In This Issue of JWOCN
This issue of the Journal focuses on urinary incontinence management. Barbara Resnick, Linda Keilman, Barbara Calabrese, Patricia Parmelee, and colleagues studied the beliefs of nursing home-based nursing assistants and nursing directors about urinary incontinence management. The results of this study are particularly valuable to WOC nursing practice because they provide insight into the beliefs and perceptions of these groups that, in certain important aspects, vary from existing evidence. Increasing our understanding of nursing home staffs' attitudes toward and beliefs about incontinence management has gained new significance with implementation of the revised Center for Medicare and Medicaid Services F-Tag 315.
Dot Smith skillfully reviews existing evidence concerning urinary incontinence among patients with diabetes mellitus. In such patients, UI rates are elevated, but our understanding of the association between these two disorders remains limited. In addition to these insights, Dot points out important and often overlooked parallels and contrasts between these two chronic conditions that affect a growing number of Americans.
Finally, Joan Ostaszkiewicz describes a program designed to improve continence management in the acute care facility and following discharge. Clinical nursing leaders were mentored in a program designed to enable staff nurses to provide highest quality clinical support to patients and staff related to incontinence management, a novel method for managing bowel elimination and a framework for improved discharge care for patients with incontinence. Joan also provides evidence that practice changes were sustained over a period of 2 years, despite the gradual withdrawal of the project leader. The results of this report are valuable, regardless of whether your practice focuses mainly on ostomies, wounds, or continence, because it provides not only strategies to introduce innovations in clinical practice, but also insights into how to ensure these changes are adapted and sustained over a period of several years.
WOUND CARE
Jane Fellows and Lea Crestodina report a comparatively simple but elegant study measuring the contamination rate of normal saline prepared with distilled water and table salt compared with that of professionally prepared saline stored in patients' homes with and without refrigeration. In addition to answering important questions about the safety of "homemade" saline for use in wound management in the home care setting, this article should be viewed as an excellent example of a study that addresses a common but previously unanswered question derived from daily clinical practice. Many such questions exist in all phases of WOC practice, and the vast majority will be answered only if you extend your clinical expertise to become a clinical investigator by systematically answering the persistent questions in your own practice that lack evidence to determine whether they help, harm, or even affect important clinical outcomes.
This month's Clinical Challenges also addresses wound management in the home care setting. Deb Schimmelpfenning and Sharon Mollenhauer present a case study comparing an absorbent acrylic dressing to a hydrocolloid in a pressure ulcer in a patient with paraplegia and diabetes mellitus. While such case reports do not prove or refute efficacy, they are important because they provide evidence of the feasibility of a product or intervention, and they serve as the foundation for the randomized clinical trials needed to demonstrate efficacy and define clinical indications for a product, procedure, or intervention.
PROFESSIONAL PRACTICE
Almost all WOC nurses manage aged patients on multiple medications, and a growing number are advanced practice nurses who prescribe drugs for elders. This issue's CE article reviews pharmacodynamics and pharmacokinetics in elders where polypharmacy, co-morbidities, and physiologic aspects of aging profoundly influence when a drug is prescribed, its dosage and scheduling, and ongoing monitoring for therapeutic and adverse side effects.
Evidence from Other Publications
WOUND CARE
While all clinicians involved in wound management strive to improve wound healing and maintain the patient's quality of life, WOC nurses pay special attention to the psychosocial dimensions of a chronic wound and its impact of the patient's quality of life. In the June 2006 issue of the British Journal of Nursing, Jones and associates1 describe the prevalence of anxiety and depression in a group of 190 patients with chronic venous ulcerations. Twenty-seven percent scored as having depression, and 26% were found to have clinically relevant anxiety. Wound pain and odor, factors that have been studied in previous issues of the Journal, were significantly related to anxiety and depression. In addition to alleviating the emotional distress associated with the presence of these factors, aggressive nursing management of pain and odor are advocated as especially important because depression is also associated with impaired wound healing.2
OSTOMY CARE
Upper urinary tract distress (hydronephrosis, ureteral dilation, and/or impaired renal function) are well-known, long-term complications of ileal conduits in some patients. The mechanisms that lead to these complications remain largely unknown, as are co-morbid conditions that increase the risk for upper urinary tract distress. In a recent issue of Urology, Yang and coworkers3 reported on long-term results (5 years or longer) of 100 patients who underwent creation of a Bricker ileal conduit with radical cystectomy because of bladder cancer. Ten subjects (10%) had an elevated serum creatinine and 14% (n = 14) had dilation of the upper urinary tracts. In addition, 36 patients experienced complications requiring hospital admission, including pyelonephritis, urinary calculi, and renal failure. Diabetes mellitus, chronic pyelonephritis, urinary calculi, and ureteroileal anastomotic stricture were associated with risk of upper urinary tract distress. Although these data are not surprising to the experienced WOC nurse, they do demonstrate the high prevalence of significant urologic complications associated with a long-term ileal conduit, and they provide some insight into possible risk factors. More importantly, they re-emphasize the significance of long-term urologic and WOC nurse follow-up for the patient with a urostomy and the tragic and sometimes lethal consequences that occur when ongoing monitoring is not pursued.
CONTINENCE CARE
It has long been recognized that younger community-dwelling adult women are at greater risk for fecal incontinence than are men. In a recent article in the American Journal of Gastroenterology, Bharucha and associates4 surveyed 5300 community-dwelling women and achieved a robust response rate of 53% (2800). In contrast to current perceptions, obstetric trauma was not found to be the predominant risk factor for fecal incontinence in community-dwelling women. Instead, rectal urgency (odds ratio [OR] 8.3; 95% confidence interval [CI] 4.8-14.3) and age (OR per decade 1.3; 95% CI 1.2-1.4) emerged as the primary risk factors for fecal incontinence, and anorectal surgery and prior pregnancy yielded an OR of 1.25 (95%CI 1.1-1.7), and anorectal surgery alone yielded an OR of 2.3 (95% CI 1.6-3.3). The researchers concluded that these findings emphasize the importance of behavioral and lifestyle interventions for the prevention of fecal incontinence, an insight shared by continence nurse experts over a period of years.
References