Showing papers in "Journal of Wound Ostomy and Continence Nursing in 2008"

Demographic and clinical factors related to ostomy complications and quality of life in veterans with an ostomy.

Abstract: Purpose The purpose of this study is to describe demographic, clinical, and quality-of-life variables related to ostomy complications (skin irritation, leakage, and difficulty adjusting to an ostomy) in a veteran population in the United States. Design The original study employed a descriptive crosssectional study using a mixed method design. This secondary analysis used the quantitative data collected. Sample and setting Two hundred thirty-nine veterans with intestinal ostomies from 3 Veteran's Administration hospitals participated in the study. Methods Instruments used for this investigation included the City of Hope Quality of Life: Ostomy Instrument. Demographic and medical history data were collected from the survey, the Veteran's Administration health information system, and the Tumor Registry database. A self-administered survey questionnaire (mCOH-QOL-Ostomy) was mailed to each participant. Results The severity of skin irritation, problems with leakage, and difficulty adjusting were significantly related to demographic, clinical, and quality-of-life domains. Univariate analyses showed that age, income, employment, preoperative care (stoma site marking and education), having a partner, ostomy type, reason for ostomy, time since surgery, total quality-of-life scores and scores on all 4 domains of quality of life were related to the severity of these ostomy complications. Age was inversely related to severity of all 3 ostomy complications (skin irritation, leakage, and difficulty adjusting). Having an ileostomy, rather than a colostomy, was associated with higher severity of skin irritation. Having had the stoma site marked preoperatively was associated with less difficulty adjusting to an ostomy, and having had preoperative ostomy education was associated with less severe problems with skin irritation and leakage. Severity of each ostomy complication predicted total quality-of-life scores. Difficulty adjusting to the ostomy was related to all 4 quality-of-life domains (physical, psychological, social, and spiritual). Conclusions This study found important relationships between demographic and clinical factors and ostomy complications. Skin problems, leakage, and difficulty adjusting predicted total quality of life scores and domains. Establishing relationships among ostomy complications and demographic, clinical factors, and quality of life can enhance identification of patients at risk for the development of complications and is an important first step in identifying the development of effective interventions to reduce the negative impact of complications for people with ostomies. Further study of predictors and outcomes of ostomy complications is needed to improve care.

Enzymatic wound debridement.

Abstract: Background Clinical experience and existing research strongly support debridement as a necessary component of wound bed preparation when slough or eschar is present. Multiple techniques are available, but the indications for each technique and their efficacy are not clearly established. There is little evidence to guide the clinician in the selection of a safe, effective debridement method for the patient with a chronic wound. Objectives We sought to identify evidence related to the efficacy of enzymatic debriding agents collagenase and papain-urea in the removal of necrotic tissue from the wound bed and its impact on wound healing. Search strategy A systematic review of electronic databases was undertaken using key words: (1) debridement, (2) enzymatic debridement, (3) collagenases, (4) papain, (5) urea, and (6) papain-urea. All prospective and retrospective studies that compared enzymatic debridement using collagenase or papain-urea (with and without chlorophyllin) on pressure ulcers, leg ulcers, or burn wounds were included in the review. All studies that met inclusion criteria and were published between January 1960 and February 2008 were included. Results Collagenase ointment is more effective than placebo (inactivated ointment or petrolatum ointment) for debridement of necrotic tissue from pressure ulcers, leg ulcers, and partial-thickness burn wounds. Limited evidence suggests that a papain-urea-based ointment removes necrotic material from pressure ulcers more rapidly than collagenase ointment, but progress toward wound healing appears to be equivocal. Limited evidence suggests that treatment of partial-thickness burn wounds in children with collagenase ointment may require an equivocal time to treatment with surgical excision and that combination treatment may reduce the need for surgical excision. Insufficient evidence was found to determine whether collagenase ointment removes necrotic tissue from leg ulcers more or less rapidly than autolytic debridement enhanced by a polyacrylate dressing. Implications for practice Enzymatic debriding agents are an effective alternative for removing necrotic material from pressure ulcers, leg ulcers, and partial-thickness wounds. They may be used to debride both adherent slough and eschar. Enzymatic agents may be used as the primary technique for debridement in certain cases, especially when alternative methods such as surgical or conservative sharp wound debridement (CSWD) are not feasible owing to bleeding disorders or other considerations. Many clinicians will select enzymes when CSWD is not an option. Clinical experience strongly suggests that combined therapy, such as initial surgical debridement followed by serial debridement using an enzymatic agent or enzymatic debridement along with serial CSWD, is effective for many patients with chronic, indolent, or nonhealing wounds.

Incidence of complications of the stoma and peristomal skin among individuals with colostomy, ileostomy, and urostomy: a systematic review.

Abstract: The objectives of this systematic review were to assess the incidence of complications of the stoma and peristomal skin, synthesize possible reasons for variability in results, and make recommendations for future research. Twenty-one studies published in English between January 1990 and August 2007, with a prospective design that reported the number of complications of the stoma or peristomal skin among participants with colostomy, ileostomy, or urostomy, were identified. The types of complications most commonly reported were retraction, hernia, prolapse, peristomal skin problems, and necrosis. Incidence rates varied widely among studies, even when the same types of complications were measured. Inadequate reporting of attrition, the number of participants at each phase of analysis, and missing data were common problems. Differences among study durations, the absence of definitions of complications, and failure to describe how complications were evaluated contributed to variability in reported complication rates. More studies are needed that use a prospective design, consistent operational definitions, and valid and reliable measurement methods. These recommendations will help increase the availability of standardized data to make comparisons among studies possible.

The effect of washing and drying practices on skin barrier function.

Abstract: Purpose: The aim of this study was to explore the potential contribution to skin damage caused by standard washing and drying techniques used in nursing. Design: An experimental cohort design was used, with healthy volunteers (n = 15) receiving 6 different washing and drying techniques to the volar aspect of the forearm. Subjects underwent 3 washing and drying techniques on each arm; each technique was repeated twice, separated by a 2-hour rest period. Methods: Skin integrity was assessed by measuring transepidermal water loss (TEWL), skin hydration, skin pH, and erythema. Comparisons were made between washing with soap or water alone, and drying using a towel (rubbing and patting) or evaporation. The significance of any difference was assessed by nonparametric analysis. The study was approved by the local research ethics committee, and all volunteers gave informed consent. Results: TEWL was seen to increase following each type of wash, and increased further following repeated washing. Drying of the skin by patting with a towel increased TEWL to give readings identical to those obtained from wet skin. There was an increase in skin pH with all washing and drying techniques, particularly when soap was used. Erythema also increased with repeated washing, particularly when soap was used. No significant changes were observed in skin hydration as measured by a corneometer, although there was a tendency for the values to decrease with washing. Conclusions: These data suggest that washing with soap and water and towel drying has a significant disrupting effect on the skin's barrier function. There is tentative evidence to suggest that a cumulative effect may exist with damage increasing as washing frequency increases. Drying the skin by patting with a towel offers no advantage to conventional gentle rubbing as it leaves the skin significantly wetter and at greater risk of frictional damage.

Does regular repositioning prevent pressure ulcers

Abstract: Background Prolonged exposure to pressure is the primary etiologic factor of a pressure ulcer (PU) and effective preventive interventions must avoid or minimize this exposure. Therefore, frequent repositioning of the patient has long been recommended as a means of preventing PU. Objectives To review the evidence on the efficacy of repositioning as a PU prevention intervention. Search strategy A systematic review of electronic databases MEDLINE and CINAHL, from January 1960 to July 2008, was undertaken. Studies were limited to prospective randomized clinical trials or quasi-experimental studies that compared repositioning to any other preventive interventions or any study that compared various techniques of repositioning such as turning frequency. Only those studies that measured the primary outcome of interest, PU incidence, were included in our review. Results Limited evidence suggests that repositioning every 4 hours, when combined with an appropriate pressure redistribution surface, is just as effective for the prevention of facility- acquired PUs as a more frequent (every 2 hour) regimen. There is insufficient evidence to determine whether a 30 degrees lateral position is superior to a 90 degrees lateral position or a semi-Fowler's position. Implications for practice The current regulatory and legal environment has focused increased attention on PU prevention. Pressure redistribution methods and the frequency of application are among the first factors scrutinized when a PU develops. Our clinical experience validates that regular movement of the immobilized patient is important, but evidence defining the optimal frequency of repositioning or optimal positioning is lacking.

Incontinence-associated dermatitis in a long-term acute care facility

Abstract: Purpose The objectives of this study were to (1) measure the prevalence of incontinence-associated dermatitis (IAD) and pressure ulcers (PUs) on admission to a long-term acute care (LTAC) facility; (2) identify factors associated with IAD and PU on admission to an LTAC facility; and (3) measure the incidence of incontinence and PUs in LTAC patients. Design This was a longitudinal, repeated-measures study; data were collected over a 12-week period. Subjects and setting One hundred seventy-one patients, with a median age of 55 years. Fifty-four women and 117 men were evaluated. The sample comprises all patients admitted to the 4 LTAC units at the Drake Center in Cincinnati, Ohio. Methods Patients were examined using the "Hospital Survey on Incontinence and Perineal Skin Injury" instrument within 24 hours of admission and they were reevaluated weekly using the same tool until discharge. All data were collected by the Drake Center Advanced Wound Team. Prevalence was defined as the frequency of PUs or IAD identified at admission. Incidence was calculated using the formula: the number of new IAD cases/the number of patients without IAD on admission. Pressure ulcer incidence was measured using 2 formulas: (1) the number of patients with new PUs/the number of all patients who did not have PU on admission and (2) the number of patients with new PUs or a PU in a new location/the number of all patients. Results Thirty-nine out of 171 patients had IAD on admission, yielding a prevalence of 22.8%. Sixty of 171 patients had a PU on admission, yielding a prevalence of 35.1%. Ten of 132 patients who did not have IAD at admission developed IAD during follow-ups, yielding a 7.6% incidence. Two PU incidence rates were measured; those patients without PUs on admission 3.6% (4/111) and all patients 8.2% (14/171). Conclusion The LTAC admission PU prevalence rate in this study was greater than that reported previously in acute or long-term care settings. The LTAC PU incidence rate was less than those reported for both acute and long-term care settings. The LTAC IAD admission prevalence rate closely reflected the acute care rate but was substantially higher than the long-term care rate.

Behavioral therapies for overactive bladder: making sense of the evidence.

Abstract: Overactive bladder (OAB) is a symptom-based syndrome characterized by the presence of urgency, which is defined as a sudden and compelling desire to void that cannot be postponed. OAB may significantly impact of quality of life. Numerous treatment options exist for OAB, including behavioral therapies such as pelvic floor muscle rehabilitation, bladder training, and dietary modification, as well as traditional therapies such as pharmacological therapy and neuromodulation. Behavioral therapies are considered the mainstay of treatment for urinary incontinence in general. However the efficacy of these noninvasive strategies for OAB treatment has not been well addressed in the literature. This article presents an overview of current evidence with attention to the clinical relevance of findings related to lifestyle modification, bladder training, and pelvic floor muscle training. Initial evidence suggests that obesity, smoking, and consumption of carbonated drinks are risk factors for OAB but there is less support for the contributory role of caffeine or the impact of caffeine reduction. The evidence supporting bladder training and pelvic floor muscle training is more consistent and a trend towards combining these therapies to treat OAB appears positive. Given the prevalence of OAB and growing support for the efficacy of behavioral treatments it is important and timely to augment existing evidence with well-designed multicenter trials.

Self-reported effect of childhood incontinence on quality of life.

Abstract: OBJECTIVE The aim of this study was to generate an understanding of the child's perception of the impact of bladder and bowel dysfunction on aspects of their life, in order to inform the later development of a continence-specific pediatric quality-of-life tool. DESIGN A 28-item instrument, measuring 6 domains of quality of life, was developed based on a modified Delphi consultation process and administered to children being treated for incontinence in 10 countries. RESULTS Data from 156 children between 6 and 17 years of age in Hong Kong, Japan, Australia, United States, Italy, Turkey, Germany, Holland, Belgium, and Denmark were analyzed. Mean domain scores, when ranked in descending order, were self-esteem 57%, mental health 52%, independence 48.5%, family 46%, social interaction 43%, and body image 39.5%. Significant variables associated with a high total score (indicating greater impairment in quality of life) were combined day-and-night symptoms (P = .031) and male gender (P = .027). All domain scores were more significantly impaired (higher scores) when a bowel disorder coexisted with bladder dysfunction. Low treatment efficacy was significantly associated with more impaired self-esteem and mental health scores (r = -0.125, P = .025; r = -0.241, P = .005; r = -0.174, P = .045, respectively). CONCLUSIONS Multiple domains reflecting quality-of-life effects are adversely affected in children with incontinence, indicating the need to measure the impact of impairment in affected children and the influence of treatment. Boys who experience day-and-night lower urinary tract symptoms and experience bowel dysfunction are at greatest risk.

New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care Present on Admission (POA) indicators/hospital-acquired conditions (HAC) policy. A consensus paper from the International Expert Wound Care Advisory Panel

Abstract: As part of the Deficit Reduction Act of 2005, the Centers for Medicare & Medicaid Services (CMS) initially identified eight preventable adverse events on August 1, 2007, with nine more conditions proposed on April 14, 2008.1,2 They have introduced a plan to help contain costs by rejecting payment of the higher diagnostic category when such events occur as a secondary diagnosis in acute care facilities. This policy, which began a phased rollout in the acute-care setting in October 2007 (culminating in October 2008), has created some logistical and implementation concerns in the clinical community. The financial implications for pressure ulcers will be determined by the Present on Admission Indicator (POA). The POA Indicator identifies if a patient has a pressure ulcer at the time the order for admission occurs. Now there is a renewed urgency and heightened focus on prevention because beginning in October of 2008, the hospital will not receive additional reimbursement to care for a patient who has acquired the pressure ulcer while under the hospital’s care. Like any groundbreaking policy, this provides impetus for change. We view this payment provision as challenging, but one that provides all clinicians and particularly wound care specialists with an opportunity to assume leadership in important preventive healthcare strategies. Pressure ulcers represent the possibility to implement best practices to improve outcomes. In FY 2007, CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnoses.2,3 The average cost per case in which pressure ulcers were listed as a secondary diagnosis is estimated to be $43,180 per hospital stay.2,3 The incidence of new pressure ulcers in acute-care patients is around 7 percent, with wide variability among institutions.4 The Medicare program’s hospital inpatient prospective payment system (PPS), as currently set forth, will no longer assign a higher DRG for facility-acquired pressure ulcers effective October 1, 2008.5 Physician/provider* determination and documentation during the hospitalization that J Wound Ostomy Continence Nurs. 2008;35(5):485-492. Published by Lippincott Williams & Wilkins

Intestinal diversion (colostomy or ileostomy) in patients with severe bowel dysfunction following spinal cord injury

Abstract: Background Spinal cord injury (SCI) affects motor and sensory nervous integrity resulting in paralysis of lower or both upper and lower extremities, as well as autonomic nervous system function resulting in neurogenic bowel. SCI leads to diminished or lost sensations of the need to defecate or inability to distinguish the presence of gas versus liquid versus solid stool in the rectal vault. Sensory loss, incomplete evacuation of stool from the rectal vault, immobility, and reduced anal sphincter tone increase the risk of fecal incontinence. Gastrointestinal symptoms are associated with depression, anxiety, and significant impairments in quality of life (QOL) in a significant portion of persons with SCI. Objectives 1. To compare clinical, functional, or quality of life outcomes in spinal cord injured patients with gastrointestinal symptoms managed by conservative measures versus intestinal diversion (colostomy or ileostomy). 2. To identify complications associated with ostomy surgery in patients with bowel dysfunction and SCI. Search strategy A systematic review of electronic databases MEDLINE and CINAHL (from January 1960 to November 2007) was undertaken using the following key words: (1) ostomy, (2) stoma, (3) colostomy, and (4) ileostomy. Boolean features of these databases were used to combine these terms with the key word "spinal cord injuries." Prospective and retrospective studies that directly compared clinical, functional, QOL outcomes or satisfaction among patients with intestinal diversions to patients managed by conservative means were included. Results Creation of an ostomy in selected patients provides equivocal or superior QOL outcomes when compared to conservative bowel management strategies. Both colostomy and ileostomy surgery significantly reduce the amount of time required for bowel management. Patients who undergo ostomy surgery tend to be satisfied with their surgery, and a significant portion report a desire to be counseled about this option earlier. There are no clear advantages when functional, clinical, or QOL outcomes associated with colostomy are compared to those seen in SCI patients undergoing ileostomy. Implications for practice 1. The WOC nurse plays a pivotal role in both conservative bowel management and the decision to undergo ostomy surgery. 2. Preoperative stoma site marking is vital for the best surgical outcome. 3. The system best suited to an individual is based on a variety of factors including but not limited to stoma location, type of effluent, peristomal plane and contours, and the individual's capabilities and preferences. 4. Some individuals with a sigmoid or descending colostomy may benefit from colostomy irrigation as a management method. 5. Postoperatively, assessment of pressure points for signs of tissue breakdown, evaluation of treatment methods for existing pressure ulcers with suitable modification, and support surface assessment should be included in ongoing annual follow-up visits.

Is ultrasonic mist therapy effective for debriding chronic wounds

Abstract: Background Ultrasonic mist debridement uses acoustic energy to remove devitalized tissue from the wound bed and to promote wound healing. Objectives We systematically reviewed the literature to determine whether ultrasonic mist therapy effectively removes necrotic debris from the bed of chronic wounds and promotes wound healing. Search strategy A systematic review of electronic databases MEDLINE and CINAHL (from January 1996 to February 2008) was undertaken using the key words: (1) therapeutic ultrasound, (2) ultrasonic, and (3) ultrasonic mist. Prospective studies that compared ultrasonic mist therapy to a sham device, to another debridement technique, or to alternative treatments for wound healing were included. Results There is insufficient evidence to determine whether ultrasonic mist therapy effectively debrides necrotic tissue in chronic wound beds. Limited evidence suggests that noncontact, low-hertz frequency ultrasonic mist therapy promotes wound healing when used in conjunction with standard wound therapy. Implications for practice Ultrasound treatment has been used on wounds associated with neuropathy, limb ischemia, venous insufficiency, trauma, as well as poorly healing surgical wounds. Few adverse effects have been noted. Pain, when reported, has been successfully addressed with topical analgesia.

Prevention and early detection of pressure ulcers in hospitalized patients.

Abstract: Skin integrity is identified as a measure of nursing care quality, yet pressure ulcers (PU) are a major health problem. Increasingly, patients admitted to acute care hospitals are older and possess multiple risk factors for PU development. The primary goal of this quality improvement project was to improve PU prevention and management. A secondary goal was to improve nursing documentation of PU prevention and intervention strategies. A preintervention, intervention, postintervention design was employed; the intervention included formal and informal education. Data were collected in 2 phases; Phase I occurred in a critical care unit and Phase II occurred on a medical-surgical unit. Demographics, PU incidence, risk factors, and comorbidity data were collected, along with nursing specific data. The results of this quality improvement project suggest that educational programs improve nursing care and documentation, and they raise additional questions regarding the concept of “avoidable versus unavoidable” PU in high-risk populations. ■ Background

The impact of stabilizing forces on postsurgical recovery in ostomy patients.

Abstract: Purpose Patient recovery from life-altering surgery is a complex event requiring interactions among multiple factors that influence recovery. Two such factors are occupational stability and spouse/partner relationship stability. Methods We surveyed persons who have undergone ostomy surgery. Subjects were recruited from the general population, without regard to geographic region or clinical setting. Participation in the study was voluntary; subjects had given prior permission to be contacted about survey-based research. Additional subjects were recruited from Web-based ostomy sites and local ostomy support group meetings. Instrument The survey instrument contains 113 items designed to investigate pre- and postsurgery aspects of the lives of those who have undergone ostomy surgery. Results Ostomates experiencing a postsurgery change in both occupation and work habits were significantly more likely to report a nonpositive life satisfaction score than those experiencing no postoperative change in occupation or work habit. Additionally, a stable spouse/life partner relationship emerged as predictive of positive life satisfaction scores. For those that were married prior to surgery and remained married after surgery, and in which there was no change in occupation or work habit, 95.7% reported a positive life satisfaction score. Conclusions Multiple stabilizing forces exist that influence the recovery of a patient following life-altering surgery such as creation of a stoma. Stability in occupation and spouse/partner relationship positively influenced life satisfaction scores following ostomy surgery.

Prevention of Pressure Ulcers A Descriptive Study in 3 Intensive Care Units in Turkey

Abstract: Purpose The aim of this descriptive study was to describe the level of preventive care provided to intensive care unit (ICU) patients at risk for development of pressure ulcers (PU). Setting and subjects Our study population comprised 126 nurses working at coronary ICU, cardiovascular surgery ICU, or a gastroenterology ICU of State Hospital in the Republic of Turkey. The study sample consisted of 30 nurses selected from these units using a layered sampling method. Instruments Data were collected using the following 4 forms: (1) ICU evaluation form, (2) demographic questionnaire form, (3) Braden Scale, and (4) observation form. The observation form was developed by the investigator to record PU prevention interventions made by the study nurses. Methods Nurses were observed while giving care to patients at risk according to Braden Scale scores and each action of the nurses to prevent PU was recorded. Data were collected until 90 observations (3 observations with each of 30 nurses) were completed. Results Nurses did not consistently engage in interventions recommended for prevention of PU. Subjects did not consistently use the risk-evaluation scale, document position changes on the appropriate form, and train auxiliary personnel about PU prevention. The most frequently fulfilled behaviors for PU prevention were avoiding hot water when cleansing the skin, helping the patient eat, avoiding placing the patient directly on a trochanter, refraining from using improper support material, and use of pressure-redistribution surfaces. The least fulfilled behaviors were (1) application of a skin barrier or protectant on moist skin and (2) application of a moisturizer to dry or compromised skin, protecting the skin during patient transfer, repositioning, and documenting prevention interventions. Conclusion This study demonstrates that critical care nurses do not consistently provide preventive care for PU.

Impact of tight glucose control on postoperative infection rates and wound healing in cardiac surgery patients.

Abstract: Approximately 1 of every 4 hospitalized patients has diabetes mellitus (DM). Type 2 DM is commonly associated with cardiovascular disease, and many undergo cardiothoracic surgical procedures such as coronary artery bypass grafting. Persons with type 2 DM are at higher risk for postoperative infections due to a muted immune response, the effects of hyperglycemia on neutrophil function and pathogen proliferation, and the negative effects of diminished perfusion. Hyperglycemia resulting from insulin resistance is common in critically ill patients, including those who have not previously been diagnosed with diabetes. Factors contributing to postoperative hyperglycemia include increased levels of catecholamines, growth hormone, and corticosteroids. Higher glucose levels may also result from pharmacologic agents commonly used during and following surgery, such as heparin and beta-blockers. Tight glucose control has been shown to improve survival and reduce morbidity after cardiac surgery and lower the incidence of wound complications. In contrast, the traditional approach to glucose management, sliding-scale insulin administration, does not provide adequate control. Continuous insulin infusion protocols may significantly reduce postoperative morbidity and mortality in patients with type 2 DM and hyperglycemia associated with metabolic syndrome.

Stoma surgery for colorectal cancer: a population-based study of patient concerns.

Abstract: OBJECTIVE: The difficulties and concerns of colorectal cancer patients with an ostomy are not well documented. This study describes the difficulties experienced by colorectal cancer patients with a temporary or permanent ostomy over the 2-year period following their diagnosis. Patients' satisfaction with the information provided to them by their healthcare providers was also assessed. METHODS: Colorectal cancer patients with an ostomy (N 5332) recruited through a cancer registry completed telephone interviews at approximately 5, 12, and 24 months following diagnosis. RESULTS: Painful or irritated peristomal skin and odor and noise from the appliance were the most commonly reported stoma-related difficulties. The proportion of participants reporting these difficulties decreased over time. Provision of preoperative information was comprehensive, and satisfaction with preoperative information was high. However, 34% of patients said they were not seen by an ostomy nurse prior to surgery. CONCLUSIONS: The ostomy nurse may be ideally placed to initiate, develop, and implement survivorship care plans for colorectal cancer patients.

The effect of Web-based Braden Scale training on the reliability and precision of Braden Scale pressure ulcer risk assessments.

Abstract: Objective To evaluate the effect of Web-based Braden Scale training on the reliability and precision of pressure ulcer risk assessments made by registered nurses (RN) working in acute care settings. Design Pretest-posttest, 2-group, quasi-experimental design. Setting and subjects Five hundred Braden Scale risk assessments were made on 102 acute care patients deemed to be at various levels of risk for pressure ulceration. Assessments were made by RNs working in acute care hospitals at 3 different medical centers where the Braden Scale was in regular daily use (2 medical centers) or new to the setting (1 medical center). Instrument The Braden Scale for Predicting Pressure Sore Risk was used to guide pressure ulcer risk assessments. A Web-based version of the Detroit Medical Center Braden Scale Computerized Training Module was used to teach nurses correct use of the Braden Scale and selection of risk-based pressure ulcer prevention interventions. Results In the aggregate, RN generated reliable Braden Scale pressure ulcer risk assessments 65% of the time after training. The effect of Web-based Braden Scale training on reliability and precision of assessments varied according to familiarity with the scale. With training, new users of the scale made reliable assessments 84% of the time and significantly improved precision of their assessments. The reliability and precision of Braden Scale risk assessments made by its regular users was unaffected by training. Conclusion Technology-assisted Braden Scale training improved both reliability and precision of risk assessments made by new users of the scale, but had virtually no effect on the reliability or precision of risk assessments made by regular users of the instrument. Further research is needed to determine best approaches for improving reliability and precision of Braden Scale assessments made by its regular users.

Emerging options for the management of fecal incontinence in hospitalized patients.

Abstract: Fecal incontinence is a common problem among hospitalized patients. It predisposes them to complications such as infections and pressure ulcers, resulting in added morbidity and increased length of stay. Despite the prevalence and clinical implications of fecal incontinence, relatively few well-designed studies have been completed assisting clinicians to determine which management strategies prevent complications most effectively. This article will review the prevalence and consequences of fecal incontinence in hospitalized patients and will provide practical suggestions for the management of fecal incontinence, including both traditional care according to clinical guidelines and the role of newer fecal collection devices.

History of ostomy surgery.

Abstract: Development of Colostomy: Indications and Construction Only sporadic accounts of ostomy surgery can be found before the 1700s. Throughout the 18th century, accepted management of intestinal perforation was to close any open abdominal wound and “hope for the best.” This treatment plan was (not surprisingly) associated with extremely high mortality rates. The earliest stomas were actually fistulas that developed spontaneously following bowel perforation; one surgeon noted the correlation between spontaneous fistula development and patient survival and stated in his journal that perhaps surgeons should “take a lesson from Mother Nature” and construct planned stomas in such cases.1,2 Any surgical advance during this period was significantly complicated by the absence of anesthesia and asepsis, which of course resulted in extremely reluctant patients and dismal outcomes. In the late 18th century (1793), an innovative surgeon performed a colostomy on a 3-day-old infant with an imperforate anus; to prepare for the procedure, he practiced on the bodies of dead babies he obtained from the city’s poorhouse. The surgery was successful, and the patient lived to the age of 45, though we lack any data as to how he actually managed the stoma.1,2 Following the development of anesthesia during the mid-1800s, surgery became a realistic treatment option; surgeons in the mid-1800s to late-1800s used diverting colostomy to manage bowel obstruction and also tried to cure patients with rectal cancer by surgical excision of the rectum (narrow abdominal perineal resection of rectum [APR]). Unfortunately, these early attempts to cure rectal cancer with APR were associated with a 100% recurrence rate, because only the rectum and anal canal were removed. Surgeons learned quickly from these failures, and in the early 1900s surgeons Mayo and Miles modified the APR procedure to include radical resection of the perirectal tissue and lymphatics as well as the rectum and anal canal.1-4 During the early 1900s, surgeons also found that proximal colostomy could be used to protect a distal anastomosis and to reduce postoperative complications.1 Early decompressive and protective colostomies were typically constructed as skin-level “loop” ostomies. They provided effective decompression of an obstructed bowel but only partial diversion of the stool, and they proved quite difficult to manage. In 1888, the support rod was introduced to prevent retraction of the loop stoma until it had granulated to the abdominal wall. The use of rods was a major advance, in that it produced a protruding stoma that provided almost complete diversion of the fecal stream.1,5 At this time, the standard of care was to leave the loop stoma closed until several days following surgery, at which point the anterior wall of the loop was opened with cautery at the patient’s bedside. The procedure was not painful but it frequently was traumatic since the patient could smell the burning tissue, and it meant that the stoma had to “self-mature” via gradual self-eversion to expose the mucosal layer of the bowel. This changed in the 1950s, when Dr Bryan Brooke made surgical maturation the standard of care for ileostomy; subsequently surgical maturation became the standard of care for colostomy construction as well.1,5,6 Henry Hartmann popularized the concept of delayed anastomosis (and the Hartmann’s Pouch) when he lectured in America during the early 1900s on his technique for managing obstructing sigmoid tumors: removal of the involved segment of bowel, closure of the distal stump, and formation of an end colostomy.1,5 Mikulicz-Radecki proposed another option for temporary diversion following bowel resection; he recommended bringing the proximal and distal segments of the bowel out as 2 side-by-side skin-level stomas, and he further recommended using a crushing clamp to create a fistula between the 2 loops of bowel (and thus restore intestinal continuity) once it was deemed safe for stool to pass through the distal bowel. He

Is larval (maggot) debridement effective for removal of necrotic tissue from chronic wounds

Abstract: Background Debridement is considered an essential component of wound bed preparation. Multiple techniques for removing necrotic tissue from wounds have been identified, but evidence concerning the efficacy and indications for each technique varies. Objectives We sought to identify evidence related to the efficacy of maggot (larval) debridement for the removal of necrotic tissue and its impact on wound healing. Search strategy A systematic review of electronic databases was undertaken using the following key words: (1) debridement, (2) maggot therapy, and (3) larval therapy. All prospective and retrospective studies published between January 1960 and February 2008 that compared maggot (larval) debridement therapy for pressure ulcers, leg ulcers, or burn wounds to autolytic debridement or other debridement techniques were included in the review. Results The evidence base for the efficacy of maggot debridement therapy (MDT) in the management of necrotic wounds is sparse. There is insufficient evidence to conclude that MDT is as effective as or more effective than other debridement methods, or that MDT promotes wound healing. Implications for practice Even though clinical evidence supporting the use of MDT for debridement of wounds is lacking, clinical experience strongly suggests that this technique is an effective and safe method of debridement for selected patients. Expert clinicians with extensive experience using this technique usually advocate MDT as a last resort treatment when conservative means for wound bed preparation prove unsuccessful or when surgery is not feasible owing to comorbid conditions or other considerations.

Bibliographic citation management software as a tool for building knowledge.

Abstract: Conducting literature reviews is an essential tool for knowledge building in nursing and health science. There are many reasons to conduct literature reviews, including preparation of an article for a peer-reviewed journal or research grant proposals, completion of requirements for academic degrees,

Systematic reviews and meta-analysis: studies of studies.

Abstract: Systematic reviews are designed to answer a focused clinical question. They employ a predetermined explicit methodology to comprehensively search for, select, appraise, and analyze studies. Meta-analysis is the statistical pooling of the results of studies that are part of a systematic review. Systematic reviews are research studies and, like other studies, they need to be based on a structured and valid methodology and take measures to minimize bias. High-quality systematic reviews can be powerful tools to support clinical decision-making, as well as summarize current knowledge in relation to an area of research interest. This article describes the methodology that should be used when doing a systematic review, presents guidelines for reporting the review, and provides a guideline for critically appraising published reviews.

The case for evidence in wound care: investigating advanced treatment modalities in healing chronic diabetic lower extremity wounds.

Abstract: BACKGROUND Major complications of diabetes mellitus include lower leg and foot ulcers, which can result in amputation. Further study is needed to determine optimal treatments for these challenging wounds. Growth factor therapy and hyperbaric oxygen (HBO) treatments are 2 advanced therapeutic modalities that hold promise. PURPOSE This descriptive, retrospective review investigated healing rates of patients with diabetes mellitus and lower- extremity ulcers managed by growth factor therapy and HBO as compared to standard wound care. DESIGN Retrospective review of medical records. SUBJECTS AND SETTING We reviewed medical records of 89 patients with diabetes and lower-extremity wounds treated at a major outpatient wound care program in the southwestern United States. METHODS Patients were categorized according to 4 treatment modalities: (1) standard wound care, (2) growth factor therapy, (3) standard wound care plus HBO, and (4) growth factor therapy plus HBO. Wounds were measured at the start of the analysis and then weekly for a total of 8 weeks. The change in wound volume from the first to the eighth week was recorded. RESULTS All patient groups demonstrated healing with the patients who received growth factor therapy alone and those who received growth factor therapy and the HBO treatments demonstrating the greatest decrease in wound volume over the 8 weeks. A 2-by-2 factorial analysis of covariance demonstrated that patients who received HBO as part of their wound care regimen demonstrated significantly greater healing than patients who received only standard wound care or growth factor therapy (P < .0001). Although the combination of hyperbaric and growth factor therapy did not show significant synergistic effects for wound healing in this study, it should be noted that the mean size of the wounds in this group was 2.8 times larger than the mean size of the wounds in the other groups. CONCLUSION Patients managed in a state-of-the-art wound care center experienced progress toward wound healing, regardless of the treatment modality selected. Those who received HBO as part of their wound care regimen healed faster than those who received standard treatment or growth factor therapy.

Reducing hospital-acquired heel ulcer rates in an acute care facility: an evaluation of a nurse-driven performance improvement project.

Abstract: Purpose A nurse-driven performance improvement project designed to reduce the incidence of hospital-acquired ulcers of the heel in an acute care setting was evaluated. Design This was a descriptive evaluative study using secondary data analysis. Data were collected in 2004, prior to implementation of the prevention project and compared to results obtained in 2006, after the project was implemented. Subjects and setting Data were collected in a 172-bed, not-for-profit inpatient acute care facility in North Central California. All medical-surgical inpatients aged 18 years and older were included in the samples. Data were collected on 113 inpatients prior to implementation of the project in 2004. Data were also collected on a sample of 124 inpatients in 2006. Methods The prevalence and incidence of heel pressure ulcers were obtained through skin surveys prior to implementation of the prevention program and following its implementation. Results from 2004 were compared to data collected in 2006 after introduction of the Braden Scale for Predicting Pressure Sore Risk. Heel pressure ulcers were staged using the National Pressure Ulcer Advisory Panel (NPUAP) staging system and recommendations provided by the Agency for Health Care Quality Research (AHRQ) clinical practice guidelines. Results The incidence of hospital-acquired heel pressure ulcers in 2004 was 13.5% (4 of 37 patients). After implementation of the program in 2006, the incidence of hospital-acquired heel pressure ulcers was 13.8% (5 of 36 patients). Conclusions The intervention did not appear to receive adequate staff nurse support needed to make the project successful. Factors that influenced the lack of support may have included: (1) educational method used, (2) lack of organization approved, evidenced-based standardized protocols for prevention and treatment of heel ulcers, and (3) failure of facility management to convey the importance as well as their support for the project.

Pulsed radio frequency energy in the treatment of complex diabetic foot wounds: two cases.

Abstract: The use of radio waves (pulsed radio frequency energy) has become well accepted in the treatment of chronic wounds. We present 2 cases of complex diabetic foot wounds treated adjunctively with outpatient pulsed radio frequency energy using a solid-state, 27.12 MHz fixed power output radio frequency generator that transmits a fixed dose of nonionizing, nonthermal electromagnetic energy through an applicator pad. This therapy, in combination with offloading, debridement and advanced dressings, resulted in closure of both wounds in approximately 16 weeks.

Urological care of the spinal cord-injured patient.

Abstract: Spinal cord injury (SCI) is a catastrophic occurrence affecting the lives of 11,000 people in the United States every year. Urologic complications account for much of the morbidity associated with SCI and as much as 15% of the associated mortality. Spinal cord-injured patients are required to digest a plethora of self-management information during the emotionally and psychologically distressing period immediately following their injury. As a vital resource in the SCI patients' recovery process, it is crucial for the WOC nurse to have knowledge of the specialized needs of this population. This article reviews the effects of SCI on bladder function, discusses potential complications of the neurogenic bladder, and provides an overview of management options to assist the patient in adaptation and restoration of quality of life.

Ostomy pouch wear time in the United States.

Abstract: PURPOSE The purpose of this study was to determine average pouch wear times of persons with an ostomy living in the United States. SUBJECTS AND SETTING In this national survey, subjects were identified by ostomy nurses and through ostomy support groups in the United States. Participants responding to a survey represented all 6 geographic regions of the United States identified by US Bureau of Census. DESIGN AND PROCEDURE Persons with colostomies, ileostomies, and urostomies were queried concerning their average pouch wear time. RESULTS The mean wear time for ostomy pouches in the United States is 4.8 days. Persons with urostomies reported an average wear time of 5.02 days (SD = 1.74), those with ileostomies reported 5.01 days (SD = 2.25), and those with colostomies reported an average of 4.55 days (SD = 2.08). CONCLUSIONS This study is the first of its kind to utilize a large, national sample to determine average wear time of ostomy pouches. Further research is needed to establish a benchmark for ostomy pouch wear time in the United States and to determine what factors affect wear time.

An innovative enterostomal therapy nurse model of community wound care delivery: a retrospective cost-effectiveness analysis.

Abstract: Purpose A Canadian specialty nursing association identified the necessity to examine the role and impact of enterostomal (ET) nursing in Canada. We completed a retrospective analysis of the cost-effectiveness and benefits of ET nurse-driven resources for the treatment of acute and chronic wounds in the community. Design This was a multicenter retrospective pragmatic chart audit of 3 models of nursing care utilizing 4 community nursing agencies and 1 specialty company owned and operated by ET nurses. An analysis was completed using quantitative methods to evaluate healing outcomes, nursing costs, and cost-effectiveness. Main outcome measures Kaplan-Meier estimates were calculated to determine the average time to 100% healing of acute and chronic wounds and total nursing visit costs for treatment in a community setting. Average direct nursing costs related to management of each wound were determined by number of nursing visits and related reimbursement for each visit. A Monte Carlo simulation method was used to help account for costs and benefits in determination of cost-effectiveness between caring groups and the uncertainty from variation between patients and wounds. Results Three hundred sixty chronic wounds and 54 acute surgical wound charts were audited. Involvement of a registered nurse (RN) with ET or advanced wound ostomy skills (AWOS) in community-level chronic and acute wound care was associated with lower overall costs mainly due to reduced time to 100% closure of the wound and reduced number of nursing visits. The differences in health benefits and total costs of nursing care between the ET/AWOS and a hybrid group that includes interventions developed by an ET nurse and followed by general visiting nurses that could include both RNs and registered practical nurses is an expected reduction in healing times of 45 days and an expected cost difference of $5927.00 per chronic wound treated. When outcomes were broken into ET/AWOS involvement categories for treatment of chronic wounds, there was a significantly faster time to 100% closure at a lower mean cost as the ET/AWOS involvement increased in the case. For acute wound treatment, the differences in health benefits and total costs between the ET/AWOS and a hybrid nursing care model were an expected reduction in healing times of 95 days and an expected cost difference of $9578.00 per acute wound treated. Again, there was a significant difference in healing times and reduced mean cost as the ET/AWOS became more involved in the treatment. The financial benefit to the Ontario Ministry of Health and Long-Term Care is estimated to increase as the involvement of nurses with ET/AWOS specialty training increases. Conclusions The greater the involvement both directly and indirectly of an ET/AWOS nurse in the management of wounds, the greater the savings and the shorter the healing times.

Use of an absorbent dressing specifically for fecal incontinence.

Abstract: PURPOSE Use of an absorbent product is a self-care strategy for managing fecal incontinence that protects against visible soiling. The purpose of this study was to examine use of a small surgical dressing that can be placed between the buttocks to absorb leaked feces. DESIGN Cross-sectional survey. SUBJECTS AND SETTING A survey was mailed to 75 randomly selected community-living people in 25 states and the District of Columbia, who ordered the dressing more than once within the past year. Thirty-six people (age = 55 ± 16 years mean ± SD), 57% men and 94% white responded. INSTRUMENT A 48-question survey that included questions asked about demographics and general health, emotional states (eg, anxiety and depression), bowel pattern and incontinence, quality of life, and use of an anorectal dressing was developed for this study. The survey also contained 2 tools, the Fecal Incontinence Severity Index and the Fecal Incontinence Quality of Life instrument. The Fecal Incontinence Severity Index is a tool that enables valid assessment of fecal incontinence severity using patient recall of symptoms of frequency and type of bowel leakage. The Fecal Incontinence Quality of Life instrument results in a valid and reliable evaluation of fecal incontinence–specific quality of life using 4 domains of lifestyle, coping/behavior, depression/self-perception, and embarrassment. RESULTS The fecal incontinence severity score was 28 ± 14 (mean ± SD); 79% leaked loose/liquid feces, 50% leaked daily, and leaked feces remained between the buttocks in 64%; 21% also leaked urine. Eighty-five percent experienced incontinence-associated dermatitis. Of those who used the dressing, 50% were men. The anorectal dressing was preferred to a pad by 92%, prevented soiling in 88%, and its ability to stay in place was rated very good or good by 76%. Eighty percent of respondents rated the dressing's comfort very good or good; 85% rated its overall effectiveness very good or good. Use of the dressing lessened anxiety about fecal soiling in 81% and was thought to improve quality of life in 76%. CONCLUSION An anorectal dressing offers an effective, comfortable alternative to a pad for absorbing leaked feces that seems acceptable to men.

Continence care for older people in England and Wales: data from a national audit.

Abstract: Introduction A number of policy documents have identified deficiencies in continence services in England and Wales, and have called for the development of integrated services. A national audit was conducted to assess the quality of continence care for older people and whether these requirements have been met. Methods The audit studied incontinent individuals aged 65 years and older. Each site returned data on organizational structure and the process of 20 patient's care. Data were submitted via the Internet, all were anonymous. Results The national audit was conducted across England, Wales, and Northern Ireland. Data on the care of patients/residents with bladder problems were returned by 141 of 326 (43%) Primary Care Trusts, 159 of 196 (81%) secondary/acute care trusts (198 hospitals), and 29 of 309 (9%) invited care homes. Fifty-eight percent of Primary Care Trusts, 48% of hospitals, and 74% of care homes reported that integrated continence services existed in their area. While basic provision of care appeared to be in place, the audit identified deficiencies in the organization of services and in the assessment and management of urinary incontinence in the elderly. Conclusion The requirement for integrated continence services has not yet been met. Assessment and care by professionals directly looking after the older person were often lacking. There is an urgent need to reestablish the fundamentals of continence care into the practice of medical and nursing staff, and action needs to be taken with regard to the establishment of truly integrated quality services in this neglected area of practice.