In This Issue of JWOCN
This issue of the journal has a dual focus, moisture-associated skin damage (MASD) and pressure ulcers. At first glance, these topics may lead the reader to believe we are exclusively focusing on wound care, but in fact, both focus areas bridge wound, ostomy, and continence care. The focus on MASD reminds us all that urinary and fecal incontinence is an essential concern for any clinician who manages patients with perineal skin wounds and that perineal skin care is a critical aspect of managing urinary or fecal incontinence. Similarly, the CE article in the pressure ulcer focus area evaluates the effect of a bowel management system on pressure ulcer incidence in the critical care units of a university-based health system.
During the next 2 years, you are likely to hear much more about the concept of MASD and its relationship to pressure ulcer risk, its significance to bariatric care, and its role in managing highly exudative wounds and fistulae. Do not be surprised that you heard it first in the Journal of Wound, Ostomy, and Continence Nursing.
The clinical manifestations of MASD are familiar to every WOC nurse, although the effort to combine disorders as varied as incontinence-associated dermatitis, intertrigo, and periwound skin maceration is relatively novel. Nevertheless, during a recent meeting with Dr Gary Sibbald, the concept of moisture-associated skin damage was discussed in some detail. Although all participants agreed that MASD is a common phenomenon, it was immediately recognized that we have only the most rudimentary understanding of how exposure to urine, stool, perspiration, or wound exudate leads to skin damage or the relationship between incontinence-associated dermatitis and pressure ulcer risk.
Donna Bliss, Cindy Zehrer, Kay Savik, and Graham Smith report their economic evaluation of 4 skin damage-prevention regimens in nursing home residents with incontinence of urine or stool. All of the regimens were based on accepted principles: cleanse, moisturize, and protect. Three programs used an ointment or cream-based skin protectant to accomplish this final principle of prevention, and the fourth used a polymer-based barrier film as a skin protectant. The program that used the polymer-based barrier film was less costly than those using ointment or cream-based barrier products, probably owing to the film barrier being applied 3 times weekly, and after known incontinence episodes, as compared to the ointments and creams that were applied more frequently. Read this article and Mandy Fader's commentary on it to gain insight from this robust and well- designed economic comparison of perineal skin prevention programs, including a better understanding of our incomplete knowledge concerning why these programs work.
In this issue's Evidence-Based Report Card, Dorothy Weir and Mikel Gray systematically review literature on maceration of the periwound skin, a common clinical manifestation of MASD. Read this review to discover the sparse evidence for preventive interventions and the absence of any evidence concerning its treatment.
The Challenges in Practice section provides a forum for promoting critical thinking about current clinical problems when evidence is lacking. In this issue's challenge, Catherine Ratliff and Marilu Dixon present the decision-making process that led to selection of a single skin protectant for their facility's neonatal care unit. This decision was based on an in-house product evaluation, demonstrating improvement in skin condition in 5 neonates with incontinence- associated (diaper) dermatitis, possibly the most common clinical manifestation of MASD encountered by WOC nurses. Linda Bohacek's subsequent commentary focuses on existing knowledge about prevention vs intervention when managing incontinence-associated dermatitis and offers alternatives to this intervention.
Included in this issue is a round-table discussion of moisture vs pressure in MASD, attended by Linda Bohacek, Dorothy Weir, Jan Zdanuk, and Mikel Gray. The relationship between urinary incontinence, fecal incontinence, pressure ulcer risk, and the need to enable nurses who are not wound or skin care experts to differentiate between these conditions is described in some detail. Read this round-table discussion for an overarching summary of the concept of MASD, its most common clinical manifestations, and current knowledge about treatment alternatives for perineal skin care in particular.
The second special focus of the journal is pressure ulcers (PU). Ulceration caused by pressure and shear is a recurring theme in the journal and one of the most commonly encountered problems WOC nurses face in their daily practice. Nevertheless, despite a wealth of information published in selected journals, including the Journal of Wound, Ostomy, and Continence Nursing, the research and clinical evidence base in this area remains modest. The editorial board remains unequivocally committed to expanding the available body of evidence related to this essential aspect of WOC nursing.
Richard Benoit and Carolyn Watts note that moisture, the theme explored in the MASD focus, is a predictor for pressure ulcer risk. They report on their experience introducing a bowel management system into the surgical intensive care unit of their university-based hospital as an important component of a pressure ulcer prevention strategy. Read this article for an innovative and effective strategy to reduce pressure ulcer prevalence in a patient group at high risk for pressure ulceration and perineal skin damage.
Jill Walsh and Donna Plonczynski investigated the effects of a prevention and early intervention program designed to prevent nosocomial heel pressure ulcers. They also sought to expand knowledge of the epidemiology of this problem by identifying factors associated with an increased risk for ulceration of the heels. Read this article to gain insights into the effects of a prevention/early intervention program that reduced heel pressure ulcer incidence in their facility and to identify comorbidities associated with increased risk for heel ulceration.
Honey has been used as a treatment for open wounds since antiquity. In a previous issue of the journal, Lusby, Coombes, and Wilkinson1 reviewed research related to the potential healing properties of honey. In this issue of the journal, Ulku Gunes and Ismet Eser compared the effects of a honey dressing to a dressing with ethoxy-diaminoacridine and nitrofurazone (a form of nitrofurantoin commonly used for topical application to promote wound healing by reducing bioburden). Read this article for additional clinical evidence concerning the potential efficacy of honey as a treatment option for pressure ulcer healing in the modern world and for a timely reminder that ancient knowledge went beyond astronomy and philosophy.
In this issue's wound care section, Donnalee Jerome reviews clinical experiences with the latest version of vacuum-assisted closure therapy. This system combines negative pressure wound therapy with the ability to instill medications or solutions directly into the wound. Read this article for insights into practical clinical applications of the system and for important safety concerns designed to prevent medical errors, an area of growing concern among the public and healthcare providers alike.
Evidence From Other Publications
WOUND CARE
The importance of support groups for some patients has been well documented, particularly when facing a diagnosis such as a new ostomy or chronic wound associated with fears of odor and its associated social stigma. Nevertheless, some patients do not readily engage in patient-led support groups, and the longevity of these groups has been questioned, particularly since the World Wide Web creates ad hoc communities of persons without regard to geographic location. More recently, a small but growing number of physicians and nurses have begun to explore the concept of group care in different forms, such as clinician-led patient clubs, or shared appointments where several patients and their family members who share a common diagnosis or disorder meet together to gain collective insight from the care provider and from one another. In a recent issue of the Journal of Wound Care, Gordon and coworkers2 evaluated healing and associated costs in a group of patients with chronic venous insufficiency ulcers who were randomly assigned to treatment using a "leg club" model or the traditional home visit model with a community health nurse. The leg club is an informal environment where patients can gain the benefits of social support and clinician support for managing the significant demands of healing a venous leg ulcer. Based on both clinical and economic outcomes, patients managed in the leg club model benefitted more than the patients managed by home care visits. Although it may seem attractive to assume that community-based patient support groups are destined to play a less significant role in health care in the 21st century, this study demonstrates the economic and clinical benefits of social support, especially when combined with clinician support delivered in an informal group setting.
OSTOMY CARE
The frequency of parastomal herniation and its optimal management is undergoing fresh scrutiny by both ostomy clinicians and researchers. In a case report appearing in the journal Hernia, Garcia and colleagues3 report on a 63-year-old woman with a transverse colostomy who presented to a local emergency department complaining of nausea, anorexia, cramping, abdominal pain, and increased colostomy output. Inspection of the ostomy and abdomen revealed a viable pink stoma, with a mixture of gas and stool in the ostomy pouch and a 2 cm mass in the lateral aspect of the stoma at the 9-o'clock position. Both right abdominal quadrants were tender to touch, and bowel sounds were not noted upon auscultation. CT scan of the abdomen revealed a parastomal herniation involving the gall bladder. She was managed conservatively with a clear liquid diet to allow the bowel to rest, manual reduction of the gall bladder, and support to prevent reherniation. Surgical repair and laparoscopic cholecystectomy were considered, but conservative management was elected because of the patient's history of significant cardiac disease. This case reminds WOC nurses that although parastomal herniation is typically limited to the bowel, it sometimes involves other organs, including the gall bladder, and can greatly increase associated morbidity or even mortality unless the hernia is promptly reduced or repaired.
CONTINENCE CARE
The association between urinary incontinence and psychological or emotional distress remains an enigma. Upon superficial examination, it seems likely that urinary incontinence produces emotional distress, increasing the risk for psychological problems that may further intensify the urinary leakage. However, some research has emerged suggesting that depression and panic and anxiety disorders may cause overactive bladder dysfunction, providing a research-based explanation for the old adage that one can be "scared so bad I peed my pants." In a recent issue of Pediatrics, Joinson, Heron, and von Gontard4 report on findings from 8213 children with overactive bladder dysfunction associated with daytime wetting and urge incon- tinence, who were evaluated as part of a longitudinal population-based study. They found that compared to children without daytime incontinence, those with urge incontinence were almost twice as likely to experience activity problems, oppositional behavior, and conduct problems. Although these associations are not especially surprising to clinicians who care for children who are incontinent, they do provide a robust insight into the magnitude of this association, while reminding us that aggressive and effective continence management is not an option when we "have time." Rather, it is essential to prevent or minimize the associated psychological problems that lead to emotional distress, poor academic performance, and stigmatization of affected children as "wetters" or "behavioral problems" rather than children crying out for our support and assistance.
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