Ostomy Wound Management最新文献

The optimal timing of loop ileostomy reversal remains largely unknown, but evidence that delayed ileostomy closure may increase postoperative complication rates is increasing.

Purpose: Retrospective research was conducted to compare outcomes between patients who had early (<6 months) or late (>6 months) loop ileostomy closure.

Methods: Records of patients >18 years of age who underwent circumstomal reversal of a loop ileostomy over a period of 5 years in 1 hospital's colorectal unit were abstracted and analyzed. Data from patients who had a planned or conversion to laparotomy, a concurrent bowel resection, reversal of double-barrel small bowel and colonic stomas, or closure of an end ileostomy or patients whose records were incomplete were excluded. Demographic information, American Society of Anesthesiologists (ASA) grade, primary operation indication, surgery and inpatient dates, readmission within 30 days of discharge, reasons for readmission, complication type, and Clavien-Dindo classification were extracted and compared between early and late closure groups using independent-sample t test and Fisher's exact test.

Results: Among the 75 study participants, 25 had an early closure (mean age 68.6 [range 26 - 93] years, mean time since primary surgery 3.8 months) and 50 had a late closure procedure (mean age 71.6 [range 46 - 93] years, mean time since primary surgery 12.8 months). Gender distribution, ASA grades, primary surgery indication, and total number of readmissions were similar between the 2 groups. Hospital length of stay was significantly shorter (5.5 days vs 9.4 days; P = .01) and average number of complications was significantly lower (0.33 vs 0.61; P = .04) in the early closure group. Rates of postoperative ileus, anastomotic bleed, and wound-related complications were not significantly different.

Conclusion: Hospital length of stay and average number of postoperative complications following circumstomal loop ileostomy closure were significantly lower in the early than in the late closure group. Additional studies are warranted to help guide practice.

Pain during negative pressure wound therapy (NPWT) has been reported in the literature.

Purpose: The study was conducted to describe patients' pain experience, pain-coping skills, and the effect of NPWT-related pain on daily life activities following abdominal surgery.

Method: Using a descriptive, qualitative design, semi-structured face-to-face interviews were conducted between April 3, 2016 and December 26, 2016, in the surgical ward of a university hospital in Edirne, Turkey. Patients aged ≥18, receiving NPWT, who had at least 1 dressing change, and with no diagnosis of diabetes mellitus or neurological disease were included. Interviews were conducted at the patients' bedside 1 day after wound debridement. All wounds were covered with the NPWT black foam dressing, and NPWT settings were -50 mm Hg to -125 mm Hg. One (1) researcher led the interviews using a voice-recorder while 2 researchers observed and took notes. Data were analyzed using Colaizzi's phenomenological method.

Results: The themes identified were: 1) pain experience, 2) pain coping, 3) pain prevention, and 4) affects daily life activity. Patients mostly reported pain during foam dressing changes and wrap removal unless the dressing change occurred while receiving anesthesia. Self-applied pain-coping strategies between dressing changes included limiting mobility, trying not to cough, applying pressure, or walking; these strategies were mostly ineffective. The results are supported by many findings from other studies investigating the effects of NPWT on patient pain.

Conclusion: This study provides further insight into the patients' wound pain experiences during NPWT and its effect on daily activities. Increased awareness about NPWT-associated pain and pain control measures as well as qualitative and controlled quantitative studies are needed. Inservice training and educational meetings should be conducted at surgical clinics to expand surgical nurse and physician knowledge and awareness of how to efficiently manage pain during NPWT treatment and related procedures.

Incontinence-associated dermatitis (IAD) is a common, painful, difficult-to-treat skin condition.

Purpose: A 2-part, quasi-experimental, post-test study was conducted to evaluate the impact of prevention initiatives on IAD prevalence and incontinence practices.

Method: In part 1, from May 2017 to November 2017, a quasi-experimental post-test study design was conducted in a health district in Australia. Following an audit of IAD prevalence and identification of evidence practice gaps in 4 hospitals in a local health district (12 wards, 250 patients), an implementation science approach was used to implement evidence-based initiatives. An IAD committee was formed, staff were educated about correct incontinence pad sizing, washable and disposable underpads and plastic sheets were removed from the care setting, and barrier cream cloths for cleansing, moisturizing, and protecting skin were introduced. Patients admitted to 1 of the 12 wards who were ≥18 years of age were recruited for participation and evaluation in the post-intervention implementation IAD and incontinence care practices audit. Post-intervention data were entered into a software program and compared to pre-implementation data using descriptive and bivariate statistics. In part 2, nurses from the 12 wards were asked to participate in 1 of 6 focus groups to share their impressions about the barrier cream cloths. Discussions were transcribed verbatim and analyzed using descriptive content analysis.

Results: The rate of incontinence among audited patients (N= 259, 132 men, 124 women; mean age 73.2 ± 16.8 years) was 47.2% (119/252) and 2/259 (0.8%) had a pressure injury (PI). IAD prevalence was significantly lower in the post- than in the pre-implementation audit (6/259 vs 23/250, P = .015), as was hospital-acquired pressure injury (9/250 [3.6%] vs 2/259 [0.08%]) and the use of bed protection layers (154/238 vs 6/259; P <.01). The focus groups included 31 nurses (25 women, 6 men). Four (4) themes emerged: 1) benefits to the patient (eg, improved skin condition), 2) usability (eg, fewer steps), 3) problems encountered (eg, not seeing the barrier in place), and 4) related factors. Patient comfort was cited frequently as an important benefit.

Conclusion: Evidence-based initiatives led to a significant reduction in IAD prevalence and improved incontinence care practices. .

Preventing, identifying, and treating deep tissue injury (DTI) remains a challenge.

Purpose: The purpose of the current research was to describe the characteristics of DTIs and patient/care variables that may affect their development and outcomes at the time of hospital discharge.

Methods: A retrospective, descriptive, single-site cohort study of electronic medical records was conducted between October 1, 2010, and September 30, 2012, to identify common demographic, intrinsic (eg, mobility status, medical comorbidities, and incontinence), extrinsic (ie, surgical and procedural events, medical devices, head-of-bed elevation), and care and treatment factors related to outcomes of hospital-acquired DTIs; additional data points related to DTI development or descriptive of the sample (Braden Scale scores and subscale scores, hospital length of stay [LOS], intensive care unit [ICU] LOS, days from admission to DTI, time in the operating room, serum albumin levels, support surfaces/specialty beds, and DTI locations) also were retrieved. DTI healing outcomes, grouped by resolved, partial-thickness/stable, and full-thickness/unstageable, and 30 main patient/treatment variables were analyzed using Kruskal-Wallis, chi-squared, and Fischer exact tests.

Results: One hundred, seventy-nine (179) DTIs occurred in 141 adult patients (132 in men, 47 in women; mean patient age 64 [range 19-94]). Of those patients, 110 had a history of peripheral vascular disease and 122 had hypertension. Sixty-nine (69) DTIs were documented in patients who died within 1 year of occurrence. Most common DTI sites were the coccyx (47 [26%]) and heel (42 [23%]); 41 (22%) were device-related. Median hospital LOS was 23 (range 4-258) days and median ICU LOS was 12 (range 1-173) days; 40 DTIs were identified before surgery and 120 after a diagnostic or therapeutic procedure. Data for DTI outcome groups at hospital discharge included 28 resolved, 131 partial-thickness/stable, and 20 full-thickness/unstageable; factors significantly different between outcome groups included mechanical ventilation (15/42/12; P = .01), use of a feeding tube (15/46/12; P = .02), anemia (14/30/9; P = .005), history of cerebrovascular accident (12/27/7; P = .03), hospital LOS (67/18/37.5; P <.001), ICU LOS (23/10/12; P = .03), time-to-event (13.5/8/9; P = .001), vasopressor use after DTI (13/31/11; P = .003), low-air-loss surface (10/9/3; P = .005), and device-related (14/24/4; P = .002).

Conclusion: DTI risk factors mirrored those of other PUs, but progression to full-thickness injury was not inevitable. Early and frequent assessment and timely intervention may help prevent DTI progression.