In This Issue of JWOCN
This issue of the journal includes a special focus on pressure ulcer risk assessment. Laura Bolton provides an invaluable overview of this topic in her Evidence-Based Report Card entitled "Which Pressure Ulcer Risk Assessment Scales Are Valid for Use in the Clinical Setting?" Bolton identifies 3 scales backed by significant clinical use and validation studies. She also provides an excellent summary of evidence pertaining to the administration and scoring of these scales, including who should administer the risk assessment scale, when it should be administered, and who should be assessed. As you read her review, I urge you to pay special attention to the extensive tables summarizing the large and sometimes confusing array of research on this essential and timely issue.
Joyce Stoelting, Linda McKenna, Elizabeth Taggert, Rosalie Mottar, Brenda R. Jeffers, and M. Cecilia Wendler share their insights and experiences designing and implementing a process improvement project for preventing hospital-acquired pressure ulcers. Their article deals with a timely and often overlooked aspect of pressure ulcer risk assessment: what is done when a patient with an increased risk is identified. Read their article for insights into a project that not only tracked an individual unit's ability to assess pressure ulcer risk and implement preventive interventions, but also provided a pragmatic and innovative method for improving the quality of care based on individual case analysis of nosocomial pressure ulcers within their facility.
Katrin Balzer, Claudia Pohl, Theo Dassen, and Rudd Halfens compared the predictive validity of the Norton, Waterlow, and Braden pressure ulcer risk assessment scales to results of a care dependency scale in a robust group of 754 patients in 3 acute care facilities based in Berlin. Their study is valuable because it is one of the few that compares 3 widely used and validated scales in a prospective study with a large, multisite sample, and because it compares results with a tool that evaluates many shared and closely related risk factors. Read it to gain insight into the performance of these scales in a multisite acute care population in a major urban area, and to compare their performance with a generic instrument designed to measure care dependency.
Daria L. Kring summarizes reliability and validity data for a single risk assessment instrument, the Braden Scale for Predicting Pressure Ulcer Risk. In addition to a skilled summary of the existing research used to establish the reliability and validity of the Braden Scale, you should read Daria's article to gain a better appreciation of the importance of parsimony in an instrument, an essential characteristic for any instrument to gain widespread use in the clinical setting. You should also read her article and consider her discussion of the potential advantages and limitations associated with design of an expanded Braden Scale and its potential role in clinical and research settings.
Berrin Leblebici, Nur Turhan, Mehmet Adam, and Mahmut Nafiz Akman evaluated the incidence of nosocomial pressure ulcers in a university-based hospital in Turkey using the Waterlow Scale. They retrospectively analyzed 22,834 patients hospitalized at their facility over a 1-year period and identified 360 who developed hospital-acquired pressure ulcers. Their study is novel for its use of a single nurse-physiotherapist to assess each of these subjects, and its analysis of the predictive validity of the Waterlow Scale in such a large population.
In this issue's CE article, Joyce Pittman integrates current research and clinical wisdom in a comprehensive discussion of the effects of aging on wound healing. Read her article to review and update your knowledge of how normal aging influences wound healing and tissue repair, and how this process is compromised when comorbid conditions exist. You should also read Pittman's discussion to increase your knowledge about theories of cellular senescence and genetic factors that influence wound healing.
This issue's Clinical Challenges sounds a word of caution when using vacuum-assisted closure in the management of abdominal wounds. Syed Imran Hussain Andrabi and Jawad Ahmad describe a case where a change in subatmospheric pressure, repositioning of the suction point of the dressing, and placement of omentum between bowel and suction port prevented bowel leak. In her commentary, Jacalyn A. Brace reviews a variety of options when managing abdominal wounds using techniques of negative pressure wound therapy, and emphasizes the need to adhere to clinical guidelines when using these products to manage these complex and fragile wounds.
When asked about indwelling catheterization, most nurses in North America tend to visualize a urethral catheter attached to a leg-bag or bedside drainage. Alyson Sweeney, Ann Harrington, and Didy Button report on a descriptive study of persons living with a suprapubic catheter. Read this article to gain insights into the 2 primary themes gained from participant interviews: inadequate preparation for the catheterization experience by health care professionals, and the gradual shift from a mainly negative to a more positive perspective on its presence in their lives.
Evidence From Other Publications
Wound Care
Calciphylaxis is a rare, but frequently fatal syndrome usually seen in patients with end-stage renal disease and elevated serum calcium and phosphate. It is also observed in patients with normal calcium and phosphate and apparently adequate renal function. Calciphylaxis can be characterized as a systemic hypersensitivity analogous to a severe allergic response. Incomplete knowledge of its etiology, pathophysiology, and natural history probably contribute to the lack of effective treatments. In a recent issue of the Journal of the American Academy of Dermatology, Weenig and coworkers1 retrospectively reviewed their experiences with 64 patients with calciphylaxis treated over a period of 11 years. Findings are compared to a cohort of 98 patients with end-stage renal disease managed by dialysis. They summarize existing hypotheses about potential causative factors, including abnormalities in the body's use of parathyroid hormone, corticosteroid use, aluminum, hepatic disease, and warfarin. The results are predictably grim. The 1-year survival rate for patients with calciphylaxis was 45.8%. Factors associated with calciphylaxis included obesity, liver disease, systemic corticosteroid use, calcium-phosphate product more than 70 mg2/dl2, and serum aluminum > 25 ng/ml. Parathyroidectomy did not improve survival, but surgical debridement did improve 1-year survival (61.6% vs. 27.4%, P = .008). While this report includes all the apparent weaknesses of a retrospective study, it remains a particularly important contribution to a condition whose negative impact is almost certainly aggravated by our lack of knowledge about its etiology and pathophysiology.
Ostomy Care
Clinical and research experts in the field of urologic surgery gathered for a meeting sponsored by the World Health Organization (WHO) and Societe Internationale d'Urologie (SIU) to review research and clinical evidence about urinary diversion or reconstruction following cystectomy.2 Based on critical analysis of more than 300 articles, they report that 47% of all diversions described in the world's health care literature were neobladders, 33% were ileal conduits, 8% were continent cutaneous diversions, 10% were anal diversions, and 2% were incontinent cutaneous diversions. This report clearly reflects the trend toward neobladder diversion, and away from continent cutaneous diversions. The report also notes that although randomized clinical trials comparing quality of life among the various diversions are desirable, they are "probably difficult to conduct." Surgical wisdom in urinary diversion and diversion following cystectomy has historically followed trends, from the popularity of the ileal conduit in the 1960s and 1970s to the rise of the continent cutaneous diversion in the 1990s and the meteoric rise of neobladder construction in the early 21st century. The assertion that prospective randomized trials are "difficult to conduct" is certainly true, but this is not a sufficient rationale for failing to conduct such trials. Gray and Beitz3 reviewed existing evidence comparing quality of life among patients undergoing a variety of urinary diversion or reconstruction techniques and failed to find apparent differences in quality of life. This lack of evidence is not merely inconvenient, it is a central question that must be addressed before we can provide patients undergoing life-altering surgery with the best information on how their surgical procedure will affect the rest of their life on earth.
Continence Care
As noted in the previous report from the WHO and SIU, evidence concerning the quality of life following cystectomy and neobladder construction is lacking. The breadth of factors that comprise quality of life is so broad that it renders the phenomenon difficult, though far from impossible, to adequately define and study. Based on the limited knowledge we have, we know that lower urinary tract symptoms such as incontinence, difficulty urinating, and incomplete bladder emptying affect quality of life following neobladder construction. In a recent issue of the Scandinavian Journal of Urology and Nephrology, Thorstenson and colleagues4 evaluated fecal elimination symptoms in 28 patients undergoing neobladder construction using the distal ileum. When compared to a small cohort of patients (n = 10) with bladder cancer who were managed endoscopically, 25% of those who underwent neobladder construction experienced daily rectal urgency and diarrhea versus 0% of the comparison group. While this comparison seems a bit unfair since it compares patients undergoing major reconstruction with a group of patients able to avoid cystectomy, it does emphasize the need for prospective clinical trials that evaluate a variety of sequelae following the various urinary diversions, and it provides a timely alert for WOC nurses to include counseling about ongoing rectal urgency and diarrhea in patients who undergo neobladder construction.
References