In This Issue of JWOCN

This issue of the Journal includes multiple articles with a special focus on ostomy care and research. Susan Steele reviews existing research and clinical knowledge of ostomies created as the result of traumatic injury. She reviews the most common types of traumatic injuries that result in ostomy surgery and the Wound, Ostomy, and Continence (WOC) nurse management of this specialized population. In addition to updating and refreshing your knowledge about traumatic injury and ostomies, you should read this article for insights into how the WOC nurse can most effectively interact with the trauma team.

Vicky Haugen, Donna Bliss, and Kay Savik report on perioperative factors that influence long-term adjustment to an incontinent ostomy. This research report represents the first published report from a project funded by the WOCN Center for Clinical Investigation's Small Grant Program. Haugen's research team includes a statistician (Kay Savik) and a research mentor (Dr Donna Bliss), who now serves as the director of the Center. Many of their findings are of particular interest, including observations on the creation of ostomies by specialist surgeons, and how helpful WOC nurse education was perceived to be by study participants following ostomy surgery.

Vera Lucia Conceicao de Gouveia Santos, Eliane Correa Chaves, and Miako Kimura also report on quality of life and coping strategies associated with temporary and permanent ostomies. Although both temporary and permanent ostomy groups had similar quality of life scores, there were important differences in the coping skills used to manage life with an ostomy between these patient groups. These differences provide valuable insights into the educational and support needs of persons with temporary versus permanent ostomies, a research need that was commented on by Steele in her review of trauma and ostomy surgery.

Yuko Omura, Seki Kazuhara, and Oishi Kenji report on a novel method to test the adhesive properties of skin barriers. This research report represents a departure from the traditional research articles found in this journal. This is a basic science study, rather than a clinical research project, focusing on physical models constructed to test and compare skin barriers integrated into pouching systems. Commentary by Ostomy Section Editor, Barbara Hocevar, provides a cogent and persuasive argument as to why you should become familiar with this level of research. This article is an informative and thought-provoking addition to this ostomy-focus issue.

Merilyn Annells examines a single aspect of long-term adjustment to gastrointestinal ostomy, gas or flatus. She uses qualitative methods (hermeneutic phenomenology) to explore the lived experiences of persons with fecal ostomies. However, in contrast to many phenomenology research reports, she constructs a narrative illustrating common lived experiences associated with involuntary passage of flatus, rather than direct quotes from study participants.

The two Clinical Challenges also focus on ostomy issues. Molly Pierce uses a case study to illustrate management issues associated with diversion of urine and stool into a sigmoid colostomy, commonly called a wet colostomy. Michelle Rice and Jane Fellows then examine the use of soft silicone foam for the treatment of peristomal skin breakdown. In a commentary covering both of these unique and novel cases, Ginger Salvadalena provides commentary summarizing existing, if incomplete, evidence surrounding both of these clinical scenarios.

Wound Care

Two articles in the Journal focus on wound care. Dr. Laura Bolton provides an Evidence-Based Report Card that examines the safety and efficacy of silver products used to manage pressure ulcers, venous ulcers, and diabetic foot ulcers. Her report provides essential insights into the existing evidence related to the ever-growing group of products seeking to incorporate silver ions in order to reduce wound bioburden in a variety of chronic wounds and the critical issue of safety. It also serves as an ideal follow-up to the classic integrative literature on silver products and wound bioburden authored by Nancy Tomaselli in the last issue of the Journal.

Dorothy Weir and Kathleen Farley report on an investigation of ointment versus spray for delivering a preparation of papain, urea, and chlorophyllin copper complex sodium to the wound bed. Data for their research, collected at the 2005 WOCN National Conference, have been used to investigate both a physical model of a wound bed and results of a survey to determine WOC nurses' impressions of the impact of delivery vehicle on the convenience of product application by professional and lay care providers and the potential for product contamination with repeated use. They also provide a pharmaco-economic evaluation of projected costs of a spray versus an ointment formulation. From overactive bladder drugs to wound care products, clinicians and pharmacologists are becoming more and more aware of the importance of the delivery vehicle in terms of product efficacy and safety. Read this article to gain insights into the potential clinical implications of a spray versus an ointment to deliver papain, urea, and chlorophyllin copper complex sodium to the wound bed.

Continence

Does privacy affect toileting in the acute, long-term care or homecare settings? This question might seem irrelevant to many physician colleagues, and even to some nurses in certain specialty practices, but its importance is driven home every time a continence nurse must coax a patient to urinate in the urodynamic laboratory or a WOC nurse is called on to manage constipation or fecal impaction in a patient who is unable to defecate in an acute care setting. In a study of 120 adults with fecal incontinence, Asangaedem Akpan, Margot Gosney, and James Barrett explore the impact of care setting and the level of dependence on privacy associated with fecal elimination. In this era of increasing concern about the privacy of medical information, this study confronts a seldom considered but critically important issue facing patients (and particularly those with fecal incontinence) on a daily basis: How do we maximize privacy during defecation while maintaining safety for patients with impaired mobility and dexterity?

Evidence from Other Publications

Wound Care

WOC nurses have long advocated the significance of nutritional assessment and intervention in order to facilitate chronic wound healing, but clinical evidence examining the influence of nutritional supplements on pressure ulcer healing remains sparse. In the 2006 issue of Advances in Skin and Wound Care, Lee and associates1 compared PISH scores at 8 weeks in nursing home residents with stage II, III, and IV pressure ulcers who were randomized to standard care, or standard care plus supplementation with a concentrated, fortified collagen protein hydrolysate supplement. Not surprisingly, subjects randomized to receive the nutritional supplement showed approximately twice the rate of wound healing as did those randomized to receive treatment without nutritional supplementation.

Ostomy Care

Is a 1-stage procedure feasible for selected patients undergoing restorative proctocolectomy, or is a temporary diverting ileostomy needed to prevent septic complications? Remzi and coworkers2 reviewed medical records of 277 selected patients undergoing a 1-stage approach by comparing it with those of 1725 patients who underwent an ileo-anal pouch anastomosis using a 2-stage procedure. Subjects undergoing the 2-stage procedure tended to be older, heavier, and taking higher doses of steroids than those selected for a 1-stage approach. Nevertheless, when outcomes were compared, no differences emerged in the incidence of septic postoperative complications, or long-term quality or functional outcomes. Although this retrospective trial does not provide definitive evidence that a 1-stage procedure is superior to a staged approach, it does demonstrate the feasibility of this approach in carefully selected patients.

Continence Care

Radiation therapy is associated with an increased risk for postoperative fecal incontinence in patients who undergo surgery for colorectal cancer. To determine the impact of radiotherapy on pelvic floor muscle rehabilitation, Allgayer and associates3 compared results in a group of 41 patients who underwent surgery for colorectal cancer with radiation therapy with those of 54 subjects managed by surgery alone. As expected, patients managed by surgery and radiation experienced more severe fecal incontinence and more severe rectosigmoidal inflammation than those managed by surgery alone. Nevertheless, following a 3-week period of intense, clinician directed pelvic floor muscle training, patients managed with radiotherapy achieved equivalent short-and long-term treatment effects when compared with those managed by surgery alone. The findings of this quasi-experimental trial are encouraging because they demonstrate that even patients with comparatively severe postoperative fecal incontinence and rectal urgency associated with rectosigmoidal inflammation can achieve significant improvements in continence with pelvic floor muscle training, a noninvasive intervention that forms the cornerstone of behavioral interventions.

References