed by negative pressure wound therapy using a vacuum-assisted closure device. You will want to carefully review this article to gain more insight about the progression of these cases and judge the probable impact of negative pressure wound therapy to their management.

Evidence From Other Publications

Wound Care

This issue's WOC Consultation serves as a timely reminder to every wound care nurse that management of lower extremity ulcers involves more than topical management of local factors; it also requires identification and management of systemic factors that increase risk for such ulcerations. Multiple factors are suspected to increase the risk for LEAD, including chronically low levels of the thyroid hormones. Hypothyroidism has been shown to contribute to stiffening of the arterial wall over time, but its effect on the pathogenesis of peripheral arterial disease remains unclear. In a recent issue of Vascular Health and Risk Management, Mazzeffi and colleagues2 report a retrospective case-control study of 614 cases and 529 controls to determine the relationship between hypothyroidism and LEAD. As anticipated, subjects with LEAD had higher incidences of diabetes mellitus, dyslipidemia, hypertension, and ischemic heart disease when compared to controls. However, analysis of all cases and controls revealed no statistically significant relationship between hypothyroidism and an increased risk for LEAD (unadjusted odds ratio [OR], 0.88; 95% confidence interval [CI], 0.61-1.28). Nevertheless, additional analysis that incorporated the effect of gender found surprisingly different results. In men, hypothyroidism was found to act as an independent risk factor for LEAD (adjusted OR, 2.65; 95% CI, 1.19-5.89). Even more surprising, hypothyroidism appeared to act as a protective factor in women (adjusted OR, 0.22; 95% CI, 0.11-0.46). While these findings are provocative, they are based on retrospective data and a prospective study is needed to confirm the effect of hypothyroidism on both women and men at risk for LEAD. Nevertheless, these results clearly demonstrate the need for additional research. In the meanwhile, identification and proper treatment of hypothyroidism in patients with LEAD and lower extremity ulcers are indicated.

Ostomy

Peristomal skin problems are prevalent among persons with ostomies, and their prevention and treatment are a cornerstone of WOC nursing care. Despite the prevalence of these problems, few valid instruments have been developed to assess the severity of peristomal skin problems. Jemec and colleagues3 describe a study that assessed interrater reliability of the Ostomy Skin Tool (OST). The OST is based on assessment of 3 components of the peristomal skin, discoloration, erosion, and tissue overgrowth. The instrument requires the clinician to evaluate the area of affected skin (ranked on a scale of 0-3) and the severity of the skin damage (ranked on a scale of 0-2). Jemec's group presented 30 photographs to 20 ostomy nurses in order to determine intranurse and internurse reliability using the OST. Weighted [kappa] coefficients found a high intranurse agreement (0.84) and moderate agreement between nurses (weighted [kappa] coefficient, 0.54-0.70). While additional validation studies are needed to determine whether the OST is sufficiently valid and reliable for widespread use in the research or clinical setting, this study provides valuable data needed to characterize the OST as a "validated instrument." (Readers who want to learn more about the process of establishing validity and reliability of instruments should read this month's Research Spotlight authored by Continence Section editor Sandie Engberg and Lut Berben.)

Continence

Clinical experience strongly suggests that postoperative urinary retention is one of the most common causes of prolonged indwelling catheterization in the acute care setting. Despite its clinical relevance, little is known about risk factors for postoperative urinary retention. Hansen and colleagues4 evaluated factors associated with urinary retention via bladder ultrasound in 773 consecutive patients who underwent surgery during a 5-month period. Urinary retention was operationally defined as inability to void within 1 hour despite documented presence of 400 mL or more in the bladder. Subjects underwent a variety of surgical procedures including orthopedic, abdominal, gynecologic, and plastic surgeries; those classified as undergoing "major" abdominal surgeries (including urological procedures) and those requiring postoperative epidural pain management were excluded. Data were collected in the postanesthesia care unit immediately following surgery. The incidence of postoperative urinary retention was found to be 13%; factors associated with an increased likelihood of urinary retention were failure of voiding before entering the surgical suite, use of regional anesthesia, anesthetic time more than 2 hours, and emergency surgery. While these findings are interesting, the relatively low incidence of urinary retention (13%) is especially suggestive because it supports our evolving knowledge that the risk of retention following surgery may be less than traditionally believed. Additional research is essential before firm conclusions can be drawn, but these findings also suggest that indwelling catheterization may be necessary in a more selected patient population than traditionally identified.

References