INTRODUCTION

As a CWOCN, I am often consulted to see individuals with pressure injuries located over the sacral or ischial regions; an essential component of these visits is education on the need to prevent fecal contamination within the wound and maintain wound closure after flap surgery. While fecal diversion via a colostomy is typically advocated, I have observed that patients often ask if there are any other options for neurogenic bowel management.

Shared decision-making (SDM) is a process that enables patient to participate actively in health care decisions rather than exclusively relying on the judgment of the health care provider.1 This SDM process is based on knowledge of all evidence-based treatment options, and it must incorporate patients' values and preferences. Advocating for SDM is based on the ethical principle that individuals have a right to be involved in decisions about their health and that health care providers have a duty to inform them of all reasonable treatment options. This View From Here describes my experiences with a patient with quadriplegia and neurogenic bowel dysfunction (NBD) who desired an alternative to fecal diversion after experiencing a full-thickness pressure injury.

I was consulted on a 50-year-old female patient who sustained a C7 spinal cord injury during a motor vehicle accident, resulting in quadriplegia (spastic paralysis of lower extremities and limited movement of her upper extremities). She developed a stage 4 left ischial pressure injury that had been present for approximately 2 years when I became involved in her case. Her medical history was also significant for osteoporosis, chronic pain syndrome, constipation, and degenerative joint disease. Her body mass index was 21. She did not smoke. Bladder management at that time was intermittent catheterizations at least 4 times daily, with volumes averaging 300 to 400 mL; catheterization was provided by home-based care assistants. She denied fever or chills, pain at the pressure injury site, as well as nausea, vomiting, or headaches. Recent imaging did not show any signs of osteomyelitis of the left ischium. She stated that she was meticulous about wound care and pressure off-loading. She had an electric wheelchair with a pressure redistributing wheelchair cushion. She also had an air-fluidized bed at home. She reported being in bed 14 hours a day and only sitting to go to medical appointments.

A fecal diversion with a colostomy was recommended prior to flap surgery to close the pressure injury. She voiced understanding of the need for preventing fecal contamination of her flap and recurrent pressure injuries secondary to local irritation and maceration of the skin. Nevertheless, she adamantly declined colostomy surgery and asked about alternative means to divert her fecal stream.

NEUROGENIC BOWEL DYSFUNCTION

Neurogenic bowel dysfunction occurs in approximately 80% of persons with spinal cord injuries.2 Clinical manifestations include constipation and fecal incontinence, sometimes accompanied by abdominal pain. First-line bowel management is diet and fluid management, maximizing physical activity, regular administration of stimulants and/or stool softeners, a scheduled bowel regimen, and use of rectal evacuation methods. Transanal or rectal irrigation is a second-line bowel management technique that offers a possible alternative to fecal diversion. Research indicates that routine use of transanal irrigation (TAI) is associated with less constipation, less fecal incontinence, and improved health-related quality of life among patients refractory to primary management techniques.3 Several commercially available systems may be used to facilitate irrigation and, unlike surgical options, irrigation does not require surgical reconstruction and can be initiated or discontinued at any time.4

Following extensive discussion about options for fecal management, this patient elected to use TAI for bowel management. After switching to TAI, the left ischial pressure injury closed without flap surgery and she continues to use TAI.

SHARED DECISION-MAKING AND WOC CARE

Whether your practice primarily focuses on caring for patients with WOC or foot and nail care disorders, SDM within an interdisciplinary care team should be a key element of your skill set. Your role in facilitating SDM includes encouraging patients to ask what are all their options for treatment? What are the possible benefits and harms of those options? and How are each of those benefits and harms likely to happen to them?5

As a CWOCN, I knew it was my responsibility to discuss bowel management options for all patients with sacral area pressure who do not desire to undergo fecal diversion. In this case, I further concluded that I needed to support this patient in her decision-making process, even if it not the treatment option I would initially present. Shared decision-making is not based on rigid adherence to guidelines or tradition; instead, it must incorporate the needs of each individual, current best practices, and ongoing evaluation of individual patient outcomes. In addition, SDM principles recognize that a patient's decision may change with time. For example, this patient has developed a second ischial pressure injury on the right and SDM involves revisiting the option of fecal diversion, along with continuation of TAI. By partnering with each health care consumer and collaborating with other health care providers, WOC nurses like myself are able to individualize care and optimize the individual's outcomes.

REFERENCES