In This Issue of JWOCN
TOPICAL SILVER PREPARATIONS AND WOUND HEALING
This issue's CE article is a review of current knowledge of topical wound care products containing silver. Nancy Tomaselli provides a comprehensive and analytical review of the growing variety of products that contain silver and research-based insights into their role in wound management. Her article provides a primer for the novice clinician and a state-of-the-science review for the experienced clinician interested in wound care products containing silver. For the expert clinician, Nancy's critical observations about the concept of bacterial bioburden are particularly enlightening. Origins of this concept appear in the wound literature in the mid-1960s, when Bendy and coworkers1 and Robson and coworkers2 noted that increased bacterial colonization impeded wound healing, even when quantitative colony counts were less than 105 colony forming units (CFU)/mL. Nancy Tomaselli observes that indolent wounds are often found to have evidence of bacterial colonization but absence of signs of clinically apparent infection or quantitative colony counts exceeding 105 CFU/mL. Products containing silver are particularly attractive for this clinical scenario because they can reduce bacterial colonization without the potential adverse side effects associated with systemic antimicrobial therapy. Nevertheless, as Nancy points out, objective or widely accepted clinical criteria for diagnosing clinically bacterial bioburden in a wound remain elusive. In addition, the precise mechanisms that arrest or slow wound healing when bacterial colonization reaches a critical mass remain unknown; is it the production of toxins, a direct action of bacterial growth and reproduction, or a combination of these factors?
CONTINUOUS LATERAL ROTATION THERAPY
Patricia Turpin and Valerie Pemberton report on a pilot study of critically ill but stable patients placed on continuous lateral rotation therapy (CLRT). They compared tissue interface pressures among 6 subjects receiving CLRT alone with interface pressures for the same subjects receiving CLRT plus repositioning using pillows. Not only did the addition of pillows raise tissue interface pressures when assessed qualitatively using pressure mapping, but the authors also hypothesized that repositioning may increase shear in certain patients and reduce the pulmonary benefits that CLRT is principally designed to provide. Although the results of this preliminary study must be replicated in a larger trial with quantitative and reproducible results before they can be verified, they remain an important reminder that we must question all aspects of our care, and particularly those intuitive actions such as repositioning to maximize comfort or reduce pressure ulcer risk to first ensure we do no harm.
DIABETIC FOOT CARE
This issue features 2 Clinical Challenges focusing on the management of diabetic foot. In the first Clinical Challenge, Karen Wood-Belford presents an alternative method for pressure off-loading in the case of a patient with a diabetic foot ulcer and Charcot foot deformity. In this case, the author used soft casting to off-load pressure rather than total contact casting, acknowledged as typical first-line treatment. She presents clearly the rationale for her treatment, as well as the outcomes of her case. In her follow-up remarks, Myra Varnado (certified as a diabetes educator [CDE] and wound, ostomy and continence nurse [WOCN]) reviews principles of managing Charcot foot deformities, including the critical need to off-load pressure to heal both ulcers and the structure of the foot itself. In the second Clinical Challenge, Cindy Kiely describes the difficulties and presents strategies for imparting knowledge to persons with diabetes about routine foot care and enabling them to translate these strategies into behavioral changes. The results of a Cochrane review elegantly illustrate the 2-tier challenge that Cindy describes; the authors note that although the 9 randomized clinical trials included in their systematic review clearly demonstrate that the participants increased knowledge about diabetic foot care after education, only weak evidence exists to support the conclusion that this knowledge provokes patients to change their behaviors and reduce the risk for foot ulceration or amputation. In her commentary to this feature, Lea Crestodina advocates that WOC nurses expand both their knowledge and expertise in this area of management to incorporate not only the management of existing ulcers, but also primary and secondary prevention strategies.
In addition to these discussions, this issue's Evidence Based Report Card focuses on the efficacy of total-contact casting for pressure off-loading among patients with diabetic foot ulcers.
CONTINENCE EDUCATION BROCHURE AS A THERAPEUTIC INTERVENTION
Bev O'Connell, David Wellman, Linda Baker, and Keren Day report on a study of the impact of a continence promotion brochure in a group of 631 patients in rural Australia. Similar to Kiely, they were interested in determining whether a simple educational tool led to behavioral actions designed to promote continence. When interviewed by telephone 2 to 3 months after being given the brochure, 44% of the patients reported that they had engaged in behaviors to improve their continence as a direct result of reviewing the brochure, such as seeking care from a physician or implementing simple behavioral interventions described in the pamphlet. Over the years, I have been both gratified and amused when researchers and pharmaceutical manufacturers alike were astounded that the simple act of completing a bladder log resulted in an improvement in lower urinary tract symptoms in as many as 40% of participants. Despite its limitations, patient education about continence, diabetic foot care, or ostomy management remains a powerful and effective intervention when wielded by a caring and expert nurse.
URINE DIPSTICK/PAD METHOD
In the last issue of the Journal, Susan Midthun and A. Wayne Bruce reported on a urine dipstick/pad method for the diagnosis of urinary tract infection in incontinent elderly adults. This technique is potentially relevant because of the considerable difficulty obtaining a clean catch urine specimen from frail elders with significant urinary incontinence (UI). In this issue, Susan Midthun, Ruth Paur, and A. Wayne Bruce follow-up with 2 reports. The first provides a protocol for completing the procedure, and the second reports on a survey regarding use of the method sent to nurses, geriatricians, family practice, and internal medicine physicians. Ninety-five percent of respondents stated that they would consider using the dipstick/pad method described, particularly to determine whether further testing is warranted.
Evidence From Other Publications
WOUND CARE
In a recent issue of Lancet, Armstrong and Lavery3 reported results of a multicenter randomized clinical trial comparing negative wound pressure using the Vacuum Assisted Closure (VAC) device (KCI, San Antonio, TX) to standard care, defined as moist topical therapy using alginates, foam dressings, hydrogels, or hydrocolloids. Pressure off-loading, using a pressure-relieving walker or sandal, was provided for subjects in both groups. One hundred sixty-two subjects from 18 facilities in the United States were enrolled who underwent partial amputations of one foot, up to the transmetatarsal level. After 16 weeks, amputation wounds treated with VAC device had a greater rate of granulation tissue formation and were more likely to heal than were wounds treated with standard therapy. The occurrence of adverse events was similar for both groups. Negative pressure wound therapy has long suffered from a paucity of evidence, and available studies have been plagued by high dropout rates and significant methodological issues. Although the findings of this study could be strengthened by replication, I find it particularly important because it provides evidence supporting application of the VAC device to postamputation wounds in a reasonably designed randomized clinical trial, rather than the anecdotal studies, case reports, or case series that are too often used to argue for efficacy or differentiate one negative pressure wound therapy approach from another.
OSTOMY CARE
Notter and Burnard4 reported on the lived experiences of women with inflammatory bowel disease undergoing loop ileostomy in preparation for restorative proctocolectomy. Fifty women participated in the research, which employed a qualitative methodology (descriptive phenomenology) to describe their lived experiences during the immediate postoperative period. Even though these women had experienced significant morbidity associated with their irritable bowel disease, they nevertheless saw ileostomy surgery as a pivotal point in their lives. Specifically, it was perceived as a significantly traumatic event, and it provoked a sense of irreversible loss among patients fully recovering from their bowel disease. Adjusting to the needs of the temporary ileostomy and permanent reconstructed rectal pouch was seen as a traumatic event that provoked considerable emotional and physical challenges, including pain, a negative impact on body image, and an often devastating perception of the self as a sexual being. As with many phenomenological studies, Notter and Burnard's report reinforces the significant gap between how clinicians perceive and interpret a major healthcare encounter (undergoing reconstructive surgery for inflammatory bowel disease) and how our patients experience and interpret that experience. Although we see our role as preserving the anal sphincter and fecal elimination while avoiding permanent diversion, these patients perceived the surgery as a final admission that a cure is not possible and a traumatic experience associated with pain, management problems related to the temporary ileostomy, and permanent reconstructed bowel. This difference is more than superficial; instead, it is essential for us as WOC nurses to understand and incorporate this information into our practice as more and more patients with inflammatory bowel disease undergo this profound reconstructive surgical procedure and learn to live with the physical and psychological consequences it produces.
CONTINENCE CARE
Although the past decade has led to significant strides in the treatment options for erectile function in men; we are just now beginning to scratch the surface of the pathophysiology and treatment of sexual dysfunction in women. In the January 2006 issue of International Urogynecology Journal, Ozel and colleagues5 compared libido, self-reported excitement during intercourse, and ability to achieve an orgasm in incontinent women with and without pelvic organ prolapse. Women with UI and pelvic organ prolapse were more likely to report poor libido, lack of excitement during intercourse, and absence of orgasm during intercourse than were women with UI alone. Although the results of this study do not reveal how we might alleviate sexual dysfunction among women with pelvic organ prolapse, it remains an important advancement simply because it addresses issues of sexual function in older women. Sexual function remains an essential but often silent need that affects all of our patients. After years of misinformation and myth, it is refreshing and enlightening to see a small but growing group of clinicians publishing meaningful and scientifically rigorous research focusing on sexual function in women.
References