In This Issue of JWOCN
This issue of the journal blends reports of original research with summaries of existing clinical evidence. Phyllis Bonham, Marguerite Cappuccio, Tara Hulsey, Yvonne Michel, Teresa Kelechi, Carolyn Jenkins, and Jacob Robison report on whether ankle and toe brachial indices using a pocket Doppler device agree with measurements obtained by an experienced registered technologist in a vascular laboratory setting. Their findings indicate that ankle brachial indices obtained using a pocket Doppler were comparable to traditional vascular laboratory testing. In addition to providing clinical evidence supporting the validity of results when a WOC nurse performs ankle brachial testing, this study represents a challenge to WOC nurses to expand and refine our assessment skills in the area of lower extremity vascular competence. It also provides a concrete example of the growing importance of hand-held, noninvasive technologies that may one day be used for urodynamic testing, evaluation of deep tissue injury, and many other assessments not yet envisioned.
In July 2005, a panel of continence and skin care experts met in Chicago for a consensus conference on the topic of incontinence-associated dermatitis (IAD). This integrative review article, authored by panelists Donna Bliss, Dorothy Doughty, JoAnn Ermer-Seltun, Karen Lou Kennedy-Evans, Mary Palmer, and Mikel Gray, summarizes current knowledge about IAD (including a rationale for why the term IAD is preferred over the term perineal dermatitis) and the significant gaps in our current understanding of this common but underdiagnosed and undertreated complication of urinary and fecal incontinence. Read this article for a summary of existing knowledge about IAD and for the gaps in our knowledge base, including basic questions about its prevalence and incidence, risk factors, assessment tools, and treatment protocols. The panelists explicitly acknowledge the appalling inadequacy of existing research, and they challenge readers to undertake research to fill in the multiple knowledge and evidentiary gaps in IAD.
In this issue's Evidence-Based Report Card (EBRC), Laura Bolton summarizes existing clinical and preclinical evidence to provide an operational definition for moist wound healing and healing outcomes related to its application in clinical practice. Although basic principles of moist wound healing are widely accepted and well supported by clinical and preclinical evidence, an operational definition for moist wound healing in the context of topical wound therapy is lacking. Bolton's systematic literature review and discussion provide a masterful synthesis of existing evidence and a stronger base for making evidence-based clinical decisions when selecting a dressing for a specific wound.
Janice Colwell and Janice Beitz provide the second research report to arise from our Center for Clinical Investigation Small Grant Program. Specifically, they completed a survey of WOC nurses and sought to validate definitions of stomal and peristomal complications. Given the rich history of ostomy management by WOC and ET nurses and other clinicians over the past 6 decades, it may seem that the terms we use to describe these complications would hardly need validating. However, as these researchers point out, important differences in the way researchers and clinicians name and define stomal and peristomal complications hinder both our ability to quantify and study them in the research setting, as well as our ability to diagnose and manage them in clinical practice. Read this report to see if you agree or disagree with the terms and definitions put forward by the authors. Agreement should challenge you to ensure that your practice is consistent with the definitions proposed in this article and to consider tracking the prevalence, incidence, and risk factors that predict the occurrence of these complications in your practice. Disagreement with one or more definitions should challenge you to generate the research to change the accepted definition; it can be done only when clinical experts generate the data that challenge and change current thinking. Agree or disagree, the results of this article should both challenge you to examine your current patterns of diagnosing and managing stomal and peristomal complications and provoke you to attend this year's ostomy consensus conference in Salt Lake City so you can participate in this ongoing and clinically relevant process.
Leanne Richbourg, Joshua Thorpe, and Carla Rapp reported on a survey that queried patients about stoma-related difficulties with a new ostomy after discharge from hospital, whom they sought help from and whether they perceived the advice as helpful. Results of this study add to the evidence base for WOC practice by identifying the most common and bothersome problems persons with a new ostomy are likely to experience and who they were most likely to go to when seeking advice on alleviating or resolving these issues. This research report adds to existing evidence about the frequency and type of concerns and problems patients with a new ostomy face following hospital discharge, and it provides unique insights concerning who these patients tend to seek advice from and their perceptions of the value of advice and counseling they receive. A final pearl of information concerns average pouch wear time. This issue generated interesting and lively debate at last year's WOCN Ostomy Consensus Conference, and this report provides sorely needed evidence of wear time among persons with a new ostomy.
Tess Briones and Ginger Salvadalena review current literature about the genetics of Crohn's disease. Recent advances in our knowledge of genomics have led to a revolution in our ability to identify and characterize genetic factors that influence the risk for a variety of diseases, including inflammatory bowel diseases. Read this article for both an introduction to basic principles of genomics and information on a specific disease, Crohn's, with profound clinical relevance to WOC nursing and ostomy care in particular.
Evidence From Other Publications
WOUND CARE
Moisture-related skin damage, including that associated with urinary and/or fecal incontinence, affects both infants and adults. In the February 2006 issue of Cutis, Spraker and coworkers1 report a randomized clinical trial of a petrolatum/zinc oxide ointment containing 0.025% miconazole nitrate in 236 subjects with diaper dermatitis and KOH stained proven candidiasis. Subjects were randomized to either the miconazole-enriched ointment or an inert petrolatum/zinc oxide ointment applied to visibly affected skin at each diaper change and after bathing. After 14 days, the cure rate (clinical cure and microbiological cure) for the miconazole-enriched group was 23% as compared to 10% for the control group managed by the inert skin protectant. The rate of clinical cure (based on visual inspection) was 38% for the miconazole nitrate treated group vs 11% for controls, and the rate of microbiological cure was 50% for the miconazole group vs 23% for controls. This study is significant to WOC practice because it compares data about the clinical and microbiological performance of an inert skin protectant versus one enriched with an antifungal (miconazole nitrate). It is hoped that this type of robust, well-designed randomized clinical trial will be reproduced with the plethora of products marketed by industry partners for management of moisture-related skin damage in adults.
OSTOMY CARE
Although colorectal cancer remains the most common indication for colostomy creation, diversion is also considered a viable management option for patients with neurogenic bowel following spinal cord injury. However, little research has been completed comparing satisfaction and quality of life in patients managed by a colostomy vs those managed by traditional programs such as digital stimulation. Luther and colleagues2 compared 74 veterans with spinal cord injuries and colostomies with 296 veterans managed by traditional bowel programs. Although both groups reported overall dissatisfaction with bowel management programs, no statistically significant differences were found between those managed by a colostomy and those using traditional fecal elimination protocols. Given the invasive surgery required for colostomy creation, it seems reasonable to reserve colostomy formation for those spinal cord injured patients who experience significant difficulty managing fecal elimination using traditional programs.
CONTINENCE CARE
How many times did you void yesterday or the day before? If we, as care providers, experience difficulty in accurately quantifying this number, is it likely our patients do as well, when queried about daytime voiding frequency during a focused history. In a recent edition of the Journal of Urology, Kenton and associates3 compared verbal recall of women with urge urinary incontinence (UI) to the frequency of UI episodes recorded on a voiding diary (bladder log). Participants tended to recall more frequent episodes than were recorded on the voiding diary; the correlation fell even further in women reporting moderate-to-severe bother associated with urge UI episodes. These findings provide further evidence that the magnitude of bother associated with a specific symptom or event profoundly influences perceptions of frequency and severity and that a comprehensive UI assessment should combine objective or semiobjective data with subjective perceptions to provide a balanced evaluation of UI frequency and severity.
References