Ostomy 101: Colostomy, ileostomy, and urostomy

Colostomy, ileostomy, and urostomy

By Jackie Doubleman, BSN, RN, CWOCN

Most patients are distressed to learn they need ostomy surgery to divert stool, urine, or both. Adapting to ostomy surgery can be difficult at best, even with today’s advanced technology and the wide assortment of ostomy supplies available. While recovering from the surgery itself, patients must learn how to contain or control feces or urine and how to minimize odor—without feeling like a social outcast.

This article reviews three types of ostomy surgery—colostomy, ileostomy, and urostomy. Subsequent articles will discuss ostomy management and treatment of stomal and peristomal skin complications. (more…)

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How to keep your communications professional

By Kathleen D. Pagana, PhD, RN

As clinicians, we’re proud of the expert care we provide patients. But we also know that just doing our job isn’t enough to advance our careers. Mastering good communication skills is essential for all clinicians at all career stages—especially with today’s flatter organizational structures and more participatory management styles. Knowing how to communicate in a professional manner can give you the edge you need for career advancement.

Opportunity rarely knocks any more. Instead it may present as a phone call, voice mail, e-mail, or text message. Be sure to use proper etiquette with all communication forms.

Speaking with managers

When dealing with your manager, use a solution-focused approach. Don’t be a complainer. Some communication experts point out that people complain about things they can do something about—not things they have no power over. For example, they don’t complain about their foot size because there’s nothing they can do about it. Yet people often complain about their jobs because they’re unwilling to take the risk of making a change.

We need to take charge of our lives. We can accept the fact—without complaining—that we’re making the choice to stay where we are. Or we can make a request or take action to achieve a desired outcome. Suppose you work on a clinical unit and disagree with the way your manager makes clinical assignments. You have several options:

  • Complain to coworkers and make the workplace miserable for others.
  • Speak with your manager and make suggestions for improvement.
  • Leave your job and go elsewhere if you can’t work with your manager to make things better.

If you decide to stay in your job, accept the fact that you’ve made that choice. Take responsibility for it and stop complaining.

Speaking on the phone with physicians

For clinicians who are not physicians, the key to effective communication with physicians is to remember you’re an important member of the healthcare team. An effective way to guide your communication with physicians and other colleagues is to use a tool such as SBAR (Situation, Background, Assessment, Recommendation). Say, for instance, you want to suggest the doctor order an anxiolytic for your patient. Here’s how you might do it using SBAR:

Situation: “Mrs. Smith is complaining of severe anxiety.”
Background: “She is 1 day post-op from a lumbar laminectomy.”
Assessment: “She is alert and oriented and her vital signs are stable. She has no numbness or tingling in her extremities.”
Recommendation: “She said she takes lorazepam 2 mg orally at when she’s anxious. Would you like to order something for her?”

Before ending the conversation, repeat and clarify the medication order (if the doctor gives one).


The sound of your voice and your manners are essential components of phone etiquette. Smile—the smile on your face comes through in your voice. Here are five more tips:

  1. Get yourself organized before placing the call.
  2. Minimize background noise.
  3. Immediately identify yourself. Don’t assume the recipient will recognize your voice.
  4. Concentrate on listening and avoid multitasking.
  5. Schedule phone conversations to avoid playing phone tag.

Voice mail

Voice mail is an efficient way to communicate. Again, five tips:

  1. Always be prepared to leave a message. Jot down your key message points before you call, to avoid stuttering and stammering.
  2. Be concise and to the point.
  3. State your name and the date, time, and purpose of your call.
  4. Enunciate clearly and speak slowly.
  5. State your name and phone number twice at the end of the message so the recipient doesn’t need to replay your message.


In many business settings, e-mail has almost replaced letters and memos. In many cases, an e-mail is a recipient’s first impression of you, so follow these tips:

  1. Make the subject line specific. This helps the reader prioritize the message and file it for easy retrieval.
  2. Use a greeting and a close. It’s more polite and less impersonal.
  3. Keep your message concise.
  4. Keep your tone polite and businesslike.
  5. Use your e-mail signature function, which provides several ways to contact you.

Text messages

This form of communication can be the most challenging and unpredictable. Some people send text messages routinely, while others may be unfamiliar with this method. You can’t go too far wrong if you take this advice:

  1. Get to the point quickly. No one wants to read a long message on a mobile phone.
  2. Don’t text during meetings. It’s rude to do so, and others can hear you clicking away or see the light from your screen.
  3. Consider the recipient before using text abbreviations. Some people may not understand text lingo.
  4. Consider the time when sending a text. Although you may be awake at 5 a.m., the sound of your incoming message might disturb a sleeping recipient.
  5. Don’t expect an immediate response to your text. If the message is time sensitive, pick up the phone instead.

Improving the way we speak with managers and physicians can go a long way toward career advancement and professional satisfaction. Common courtesy is just as essential in e-mail, voice mail, and text messages as in face-to-face communication. When you follow the guidelines I’ve given, you’ll elevate your professional communications a few notches.

Selected references
Canfield J, Switzer J. The Success Principles: How to Get from Where You Are to Where You Want to Be. New York, NY: Morrow; 2006.

Kramer M, Schmalenberg, C. Confirmation of a healthy work environment. Crit Care Nurse. 2008 Apr;28(2):56-63.

Pagana K. The Nurse’s Communication Advantage: How Business Savvy Communication Can Advance Your Nursing Career. Indianapolis, IN: Sigma Theta Tau International; 2011.

Pagana K. The Nurse’s Etiquette Advantage: How Professional Etiquette Can Advance Your Nursing Career. Indianapolis, IN: Sigma Theta Tau International; 2008.

A keynote speaker, Kathleen D. Pagana is a professor emeritus at Lycoming College in Williamsport, Pennsylvania, and president of Pagana Keynotes and Presentations. She is the author of The Nurse’s Communication Advantage and The Nurse’s Etiquette Advantage. To contact her, visit www.KathleenPagana.com.

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Clinician Resources


Here are resources that can help you in your busy clinical practice by giving you information quickly.

Pressure ulcer resources

Instead of searching through Google or another search engine for pressure ulcer resources, start with this comprehensive list on the Centers for Medicare & Medicaid Services website.
Examples of resources included are:

  • “Preventing pressure ulcers in hospitals: A toolkit for improving quality of care.” This toolkit from the Agency for Healthcare Research and Quality (AHRQ) is designed to help hospitals in implementing pressure ulcer prevention strategies.
  • “On-time pressure ulcer healing project.” Another AHRQ initiative, this resource is designed for those working in long-term care facilities.
  • “Pressure ulcer prevention.” This table from the Institute for Healthcare Improvement lists possible mentors you can work with in the area of ulcer prevention.
  • “Shawnee Medical Center wound care quick reference guide.” This is a handy one-page reference guide that includes photographs and recommendations.
  • “How-to guide: Prevent pressure ulcers—pediatric supplement.” This guide, tailored for pediatrics, describes key evidence-based care components for preventing pressure ulcers and describes how to implement these interventions.

You can also access case studies from a variety of facilities around the United States.


Lymphedema resources

The National Lymphedema Network is a nonprofit organization founded in 1988 to provide education and other information to healthcare professionals and patients with lymphedema, as well as the general public. The site includes an explanation of lymphedema that may be helpful for you to use in teaching your patients. It also includes access to some of the articles from the newsletter LymphLink.


Diabetes clinical practice guidelines

Many patients with chronic wounds have diabetes. To ensure those patients receive the best possible care, you can refer to the 2013 Standards of Medical Care in Diabetes from the American Diabetes Association, which were published in the January issue of
Diabetes Care.

The journal provides a summary of the revisions and an executive summary of the standards related to each area, including diagnosis, testing, prevention, monitoring, and pharmacologic and nonpharmacologic management.

The guidelines include valuable information related to neuropathy screening and treatment and foot care. Recommendations for foot care include performing an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations. The foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation.


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Four key ingredients make up the recipe for effective team meetings

By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN

Most of us have had days when we jump from meeting to meeting and at the end of the day wonder, “Did I get anything accomplished or am I more behind than ever?”

Many clinicians tell me that although their wound team meets regularly, the meetings aren’t meaningful enough, leaving the team still facing issues with their wound care program. As a consultant, when I review the wound team agenda, it’s typically missing one or more of four key ingredients:

  • appropriate member representation
  • proactive approach that highlights prevention
  • review of the plan of care and update of the medical record
  • review of supplies and products. Here’s a closer look at each of these ingredients.

Build a top team

Having the appropriate members on the wound care team is the first ingredient for success. A comprehensive, interdisciplinary team approach is the key to preventing skin breakdown and ensuring good clinical outcomes for residents with skin breakdown. Teams should include representation from nursing, dietary, and physical and occupational therapy, as well as a nurse practitioner or physician.

Nursing representation should include nurses from all three shifts and nursing assistants, who are too often missing from the team. Keep in mind that when it comes to preventing pressure ulcers, nursing assistants carry out most of interventions (for example, turning, incontinence management, heel lift). Even when a patient has a wound, the only intervention carried out by the nurses is the topical treatment; nursing assistants perform all other interventions necessary to ensure healing. Clinicians who empower nursing assistants to have a strong influence with the wound care team—and the program—tend to have very successful prevention programs and good clinical outcomes.

Think prevention

The second key ingredient is prevention. Most wound team meetings only discuss the patients with wounds, missing the bigger goal of preventing wounds in the first place. Once the patients with wounds are discussed, the team should review all high-risk patients to ensure proper preventative measures are in place and care planned. All patients should be quickly reviewed for evidence of:

  • decline or change in mobility and activity
  • new onset or change in continence status
  • decline in nutritional status
  • decline or change in cognition.

Any triggers in these areas should prompt a review of the plan of care to ensure they are being effectively addressed.

Review and update the plan

The third key ingredient for success is to use meeting time to review and update the plan of care. I’ve observed highly productive meetings and great discussions of the care the facility is providing. Then I review the medical record and discover that none of the interventions discussed are on the plan of care. Always review the patient’s plan of care to ensure it’s accurate, reflects all interventions, and is up to date. This will give you peace of mind that the medical record reflects all the good work you’re doing and helps make the team meetings feel productive.

Discuss products and supplies

The fourth key ingredient is to take the time to quickly discuss current wound care supplies and products with the team. Ask the team if the current supplies are user-friendly, are adequate, provide good outcomes, and are in good working condition.

Many times staff will not say how they’re struggling with, modifying, or not using something until they’re asked. Remember that the most expensive product is the one that doesn’t work or doesn’t get used.

A recipe for success

Using these four key ingredients will lead you to a successful wound team meeting—and a successful program. The mix may not solve your too-many-meetings days, but will give you peace of mind that at least one meeting is productive.

Jeri Lundgren is director of clinical services at Pathway Health in Minnesota. She has been specializing in wound prevention and management since 1990.

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Unna Boot

An Unna boot is a special dressing of inelastic gauze impregnated with zinc, glycerin, or calamine that becomes rigid when it dries. It is used for managing venous leg ulcers and lymphedema in patients who are ambulatory. When the patient walks, the rigid dressing restricts outward movement of the calf muscle, which directs the contraction force inward and improves the calf-muscle pumping action, thereby improving venous flow. An Unna boot does not provide compression and is contraindicated for arterial insufficiency.

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Chronic venous insufficiency with lower extremity disease: Part 1

By Donald A. Wollheim, MD, WCC, DWC, FAPWCA

Chronic venous insufficiency (CVI) is the most common cause of lower extremity wounds. The venous tree is defective, incapable of moving all the blood from the lower extremity back to the heart. This causes pooling of blood and intravascular fluid at the lowest gravitational point of the body—the ankle.

This article has two parts. Part 1 enhances your understanding of the disease and its clinical presentation. Part 2, which will appear in a later issue, explores the differential diagnosis of similar common diseases, the role that coexisting peripheral artery disease (PAD) may play, disease classification of venous insufficiency, and a general approach to therapy.

The most common form of lower extremity vascular disease, CVI affects 6 to 7 million people in the United States. Incidence increases with age and other risk factors. One study of 600 patients with CVI ulcers revealed that 50% had these ulcers for 7 to 9 months, 8% to 34% had them for more than 5 years, and 75% had recurrent ulcers.

Thrombotic complications of CVI include thrombophlebitis, which may range from superficial to extensive. If the thrombophlebitis extends up toward the common femoral vein leaving the leg, proximal ligation may be needed to prevent clot extension or embolization.

Understanding normal anatomy and physiology

Lower extremity veins flow horizontally from the superficial veins to the perforating veins and then into the deep veins. Normally, overall venous blood flows vertically against gravity from the foot and ankle upward toward the inferior vena cava (IVC). This antigravity flow toward the IVC results from muscular contraction around nonobstructed veins and one-way valves that close as blood passes them. These valves prevent abnormal backward blood flow toward the foot and ankle region.

The lower extremities have four types of veins. Superficial veins are located within the subcutaneous tissue between the dermis and muscular fascia. Examples are the greater and lesser (smaller) saphenous veins. Perforating veins connect the superficial veins to the deep veins of the leg. The deep veins are located below the muscular fascia. The communicating veins con­nect veins within the same system.

The greater saphenous vein is on the leg’s medial (inner) side. It originates from the dorsal veins on top of the foot and eventually drains into the common femoral vein in the groin region. By way of perforating veins, the greater saphenous vein drains into the deep venous system of both the calf and thigh.

The lesser saphenous vein is situated on the lateral (outer) side of the leg and originates from the lateral foot veins. As it ascends, it drains into the deep system at the popliteal vein behind the knee. Communicating veins connect the greater saphenous vein medially and the lesser saphenous vein laterally.

Intramuscular veins are the deep veins within the muscle itself, while the intermuscular veins are located between the muscle groups. The intermuscular veins are more important than other veins in development of chronic venous disease. Below the knee, the intermuscular veins are paired and take on the name of the artery they accompany—for example, paired anterior tibial, paired posterior tibial, and paired peroneal veins. Eventually, these veins form the popliteal vein behind the knee, which ultimately drains into the femoral vein of the groin.

As the common femoral vein travels below the inguinal ligament of the groin, it’s called the external iliac vein. Eventually, it becomes the common iliac vein, which drains directly into the IVC.


Abnormally elevated venous pressure stems from the leg’s inability to adequately drain blood from the leg toward the heart. Blood drainage from the leg requires the muscular pumping action of the leg onto the veins, which pump blood from the leg toward the heart as well as from the superficial veins toward the deep veins. Functioning one-way valves within the veins close when blood passes them, preventing blood from flowing backward toward the ankle. This process resembles what happens when you climb a ladder with intact rungs: As you step up from one rung to the next, you’re able to ascend.

CVI and the “broken rung” analogy

If the one-way valves are damaged or incompetent, the “broken rung” situation occurs. Think how hard it would be to climb a ladder with broken rungs: You might be able to ascend the ladder, but probably you would fall downward off the ladder due to the defective, broken rungs.

Normally, one-way valves ensure that blood flows from the lower leg toward the IVC and that the superficial venous system flows toward the deep venous system. The venous system must be patent (open) so blood flowing from the leg can flow upward toward the IVC. Blockage of a vein may result from an acute thrombosis (clot) in the superficial or deep systems. With time, blood may be rerouted around an obstructed vein. If the acute thrombosis involves one or more of the one-way valves, as the obstructing thrombosis opens up within the vein’s lumen, permanent valvular damage may occur, leading to post-thrombotic syndrome—a form of CVI.

CVI may result from an abnormality of any or all of the processes needed to drain blood from the leg—poor pumping action of the leg muscles, damage to the one-way valves, and blockage in the venous system. CVI commonly causes venous hypertension due to reversal of blood flow in the leg. Such abnormal flow may cause one or more of the following local effects:

  • leg swelling
  • tissue anoxia, inflammation, or necrosis
  • subcutaneous fibrosis
  • Compromised flow of venous blood or lymphatic fluid from the extremity.

“Water balloon” analogy

The effect of elevated venous pressure or hypertension is worst at the lowest gravitational point (around the ankle). Pooling of blood and intravascular fluid around the ankle causes a “water balloon” effect. A balloon inflated with water has a thin, easily traumatized wall. When it bursts, a large volume of fluid drains out. Due to its thicker wall, a collapsed balloon that contains less fluid is more difficult to break than one distended with water.

In a leg with CVI, subcutaneous fluid that builds up requires a weaker force to break the skin and ulcerate than does a nondistended leg with less fluid. This principle is the basis for compression therapy in treating and preventing CVI ulcers.

Effects of elevated venous pressure or hypertension

Increased pressure in the venous system causes:

  • abnormally high pressure in the superficial veins—60 to 90 mm Hg, compared to the normal pressure of 20 to 30 mm Hg
  • dilation and distortion of leg veins, because blood refluxes abnormally away from the heart and toward the lower leg and may move from the deep venous system into the superficial veins.

Abnormal vein swelling from elevated pressure in itself may impair an already abnormally functioning one-way valve. For instance, the valve may become more displaced due to the increase in intraluminal fluid, which may in turn worsen hypertension and cause an increase in leg swelling. Increased pressure from swollen veins also may dilate the capillary beds that drain into the veins; this may cause leakage of fluid and red blood cells from capillaries into the interstitial space, exacerbating leg swelling. Also, increased venous pressure may cause fibrinogen to leak from the intravascular plasma into the interstitial space. This leakage may create a fibrin cuff around the capillary bed, which may decrease the amount of oxygen entering the epidermis, increase tissue hypoxia, trigger leukocyte activation, increase capillary permeability, and cause local inflammation. These changes may lead to ulceration, lipodermatosclerosis, or both.

Visible changes may include dilated superficial veins, hemosiderin staining due to blood leakage from the venous tree, atrophie blanche, and lipodermatosclerosis. (See CVI glossary by clicking the PDF icon above.) Both atrophie blanche and lipodermatosclerosis result from local tissue scarring secondary to an inflammatory reaction of the leg distended with fluid.

Lipodermatosclerosis refers to scarring of subcutaneous tissue in severe venous insufficiency. Induration is associated with inflammation, which can cause the skin to bind to the subcutaneous tissue, causing narrowing of leg circumference. Lymphatic flow from the leg also may become compromised and inhibited in severe venous hypertension, causing additional leg swelling.

Patient history

In a patient with known or suspected CVI, a thorough history may lead to a working diagnosis. Be sure to ask the patient these questions:

  • Do you have pain?
  • Is your pain worse toward the end of the day?
  • Is the pain relieved with leg elevation at night?
  • Is it relieved with leg elevation during the day?
  • Do you have leg pain that awakens you at night?
  • How would you describe the pain?
  • Does the skin on your leg feel tight or irritated?
  • Have you noticed visible changes of your leg?
  • Do you have a leg ulcer?

Also determine if the patient has comorbidities that may exacerbate CVI, including PAD, renal failure, venous thrombosis, lymphedema, diabetes mellitus, heart failure, or malnutrition. (See CVI risk factors by clicking the PDF icon above .)

Common CVI symptoms

Approximately 20% of CVI patients have symptoms of the disease without physical findings. These symptoms may include:

  • tired, “heavy” legs that feel worse toward the end of the day
  • discomfort that worsens on standing
  • legs that feel best in the morning after sleeping or after the legs have been
  • elevated during the day.

Although patients may report leg discomfort, the history indicates that it doesn’t awaken them at night. Be aware that discomfort from CVI differs from that caused by PAD. With PAD, patients may report pain on exercise (claudication), pain with elevation (nocturnal pain), or constant pain (resting pain).

Signs of CVI (with or without ulcers) include:

  • leg swelling (seen in 25% to 75% of patients)
  • skin changes (such as hemosiderin staining or dermatitis)
  • telangiectasia, reticular veins, or both; while these are the most common signs, they represent an overall less severe finding
  • varicose veins with or without bleeding, occurring in one-third of patients with CVI.

Venous ulcers

Venous ulcers are the most common type of lower extremity ulcer. They’re commonly found on the medial aspect of the lower extremity, from the ankle to the more proximal calf area. Usually, they arise along the course of the greater saphenous vein, but also may be lateral and may occur at multiple locations. They aren’t found above the knee or on the forefoot. Venous ulcers are shallower than arterial ulcers and have considerable exudate consistent with drainage from a ruptured water balloon. They may extend completely around the leg.

CVI: From a heavy sensation to visible changes

In patients with CVI, blood flows within a lower extremity in an abnormal, reverse direction, causing build-up of blood and intravascular fluid around the ankle. Initially, this may cause only a sensation of heavy legs toward the end of the day, with no visible changes. Eventually, it may lead to venous ulcers or other visible changes. This abnormal blood flow results from dysfunction of the normal mechanisms that drain blood from the leg against gravity into the IVC.

Selected references

Alguire PC, Mathes BM. Clinical evaluation of lower extremity chronic venous disease. UpToDate. Last updated April 18, 2012. http://www.uptodate.com/contents/clinical-evaluation-of-lower-extremity-chronic-venous-disease?source=search_result&
.  Accessed March 3, 2013.

Alguire PC, Mathes BM. Diagnostic evaluation of chronic venous insufficiency. UpToDate. Last updated May 7, 2012. www.uptodate.com/contents/diagnostic-evaluation-of-chronic-venous-insufficiency?source=search_result&search=Diagnostic+evaluation
. Accessed March 3, 2013.

Alguire PC, Mathes BM. Pathophysiology of chronic venous disease. UpToDate. Last updated April 12, 2012. www.uptodate.com/contents/pathophysiology-of-chronic-venous-disease?source=search_result&search=Pathophysiology+of+chronic+venous+disease
. Accessed March 3, 2013.

Alguire PC, Scovell S. Overview and management of lower extremity chronic venous disease. UpToDate. Last updated June 27, 2012. www.uptodate.com/contents/overview-and-management-of-lower-extremity-chronic-venous-disease?source=search_
. Accessed March 3, 2013.

Moneta G. Classification of lower extremity chronic venous disorders. UpToDate. Last updated October 22, 2011. www.uptodate.com/contents/classification-of-lower-extremity-chronic-venous-disorders. Accessed March 3, 2013.

Sardina D. Skin and Wound Management Course; Seminar Workbook. Wound Care Education Institute; 2011:92-112.

Donald A. Wollheim is a practicing wound care physician in southeastern Wisconsin. He also is an instructor for Wound Care Education Institute and Madison College. He serves on the Editorial Board for Wound Care Advisor.

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The “latest and greatest” vs. the basics

Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

If you’re keeping up on wound care, you know a lot of new things are coming to market with enough decent science behind them to make them reasonable options to consider in your practice. And as true-blooded Americans and citizens of the post-industrialized world, we want what’s newest, fastest, and best in class in everything. It’s just our nature.

But does it truly serve us to be eager to try new therapies even when the current treatment plan is successful? Perhaps. We know we must never close our eyes to new developments in our field that can lead to better outcomes. Knowing when and what to change can lead to better outcomes for the patient, the wound, and our collective pocketbook.

I’ve long maintained we can achieve excellent-quality wound care if we just stick to the basics the vast majority of the time. Why? Systemic, psychosocial, and local factors all affect wound healing—not just the dressing or cream. Our job is to provide the optimum environment possible for wound healing. That requires us to look at and support the whole body toward optimum health, not solely the wound.

The basics begin with identifying the cause of the wound and implementing interventions to reduce, control, or eliminate the cause. Next, we strive to manage local and psychosocial factors by choosing topical products that will maintain moisture balance, keep the wound warm, and protect it. If the wound doesn’t show progress toward healing within 2 weeks (or as expected, given the patient’s overall condition and ability to heal), we need to reevaluate the plan and begin making changes.

The best rule is to make one change at a time. That makes it much easier to determine what’s working and what isn’t. Once all the basics are in place and required changes have been made, if healing is still stalled or nonexistent, consider trying the available new products and specialty products.

Never close your clinical mind to advances in the field. To do that would be a disservice to your patients. But you should change the treatment plan only when a change is needed—not just for the sake of changing it.

Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS
Wound Care Advisor
Cofounder, Wound Care Education Institute
Plainfield, Illinois

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Clinical Notes

Diabetes ‘ABC’ goals improve, but work remains

The number of people with diabetes who are meeting the ABC goals—hemoglobin A1C, blood pressure, and LDL cholesterol—has risen significantly in recent years, according to a study published by Diabetes Care. Patients meeting all three goals rose from about 2% in 1988 to about 19% in 2010.

Gains were made in each of the ABC goals, based on 2007 to 2010 data: 53% of patients met A1C goals, compared to 43% in 1988 to 1994 data; 51% met blood pressure goals, compared to 33%; and 56% met LDL goals, compared to 10%.

Younger people were less likely to meet A1C and cholesterol goals. Compared with non-
Hispanic whites, Mexican Americans were less likely to meet A1C and LDL goals and non-Hispanic blacks were less likely to meet blood pressure and LDL goals.

The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988–2010” also found that statin use significantly increased from about 4% in 1988 to 1994 to about 51% in 2007 to 2010.

The researchers analyzed data from the National Health and Nutrition Examination Surveys from 1988–1994, 1999–2002, 2003–2006, and 2007–2010. Nearly 5,000 people age 20 or older participated.

Although progress had been made, the researchers conclude, “Despite significant improvement during the past decade, achieving the ABC goals remains suboptimal among adults with diabetes, particularly in some minority groups.”

Daily bathing with chlorhexidine-impregnated washcloths reduces infection risk

A study in The New England Journal of Medicine reports that daily bathing with chlorhexidine-impregnated washcloths reduces the risk of becoming infected with multidrug-resistant organisms and subsequent development of hospital-acquired bloodstream infections in intensive care unit patients.

Effect of daily chlorhexidine bathing on hospital-acquired infection” included 7,727 patients in nine intensive care and bone marrow units in six hospitals. The units were randomly assigned to bathe patients with either no-rinse 2% chlorhexidine-impregnated washcloths or nonantimicrobial washcloths for 6 months; then, the units switched to the opposite product for 6 months.

The rate of infection with multidrug-resistant organisms was 23% lower in the chlorhexidine group and the rate of hospital-acquired bloodstream infection was 28% lower in the chlorhexidine group.

Patients tend not to wear custom-made footwear for preventing diabetic foot ulcers

Adherence to wearing prescription custom-made footwear was low among patients with diabetes, neuropathy, and a recently healed plantar foot ulcer, according to a study in Diabetes Care. The low adherence was particularly notable at home, where patients did the most walking.

Adherence to wearing prescription custom-made footwear in patients with diabetes at high risk for plantar foot ulceration” studied 107 patients by using a shoe-worn, temperature-based monitor. The researchers also measured daily step count by using an
ankle-worn activity monitor.

Factors associated with higher adherence included lower body mass index, more severe foot deformity, and more appealing footwear.

Tedizolid works as well as linezolid in patients with acute bacterial skin infections

A JAMA study says that a 200-mg once-daily dose of oral tedizolid phosphate over 6 days was as effective as 600 mg of oral linezolid every 12 hours for 10 days in patients with acute bacterial skin and skin-structure infections, including cellulitis or erysipelas, major cutaneous abscesses, and wound infections.

Tedizolid phosphate vs linezolid for treatment of acute bacterial skin and skin structure infections: The ESTABLISH-1 Randomized Trial” reports a Phase 3, randomized, double-blind study conducted in 81 study centers with data analyzed from 667 adults.

A shorter course of tedizolid may be a “reasonable alternative” to linezolid for treating acute bacterial skin and skin-structure infections, the study concludes.

Water-based exercise improves ROM in patients with long-term arm lymphedema

A study of breast cancer survivors (median 10 years after surgery) with lymphedema found that a water-based exercise program improved shoulder range of motion (ROM).

Of the 29 eligible patients, 25 completed the study “Water-based exercise for patients with chronic arm lymphedema: A randomized controlled pilot trial,” published in the American Journal of Physical Medicine & Rehabilitation.

The program consisted of at least twice-weekly water-based exercise for 8 weeks. At first, participants were supervised, but later they exercised independently. Although lymphedema status didn’t change, those who performed water-based exercise had an increase in ROM, showing improvement years after surgery.

Dehydrated amniotic membrane allograft possible option for treating chronic wounds

A dehydrated amniotic membrane allograft (EpiFix) was used to treat four patients whose wounds hadn’t closed after conservative and advanced measures and who had been referred for plastic procedures. A variety of wounds healed (located on the elbow, knee, hand, and ankle) after one to three applications of the amniotic material, which patients tolerated well. The wounds remained closed several months later.

The authors of “Use of dehydrated human amniotic membrane allografts to promote healing in patients with refractory non healing wounds” recommend further investigation.

Mortality not linked to hospital readmissions in some patients

A study in JAMA reports that readmission rates aren’t linked to mortality rates in patients with an acute myocardial infarction or pneumonia and were only “weakly associated” for patients with heart failure.
Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia” studied Medicare beneficiaries. The study is likely to fuel ongoing discussions as to the value of using readmission and mortality rates as factors for reimbursement.

Study casts doubt on MLD’s role in breast cancer–related lymphedema

A meta-analysis published in the World Journal of Surgical Oncology found the “current evidence” from randomized clinical trials “does not support” the use of manual lymphatic drainage (MLD) in preventing or treating lymphedema in patients with breast cancer.

However, the authors of “Effects of manual lymphatic drainage on breast cancer–related lymphedema: a systematic review and meta-analysis of randomized controlled trials” note that the overall methodology of the studies was poor.

The authors analyzed 10 randomized clinical trials with 566 patients.

CDC issues additional prevention steps for carbapenem-resistant Enterobacteriaceae

On Feb. 14, the Centers for Disease Control and Prevention (CDC) issued additional prevention steps for carbapenem-resistant Enterobacteriaceae (CRE). Increased reports of CRE prompted the action: Of the 37 unusual forms of CRE reported in the U.S., the last 15 have been reported since July 2012.

Facilities should follow the CDC guidance for preventing the spread of CRE in healthcare settings. The CDC also now recommends the following:

• When a CRE is identified in a patient with a history of an overnight stay in a healthcare facility (within the last 6 months) outside the U.S., send the isolate to a reference laboratory for confirmatory susceptibility testing and test to determine the carbapenem resistance mechanism.
• For patients admitted to healthcare facilities in the U.S. after recently being hospitalized (within the last 6 months) in countries outside the U.S., consider performing rectal screening cultures to detect CRE colonization, and place patients on contact precautions while awaiting the results.

Examples of Enterobacteriaceae include Klebsiella species and Escherichia coli. CRE are Enterobacteriaceae with high levels of resistance to antibiotics, including carbapenems. CRE infections most commonly occur among patients who are receiving antibiotics and significant medical treatment for other conditions.

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Debridement options: BEAMS made easy


At one time or another, all wound care professionals encounter a chronic wound, defined as a wound that fails to heal in an orderly and timely manner. Globally, about 67 million people (1% to 5% of the world’s population) suffer chronic wounds. In the United States, chronic wounds affect 6.5 million people and cost more than $25 billion annually to treat. (more…)

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Positive Stemmer’s sign yields a definitive lymphedema diagnosis in 10 seconds or less

By Robyn Bjork, MPT, CWS, WCC, CLT-LANA

In a busy wound clinic, quick and accurate differential diagnosis of edema is essential to appropriate treatment or referral for comprehensive care. According to a 2010 article in American Family Physician, 80% of lower extremity ulcers result from chronic venous insufficiency (CVI). In 2007, the German Bonn Vein Study found 100% of participants with active venous ulcers also had a positive Stemmer’s sign, indicating lymphedema. (more…)

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How to choose a digital camera for wound documentation

By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

Digital cameras have many helpful features, but the most important considerations for choosing a camera are hardware features. Focus on the following when choosing a camera:

Resolution. The resolution determines picture quality. The National Pressure Ulcer Advisory Panel recommends using a digital camera with a minimum of 3 megapixels
for wound photography. A megapixel is 1 million pixels. The more pixels used to produce a photo, the less grainy it will appear and the clearer any enlargements made from it will be. In essence, the more megapixels a camera produces, the clearer and more detailed the photograph will be. (more…)

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