In This Issue of JWOCN

The clinical focus of this issue of the Journal is Bowel and Bladder Management. Although others have begun to emphasize a more comprehensive, and thus more intrinsically nursing-focused approach to management of urinary incontinence (UI) and fecal incontinence (FI), it was the WOCN who originally put forward a position paper emphasizing the need to integrate UI and FI with pelvic floor dysfunction, and to include management of the associated skin problems now called incontinence-associated dermatitis (IAD). As this issue illustrates, the WOCN remains at the cutting edge of knowledge in all 3 areas.

In addition to these platform articles, this issue contains other articles focusing on cutting-edge policy and professional practice issues. More than 230 nursing and medical journals have joined with the National Institutes of Health to focus on the problem of health and global poverty. WOCN President Jan Colwell and I have authored a joint message on this issue, to discuss how it affects WOC practice on a global basis and our daily practice in the United States. Are you aware of the problem of traumatic vaginal fistula faced by tens of thousands of impoverished women in developing countries? If not, you will be both informed and saddened when you read about this avoidable and tragic health care crisis. Do you ever face the dilemma of patients who cannot afford the supplies needed to pouch their stoma, heal their wound, or manage their incontinence? Read this message to hear how this problem affects our practice on a national basis, and what can be done to make things better.

A Joint Committee of the WOCN and American Society of Colon and Rectal Surgeons has issued a Joint Statement on the Value of Preoperative Stoma Marking for Patients Undergoing Fecal Ostomy Surgery. This historically important statement is an excellent follow-up to the last issue of the Journal, which focused on ostomy research, and to the Evidence-Based Report Card in that issue that examined the impact of stoma site marking and preoperative education on postoperative outcomes. This issue's Challenges in Practice focuses on ostomy management. J. Ahmad, S.I.H. Andrabi, and M.A. Rathore present a case of an elderly gentleman who experienced acute obstruction of the ostomy following laparoscopic cholecystectomy. The authors note that this is the first documented case of acute obstruction of a urinary stoma attributed to carbon dioxide pneumoperitoneum. You will want to read this case and the commentary by Ostomy Section Editor Barbara Hocevar to gain additional insight into the mechanism of this novel complication and how to avoid a similar complication if your ostomy patient undergoes a laparoscopic procedure.

This issue's Spotlight on Research is the final installment of the Qualitative Research Proposal series by Dr Ayres. It focuses on pragmatic issues related to this valuable research methodology. All of the practical tips provided by Dr Ayres are important and all are valuable, but if I were forced to choose a single take-home message for authors and clinical investigators, it is to read and pay heed to Dr Ayres' messages about the necessity of engaging your Institutional Review Boards (Human Ethics Committees) whenever you conduct any research involving human subjects. Finally, in this issue's View From Here, Ben Peirce provides an excellent overview of the history of our wound care practice, and he draws insightful parallels between our involvement with chronic wound management and advances in the technology of wound care.

M. Du Moulin, J. Hamers, A. Paulus, C. Berendsen, and R. Halfens report on the effect of introducing a specialty practice nurse in the care of community-dwelling women with urinary incontinence. This randomized clinical trial compared clinical and quality of life outcomes in women managed by a specialized nurse to traditional care from a general practice provider. Read this article to evaluate the positive short-term effects measured at 6 months, followed by absence of a difference at 12 months. While many continence care specialists in the United States tend to practice in interdisciplinary continence centers, it is essential to remember that the vast majority of patients experience mild to moderate urine loss and are managed in a nonspecialist setting in their communities. Insights from this well designed randomized clinical trial provide important insights for continence nurses in North America, Europe, and the United Kingdom.

M. Macaulay, E. van den Heuvel, F. Jowitt, S. Clarke-O'Neill, P. Kardas, N. Blijham, H. Leander, Y. Xu, M. Fader, and A. Cottenden report on progress in the development of a noninvasive toileting device for women. The dearth of toileting and urinary containment devices for women, particularly for women with limited mobility, is an historic and unresolved issue in continence management. Read this article to gain insight into the challenges in developing a toileting device that has the potential to offer something far beyond the female urinal, and the progress this globally known and respected group has made toward realizing this goal.

A. Palese, L. Regattin, F. Venuti, A. Innocenti, C. Benaglio, L. Cunico, and L. Saiani report on a prospective cohort study of the use of incontinence pads among patients admitted to an acute-care facility. Beyond simply reporting the epidemiology of incontinence pad use by nurses, they attempt to define and identify inappropriate use based on indications identified in health care literature. Read this research report to gain insight into patterns of pad use in acute-care facilities and implications of pad use on patients' pad use beyond their inpatient stay.

This issue's CE article focuses on principles for best practice when managing an indwelling urinary catheter. Diane Newman summarizes current knowledge about catheter management, and reminds colleagues that it is the nurse who typically makes key decisions about catheter size, material of construction, use of a securement device, and urinary drainage system, all of which profoundly impacts the patient's experience and risk for complications associated with placement of an indwelling catheter.

J. Echols, B. Friedman, R. Mullins, Z. Hassan, J. Shaver, C. Brandigi, J. Wilson, and L. Cox report on the clinical utility and economic impact of introducing a bowel management system into the management of severely ill burn patients. This retrospective before-after study examines urinary tract and soft tissue infection rates before and following introduction of the bowel management system, and its economic impact. Their results suggest that introduction of the bowel management system reduces hospital urinary tract and soft tissue infection rates, and also reduces the costs (both in terms of staff time and physical resources) of traditional management based on bed linen and dressing changes in response to fecal soiling or defecation while confined to bed. Read this article to gain insight into the challenges, benefits, and limitations of introducing this type of bowel management system into a group of severely ill, bedridden patients, and as a reminder that introduction of devices that have high front end costs may ultimately cost less than traditional methods when applied judiciously.

Rita de Cassia Domansky and Vera Lucia Conceicao de Gouveia Santos report on adaptation of the Bowel Function in the Community Instrument to a Brazilian population. A review of this well-written research report not only reminds us that adaptation of instruments to another culture goes far beyond mere translation of the items, in this case from English to Portuguese. It also requires consideration of the purpose and meaning of each item, and how this must be adapted to retain its intended purpose. Their article also reminds us of the considerable gap between public perceptions of "normal bowel habits," often mirrored by health care providers, and the dearth of knowledge about the range of bowel elimination habits among otherwise healthy individuals, in Brazil and throughout the world.

This issue's Evidence-Based Report Card completes the special focus on bowel and bladder function. Carolyn Eddins and I review the literature of probiotic and synbiotic preparations and their effect on chronic constipation and irritable bowel syndrome. These substances have been consumed by humans since biblical times for their potential health benefits. The introduction of probiotic and synbiotic enriched dietary supplements has renewed clinicians' interest in their potential health-promoting role. This issue's EBRC reviews the evidence on the effect of these products on 2 of the most common bowel elimination dysfunctions affecting our patients, and helps you to separate the hype from the evidence.

EVIDENCE FROM OTHER PUBLICATIONS

WOUND CARE

Dobbs, Spanbauer, and Datz1 report on a continuous, automated pressure ulcer monitoring system developed in a 300-bed care facility in the Midwestern United States. They combined a computer-based model to monitor problems associated with facility-acquired pressure ulcer incidence with an aggressive and research-based pressure ulcer prevention program. The prevention program incorporated essential elements including pressure ulcer risk assessment strategy, a trigger system, product evaluation, policy changes as indicated, and staff education. In order to evaluate the effects of this system, a computer-based Continuous Automated Pressure Ulcer Monitoring (CAPUM) program was designed and implemented. The program collects data about admission and ongoing skin assessments that are transmitted to the facility's WOC nurse and it prompts staff to institute appropriate interventions when a pressure ulcer occurs. These data are also used for analysis of trend projection, a complex but powerful statistical analysis technique that generates linear trend lines that allow the WOC nurse to track trends and to alter the facility's program or reinforce education as needed to ensure that facility-acquired pressure ulcer rates decline or remain quite low. Given the increasing focus on pressure ulcer incidence as a key indicator of quality of care, acute, subacute, and long-term care facilities are under increasing pressure to institute prevention programs, ensure staff compliance with these programs, and measure declines in nosocomial pressure ulcer rates. This article provides a good description of one facility's approach to this issue.

In previous issues of the Journal, Phyllis Bonham2,3 has reported her own research and reviewed the literature on ankle-brachial and toe brachial index evaluations by nurses (see the Manuscript Award feature in this issue). In a recent issue of Vascular Medicine, Holland-Letza and coinvestigators4 studied the inter-rater reliability when a vascular surgeon or vascular physician, family physician, and registered nurse with training in Doppler sonography completed ABI measurement in 108 patients. Variability between these clinicians was 9%, and variability within observers was 8%. In addition, error rates when 2 repeated measurements were produced by all 3 observer groups did not vary significantly, with the vascular specialist error rate of 8.5%, family physician error rate of 7.7%, and nurse error rate of 7.5%, P = 0.39. The findings of this study add further evidence to Bonham's assertions that lower extremity assessment via ABI and TBI using portable technology should become a routine component of WOC practice.

OSTOMY CARE

Is the neobladder or orthoptic continent urinary diversion truly "better" than the incontinent ileal conduit? Many clinicians, and particularly the surgeons who create these innovative structures for urine storage, honestly believe that they are more functional than the ileal conduit and ensure a higher quality of life for patients undergoing radical cystectomy for bladder cancer. However, an Evidence-Based Report Card authored by Janice Beitz and I5 failed to find compelling evidence that orthotopic neobladders or cutaneous continent urinary diversions consistently provide higher health-related quality of life scores on a variety of generic and disease specific instruments. Evaluation of 2 recently published studies on this issue provides an opportunity to briefly re-evaluate this ongoing question.

Gilbert and colleagues6 reviewed data from 315 patients with bladder cancer managed by radical cystectomy and urinary tract reconstruction at the University of Michigan during the calendar year 2004. They found that urinary function scores were significantly lower in patients treated with continent neobladder as compared to those who underwent construction of an ileal conduit. Harano and associates7 evaluated clinical outcomes, health-related quality of life, and complication rates in 40 patients who underwent orthotopic neobladder primarily constructed using ileum (n=21) versus cutaneous diversion resulting in an ileal conduit (n=20). No differences in health-related quality of life were noted between the groups. Further, the researchers observed 19 early complications in 18 patients (60.0%) and 7 late complications in 6 patients (20.0%) who underwent neobladder construction as compared to 15 early complications in 14 patients (36.8%) and 8 late complications in 6 patients (15.8%) with ileal conduits. These studies add even more evidence to the unavoidable but unpopular reality that the time-honored surgical creation of an ileal conduit continues to play an essential role as an option for diverting urinary flow after radical surgery.

References