Some of nursings most avid innovators are wound and ostomy care nurses. Their everyday crusade for better wound healing with reduced pain, complications and emotional effects prompts them to devise new options and research earnestly to promote healing and patient comfort.
Janice Beitz, PhD, RN, CS, CNOR, CWOCN, CRNP, APN, C, MAPWCA, director of the recently inaugurated WOCN program at Rutgers School of Nursing, Camden, N.J., said she and other nurse researchers have been creating, testing and refining algorithms for nursing care. Were testing whether these algorithms have the right stuff and whether they really work in practice, she said.
One of the four topics where Beitz and her colleagues have developed these algorithms is for preventing pressure ulcers. She said their one-page, 26-step visual algorithm helps nurses understand and prevent pressure ulcer formation. The great strength of this is that it captures much research evidence on various patient risk factors that are routinely collected and modifiable, and places them in one succinct visual aid, Beitz said.
She also observed that in wound and ostomy care, best practices regularly overlap with ongoing research. Many, many nurses who are wound care specialists are involved in developing best practice documents, she said. Beitz and a colleague recently published a paper reporting on a survey on stomal and peristomal complications, which they conducted among wound and ostomy nurses. The survey results, she said, have led to best practices supported by evidence, as well as the revelation of interventions that previously had not been well known.
One promising topical therapy Beitz has become aware of is the application of crushed steroid tablets. Lynn DeMartyn, BSN, RN, CWOCN, a wound care nurse for Pinnacle Health System in Harrisburg, Pa., is one of three nurses who recently published their experience with the use of dry topical corticosteroids to combat peristomal pyoderma gangrenosum.
With the approval of the colorectal surgeon, DeMartyn said she tried this treatment with a patient after considering that we couldnt get pyodermas healed; it was very frustrating because the patients had ostomies that couldnt maintain a seal. There was skin breakdown and they took forever to heal.
DeMartyn said her approach to these kinds of problems was to go back to her nursing textbooks and apply the basics of ET nursing practice which led her to crush some prednisone tablets and mix them with stomal powder for a dry topical agent. Over four weeks of at-home treatment, the patients PPG resolved and he was able to maintain a pouch seal.
This treatment will be the topic of upcoming research, DeMartyn said, adding she will continue to apply best practices by seeking answers in current literature, finding what hasnt been done, then taking that direction.
Patrice Dillow, MSN, RN, CWOCN, APRN, has encountered success in preventing dehiscence of wounds after hyperthermic peritoneal chemotherapy using closed incisional wound vacs (negative pressure wound therapy). These incisions have a national dehiscence rate of about 30%, but when we started using the wound vac, we dont have the big, gaping wounds we used to have, she said.
Dillow said she and colleagues at the Cancer Treatment Centers of America at Midwestern Regional Medical Center in Zion, Ill., have been using this preventive method for 6-8 months, maintaining the vac in place for 14 days, twice as long as is typically seen.
Were also doing prevention of PU with foam dressing before surgery; were instituting this hospitalwide. Dillow uses the dressings with Medihoney, another common topical she frequently applies. We use the foam dressing preventively on people with bony tailbones or on facial cancer where the skin is very fragile.
With pressure ulcers, Dillow said, she teaches her staff not to rely on the Braden risk assessment score alone. Instead, she instructs nurses to use their assessment skills to note situations that predispose to PU, but which are not part of the Braden scale.
Maybe the patients nutrition is down, maybe they have a lack of mobility so they scoot to get up. A patient sitting at a 45-degree angle most of the day due to respiratory issues is another example. Nothing replaces two eyes, and using touch and hearing in nursing assessment, Dillow said.
Looking forward, Dillow said, she is anticipating new information that will lead to more preventative options. One cool thing thats happening in pressure ulcer research is tissue engineering, she said.
Were seeing more mechanical and biochemical engineers looking at how load develops in tissues, not just on the surface, but internally where we cant see. This kind of research, she said, enables scientists to walk down to the cell level in the lab, and see how load is affecting tissue.
This will let us know when we need to institute preventative care, because we can predict tissue injury, we can know through this new research, much more exactly how the cells below the skin surface will react.