In This Issue of JWOCN
This issue provides a blend of the latest research findings, clinical experience, and expert opinion from multiple aspects of WOC nursing practice. Individual articles include assessment of lower-extremity arterial disease, reliably evaluating pressure ulcer risk, prevention of pressure ulcers in the acute care setting, and urodynamic evaluation of long-term vesicostomies. Intervention-based articles include honey for wound care and washouts for blocked indwelling catheters. Once again, authors from around the globe have come through with a set of must-read articles for every WOC clinician.
Lower-extremity arterial disease (LEAD) is distressingly common among older adults, but traditional assessment techniques have proven inadequate for early diagnosis. As a result, too many patients are diagnosed only after they seek help for clinically apparent symptoms, and these tend to occur only after the disease has progressed considerably. This issue's Wound Care section opens with an important article from Phyllis Bonham, Bonny Flemister, Margaret Goldberg, Penny Crawford, Jan Johnson, and Myra F. Varnado summarizing the new WOCN LEAD Clinical Practice Guidelines. You will want to read this article for a rapid but substantive summary of the information contained in the full guidelines and (ultimately) obtain the full publication in order to ensure that your and your facility's approach to this clinically relevant and prevalent disease is based on current best evidence and not on ineffective historical precedents.
In this issue's CE article, Barbara Pieper reviews current research on honey as a wound-healing agent. Its timeliness is apparent, given the comparatively recent availability of Manuka honey sources for wound healing in the market in both the United States and Canada. You will want to read this article and complete the attached CE opportunity, both to understand the mechanisms that enable honey to promote healing in selected wounds, and to review existing evidence concerning its indications, application, and available forms.
While the novelty of reimbursement policies of the US Centers for Medicare & Medicaid Services has now passed, there is little doubt that acute care facilities will continue to track selected hospital-acquired conditions with intense scrutiny. For the WOC nurse, 2 of these conditions, hospital-acquired pressure ulcers and catheter-associated urinary tract infection, are especially important. The Journal has placed a special emphasis over the past year on assisting you to prepare your facility to adapt to these changes by reducing the incidence of these conditions to as close to zero as feasible. Two articles in this issue provide even more resources in this essential component of WOC practice in the acute care facility. Colleen Drolshagen and Susan G. Chicano report on a staff-driven quality improvement project that reduced the incidence of hospital-acquired pressure ulcer from approximately 8% to just greater than 3% over a period of 2 years. This is another must-read article that blends knowledge of pressure ulcer prevention techniques with an understanding of principles of knowledge dissemination and diffusion into meaningful changes in clinical practice. Morris Magnan and Joanne Maklebust follow up on their recent report of Web-based training for use of the Braden Scale for Predicting Pressure Sore Risk. In this research report, they evaluate the reliability of Braden Scale scoring among 2 groups of RNs, "new users" and "regular users." You will want to read their article to gain insight into the challenges of improving nurses' reliability when assessing pressure ulcer risk using this validated instrument. I advise paying special attention to insights related to reliable scoring of the moisture and nutritional subscales.
Finally, in this month's Evidence-Based Report Card, the Journal will, for the first time since this feature was introduced in 2004, update a report about nursing interventions designed to reduce the risk of catheter-associated urinary tract infection. This update is included because of its timeliness in the context of Centers for Medicare & Medicaid Services reimbursement policies and because of the new sources of evidence contained in the update report.
In this issue's Ostomy Care section, Kingsley Simmons, Jane Smith, and Atsuko Maekawa report on validation of an important new instrument for assessing psychosocial adjustment for persons living with an ostomy, the Ostomy Assessment Inventory-23. The article describes a robust and rigid process of instrument development and validation. Reading this article will not only provide evidence that the Ostomy Assessment Inventory-23 (OAI-23) is a reliable and valid instrument, it will also provide an excellent example of the rigorous process required for designing and validating an instrument for both clinical practice and measurement in the research setting.
Jennifer Hurlow opens this issue's Continence Care section with a View From Here, summarizing her experiences with the newly approved International Classification of Diseases, Ninth Revision (ICD-9) code for functional incontinence. I have personal memories of Jennifer's e-mails about the need for a code for functional incontinence and the obstacles she faced as she attempted to navigate this project through the approval system. Anyone who has ever felt that "fighting city hall" is impossible or who has ever thought "someone should do something about that" should read this inspiring account of a colleague who did take on city hall, and won!!
Katherine Moore, Kathleen F. Hunter, Rosemary McGinnis, Chasta Bacsu, Mandy Fader, Kathy Getliffe, Janice Chobanuk, Lakshmi Puttagunta, Donald C. Voaklander, and colleagues report the results of a randomized clinical trial comparing catheter washout techniques, using sterile saline and a mildly acidic irrigating solution commercially available in the United Kingdom, for treating catheter blockage in persons managed by long-term indwelling catheters. While many of the articles in this first issue of 2009 are focused on WOC nursing practice in the acute care setting, this study was set in a home care setting, and it has profound implications for patients managed by long-term indwelling catheterization in home care, long-term care, and hospital settings. Not only are the results of this study likely to surprise you, they will also provide entirely new insights into the cause of catheter blockage and reinforce the true meaning of asymptomatic bacteriuria and its management.
This month's Clinical Challenge blends principles of wound (skin), ostomy and continence care in a report of 2 children managed with long-term vesicostomy drainage. You will want to read this article for a review of the indications and surgical techniques leading to vesicostomy formation, containment of urinary output from the vesicostomy, care of the peristomal skin, and the role of complex urodynamic testing in determining whether a long-term vesicostomy can be safely closed and lower urinary tract integrity restored.
In this issue's Research Spotlight, Eileen Harwood and Pakou Vang coauthor the first in a series of articles about the collection of primary research data. You will want to carefully read their article for a highly pragmatic and useful description of 6 essential steps for collecting primary or original data, beginning with defining a clear need or purpose for collecting data.
Evidence From Other Publications
WOUND CARE
Wound pain is both an acute event, provoked by dressing changes, debridement, or similar manipulations of the wound, and an ongoing event that diminishes quality of life and impairs the healing process itself. In a recent issue of Wound Repair and Regeneration, Gottrup and coinvestigators1 report results of a randomized clinical trial of a hydrophilic polyurethane foam dressing containing a 0.5 mg/cm2 concentration of ibuprofen. One hundred twenty-two patients with painful venous leg ulcers were randomized to treatment with the ibuprofen foam dressing or an identical foam dressing without ibuprofen. Both clinicians and patients were blinded to dressing type during the first 42 days of data collection. Pain intensity was measured using a 5-point verbal rating scale where 0 indicated no relief and 4 indicated complete relief, and the 11-point Numeric Box Scale, where 0 indicated no pain and 10 indicated the worst imaginable pain. The investigators also addressed both persistent or chronic pain and cyclical pain associated with dressing changes. Patients randomized to the ibuprofen foam dressing reported a higher level of relief and they experienced a larger reduction in pain intensity from persistent pain than those randomized to the regular foam dressing during the first 5 days of use. In contrast, no statistically significant differences were noted in pain relief or pain intensity associated with dressing changes. On days 43 to 47, all patients were switched to the regular foam only and pain outcomes were again measured. This evaluation revealed a statistically significant increase in pain intensity, a significant reduction in pain relief among patients who have been previously treated with the ibuprofen foam dressing affecting both cyclic and persistent wound pain. Wound-healing outcomes were not different between the groups.
Several aspects of this clinical trial have implications for WOC nursing practice. The most apparent is the novel attempt to impregnate a topical dressing with a nonsteroidal anti-inflammatory drug (ibuprofen) in order to promote pain relief in patients with painful lower extremity venous ulcers. In addition, the researchers should be commended on their recognition of the 2 predominant forms of pain experienced by these patients, cyclical and persistent, a phenomenon originally reported by Krasner2 in the Journal in 1998. While it is not surprising that use of the ibuprofen foam dressing exerted the greatest initial effect on persistent wound pain, it is also interesting to note that subjects experienced a significant increase in both persistent and cyclical pain when the dressing was discontinued after 42 days. Finally, it is important that both patient groups experienced pain relief when day 5 results were compared to baseline measurements. These findings are probably attributable to multiple interventions advocated in the wound-associated pain (WAP) conceptual model, acknowledgment of wound associated pain, and selection of appropriate topical therapy. While the impact (or availability) to WOC nurses of an ibuprofen foam dressing remains only speculative, the latter interventions are immediately available and their positive impact on wound care remains essential to the optimal management of painful venous ulcers.
OSTOMY CARE
It is well known that all forms of urinary diversion are associated with a significant risk of complications that require ongoing vigilance, including long-term WOC nurse management. Nieuwenhuijzen and colleagues3 compared results of 218 patients who underwent cystectomy for urinary tract malignancies, followed by ileal conduit (n = 118), cutaneous urinary diversion (n = 51), and orthotopic neobladder (n = 62). WOC nurses will not be surprised to note that patients managed with ileal conduits had no more early or late complications than did those managed by other forms of diversion. However, the results of this study did reveal that 17% of patients with an ileal conduit, 24% of those with an Indiana pouch, and 26% with an orthotopic neobladder had evidence of hyperchloremic acidosis. Twenty patients required treatment with sodium bicarbonate, and 4 were hospitalized because of acidosis and sodium wasting hypovolemia. In addition, almost 9% of these patients had evidence of vitamin B12 deficiency, and the majority required exogenous supplementation. It is well known that the liver will store sufficient vitamin B12 to compensate for deficits for a period of 2 years or longer, and the median time from urinary diversion creation to diagnosis of vitamin B12 deficiency was 41 months. Similar to the incidence of hyperchloremic acidosis, the risk of vitamin B12 deficiency did not differ based on type of diversion. Although uncommon, this article reminds WOC nurses that all patients undergoing urinary diversion or orthotopic neobladder construction are at risk for metabolic acidosis and vitamin B12 deficiency and these complications may manifest themselves months or even years after the original reconstructive surgery.
CONTINENCE CARE
Intrarectal fecal collection devices have emerged as a viable option for diverting the fecal stream in critical care settings and in patients with extensive burn wounds in particular. In a recent issue of Diseases of the Rectum & Colon, Page and colleagues4 report a case of severe rectal bleeding in a 65-year-old man using a fecal collection device. Colonoscopy revealed a 6-cm laceration of the mucosa of the anterior rectal wall that was attributed to trauma from the retention balloon of the device. Whether the event was caused by a sudden movement producing a laceration or it was the culmination of insertion-related trauma was not clear. The patient required blood transfusions and surgical endoscopic intervention. Extensive clinical experience clearly reveals that laceration and blood loss is an extremely rare complication among patients managed by fecal collection devices. Nevertheless, this case provides an important reminder that regular assessment of the stool and rectum is essential when managing patients with fecal collection devices.
References