Clinical Notes: Debridement, Optimal Wound Healing, Diabetes, Sacral Wounds

September 25, 2013February 25, 2020 Wound Care Advisor

Frequent debridement improves wound healing

A study in JAMA Dermatology reports that frequent debridements speed wound healing.

“The more frequent the debridement, the better the healing outcome,” concludes “Frequency of debridements and time to heal: A retrospective cohort study of 312 744 wounds.” The median number of debridements was two.

Most of the wounds in the 154,644 patients were diabetic foot ulcers, venous leg ulcers, and pressure ulcers. The study authors note that debridement is a “key process” in wound bed preparation and starting the healing process.

The findings are congruent with previous studies and are based on an analysis of the largest wound data set to date. (more…)

Wound Care Advisor Journal 2013 Vol2 No5

Developing a cost-effective pressure-ulcer prevention program in an acute-care setting

Pressure ulcers take a hefty toll in both human and economic terms. They can lengthen patient stays, cause pain and suffering, and increase care costs. The average estimated cost of treating a pressure ulcer is $50,000; this amount may include specialty beds, wound care supplies, nutritional support, and increased staff time to care for wounds. What’s more, national patient safety organizations and insurance payers have deemed pressure ulcers avoidable medical errors and no longer reimburse the cost of caring for pressure ulcers that develop during hospitalization.

Clinical Notes: Debridement, Optimal Wound Healing, Diabetes, Sacral Wounds

Posted: September 25, 2013

Frequent debridement improves wound healing A study in JAMA Dermatology reports that frequent debridements speed wound healing. “The more frequent the debridement, the better the healing outcome,” concludes “Frequency of debridements and time to heal: A retrospective cohort study of 312 744 wounds.” The median number of debridements was two. Most of the wounds in the 154,644 patients were diabetic foot…

Clinician Resources: Guideline Clearinghouse, Patient Safety, Diabetic Foot-Ulcers

Posted: September 25, 2013

Here are some resources of value to your practice. National Guideline Clearinghouse The National Guideline Clearinghouse, supported by the Agency for Healthcare Research and Quality, summarizes many guidelines of interest to wound care, ostomy, and lymphedema clinicians. Here are some examples: Guideline for management of wounds in patients with lower-extremity neuropathic disease Pressure ulcer prevention and treatment protocol Lower limb…

Compassionate care: The crucial difference for ostomy patients

Posted: September 25, 2013

By Gail Hebert, RN, MS, CWCN, WCC, DWC, LNHA, OMS; and Rosalyn Jordan, BSN, RN, MSc, CWOCN, WCC, OMS Imagine your physician has just told you that your rectal pain and bleeding are caused by invasive colon cancer and you need prompt surgery. She then informs you that surgery will reroute your feces to an opening on your abdominal wall.…

Dealing with difficult people

Posted: September 25, 2013

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN Unfortunately, most clinicians can’t avoid having to work with difficult people. However we can learn how to be more effective in these situations, keeping in mind that learning to work with difficult people is both an art and a science. How difficult people differ from the rest of us We can all…

Developing a cost-effective pressure-ulcer prevention program in an acute-care setting

Posted: September 25, 2013

By Tamera L. Brown, MS, RN, ACNS-BC, CWON, and Jessica Kitterman, BSN, RN, CWOCN Pressure ulcers take a hefty toll in both human and economic terms. They can lengthen patient stays, cause pain and suffering, and increase care costs. The average estimated cost of treating a pressure ulcer is $50,000; this amount may include specialty beds, wound care supplies, nutritional…

How to fit in fast at your new job

Posted: September 25, 2013

By Gregory S. Kopp, RN, MN, MHA A new job can be stimulating, but it can also be stressful. Not only will you have new responsibilities, but you’ll also have a new setting, new leaders, and new colleagues. And the quicker you can figure out who’s who and what’s what—without stepping on anyone’s toes—the better off you’ll be. But establishing…

Improving outcomes with noncontact low-frequency ultrasound

Posted: September 25, 2013

By Ronnel Alumia, BSN, RN, WCC, CWCN, OMS Achieving excellent wound care outcomes can be challenging, given the growing number of high-risk patients admitted to healthcare facilities today. Many of these patients have comorbidities, such as obesity, diabetes, renal disease, smoking, chronic obstructive pulmonary disease, and poor nutritional status. These conditions reduce wound-healing ability.

Power up your patient education with analogies and metaphors

Posted: September 25, 2013

By Janice M. Beitz, PhD, RN, CS, CNOR, CWOCN, CRNP Quality patient education is essential for comprehensive health care and will become reimbursable under healthcare reform in 2014. However, it’s difficult to provide effective education when time for patient interactions is limited. You can enhance your instruction time—and make your teaching more memorable—by using the techniques of analogy and metaphor.

Preventing pressure ulcers starts on admission

Posted: September 25, 2013

By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN The first 24 hours after a patient’s admission are critical in preventing pressure ulcer development or preventing an existing ulcer from worsening. A skin inspection, risk assessment, and temporary care plan should all be implemented during this time frame. Essentially, it’s the burden of the care setting to prove to insurers, regulators,…

Taking care of the caregiver—you

Posted: September 23, 2013

By: Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS Why is it that the people who are the most caring toward others neglect their own needs? Have you noticed this? I’ve seen it time and time again. The healthcare worker who’s always the last to leave work, who always volunteers to work those extra shifts so patient care won’t be…

2013 Journal: September – October Vol. 2 No. 5

Clinical Notes: Ischemia, Breast Cancer, ICU Patients

July 23, 2013February 25, 2020 Wound Care Advisor

Critical limb ischemia may not increase mortality risk in patients with diabetes

Diabetic patients with critical limb ischemia (CLI) who are assessed quickly and treated aggressively do not have an increased risk of long-term cardiac mortality, according to a study in Diabetes Care. (more…)

Understanding stoma complications

July 23, 2013February 25, 2020 Wound Care Advisor

By Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, WCC, OMS; and Judith LaDonna Burns, LPN, WCC, DFC

About 1 million people in the United States have either temporary or permanent stomas. A stoma is created surgically to divert fecal material or urine in patients with GI or urinary tract diseases or disorders.

A stoma has no sensory nerve endings and is insensitive to pain. Yet several complications can affect it, making accurate assessment crucial. These complications may occur during the immediate postoperative period, within 30 days after surgery, or later. Lifelong assessment by a healthcare provider with knowledge of ostomy surgeries and complications is important. (more…)

Understanding stoma complications

Clinical Notes: Ischemia, Breast Cancer, ICU Patients

Posted: July 23, 2013

Critical limb ischemia may not increase mortality risk in patients with diabetes Diabetic patients with critical limb ischemia (CLI) who are assessed quickly and treated aggressively do not have an increased risk of long-term cardiac mortality, according to a study in Diabetes Care.

Compression therapy for chronic venous insufficiency, lower-leg ulcers, and secondary lymphedema

Posted: July 19, 2013

By Nancy Chatham, RN, MSN, ANP-BC, CCNS, CWOCN, CWS, and Lori Thomas, MS, OTR/L, CLT-LANA An estimated 7 million people in the United States have venous disease, which can cause leg edema and ulcers. Approximately 2 to 3 million Americans suffer from secondary lymphedema. Marked by abnormal accumulation of protein-rich fluid in the interstitium, secondary lymphedema eventually can cause fibrosis…

Forging a communication bond with prescribers

Posted: July 23, 2013

By T. Michael Britton, RN, NHA, WCC, DWC As wound care professionals, we’ve all experienced a time when we felt that our patient didn’t have the appropriate wound treatment orders. However, the physician, nurse practitioner, or other prescriber wouldn’t follow your recommendation. This situation is not only frustrating but can delay the healing process. This article explores why a prescriber…

From the Editor – Wound care superhero

Posted: July 23, 2013

by Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS What an honor it is to be the wound care “superhero”—the guru, the healer, the go-to person. Unfortunately, this honor may be accompanied by wound care overload—too much to do in too little time. Once someone is crowned the superhero specialist, others may try to transfer every aspect of wound and…

Understanding stoma complications

Posted: July 23, 2013

By Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, WCC, OMS; and Judith LaDonna Burns, LPN, WCC, DFC About 1 million people in the United States have either temporary or permanent stomas. A stoma is created surgically to divert fecal material or urine in patients with GI or urinary tract diseases or disorders. A stoma has no sensory nerve endings and…

What’s causing your patient’s lower-extremity redness?

Posted: July 19, 2013

By Robyn Bjork, MPT, CWS, WCC, CLT-LANA The ability to understand or “read” lower-extremity redness in your patient is essential to determining its cause and providing effective treatment. Redness can occur in multiple conditions—hemosiderin staining, lipodermatosclerosis, venous dermatitis, chronic inflammation, cellulitis, and dependent rubor. This article provides clues to help you differentiate these conditions and identify the specific cause of…

Wounds on the Web: Accessing the best online resources

Posted: July 23, 2013

By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS Knowledge is exploding online, making it essential that you’re comfortable using the Internet. You can also go online to save time and find a job, among other tasks. (See Online value.) However, you also need to keep in mind that anyone can put information on the Internet. As the caption of…

WC July August 2013-717_FINAL

What’s causing your patient’s lower-extremity redness?

July 19, 2013January 25, 2024 Wound Care Advisor

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

The ability to understand or “read” lower-extremity redness in your patient is essential to determining its cause and providing effective treatment. Redness can occur in multiple conditions—hemosiderin staining, lipodermatosclerosis, venous dermatitis, chronic inflammation, cellulitis, and dependent rubor. This article provides clues to help you differentiate these conditions and identify the specific cause of your patient’s lower-extremity redness. (more…)

When you can’t rely on ABIs

May 28, 2013February 25, 2020 Wound Care Advisor

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

One of the worst fears of a wound care clinician is inadvertently compressing a leg with critical limb ischemia—a condition marked by barely enough blood flow to sustain tissue life. Compression (as well as infection or injury) could lead to necrosis, the need for amputation, or even death. The gold standard of practice is to obtain an ankle-brachial index (ABI) before applying compression. However, recent research and expert opinion indicate an elevated or normal ABI is deceptive in patients with advanced diabetes. What’s worse, in the diabetic foot, skin may die from chronic capillary ischemia even when total blood perfusion is normal. For information on how to perform an ABI and interpret results, click on this link. (more…)

Clinician Resources

March 25, 2013February 25, 2020 Wound Care Advisor

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.

http://partnershipforpatients.cms.gov/p4p_resources/tsp-pressureulcers/
toolpressureulcers.html

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.

http://www.lymphnet.org

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.

http://care.diabetesjournals.org/content/36/Supplement_1

Clinical Notes

March 25, 2013February 25, 2020 Wound Care Advisor

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.

Debridement options: BEAMS made easy

March 25, 2013February 25, 2020 Wound Care Advisor

By Cindy Broadus, RN, BSHA, LNHA, CHCRM, CLNC, CLNI, WCC, DWC, OMS

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…)

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

March 25, 2013February 25, 2020 Wound Care Advisor

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…)

Helping ostomates and amputees adapt to their new circumstances

January 30, 2013February 25, 2020 Wound Care Advisor

By Rosalyn Jordan, BSN, MSc, RN, CWOCN, WCC

In most cases, amputation (removal of an extremity, digit, or other body part) is a surgical intervention performed to remove tissue affected by a disease and, in some cases, to provide pain relief. Fecal and urinary diversion surgeries also are considered amputations. Amputations and fecal or urinary diversions (ostomies) require extensive rehabilitation and adaptation to a new way of life, with physiologic and psychological impacts. Although diversions and ostomies usually are less visible to others than other types of amputations, they call for similar patient education, rehabilitatio n, and lifelong counseling.
The primary goal of therapy for ostomates and amputees is to resume their presurgical lifestyle to the greatest extent possible and to adapt to their new circumstances. Preoperative assessment and training interventions have proven valuable. Having a clear understanding of the surgical intervention helps reduce postoperative anxiety and depression, which can pose roadblocks to patients’ adaptation or response to their new situation. Successful interventions should be done by healthcare professionals who are trained in caring for ostomates and amputees.
Ostomates and amputees experience similar psychosocial challenges, body-
image problems, and sexuality concerns. This article focuses on these three issues. For a summary of other issues these patients may experience, see Other problems amputees and ostomates may face by clicking the PDF icon above.

Psychosocial challenges

Ostomates and amputees may experience depression, anxiety, fear, and many other concerns related to the surgical procedure—concerns that center on whether they’ll be able to resume their presurgical lifestyle. Many worry about social isolation and loss of income. Some fear both the primary disease process and the lifestyle changes induced by surgery. Anxiety may impede their social interactions and lead to significant psychological problems. Appropriate and effective counseling and therapy must be planned and provided. (But be aware that untrained or inexperienced healthcare professionals may not be able to provide the guidance the patient needs to feel comfortable; some may be unable even to offer information about available support systems.)
These patients also may find themselves socially isolated, in part due to loss of employment or the socioeconomic consequences of a decreased income. Some experience fear and worry when anticipating lifestyle changes caused by loss in or change of function, adaptation to the prosthesis, and treatment costs.
Maintaining social contact after surgery is extremely important to recovery and adaptation to the amputation or ostomy. The United Ostomy Associations of America and the Amputee Coalition encourage patients to maintain social involvement. Both groups suggest patients discuss their feelings, thoughts, and fears with a trusted family member, friend, or partner. Both organizations sponsor and encourage support-group involvement. In some cases, emotional support from other amputees or ostomates with a similar experience may be appropriate; some patients may be more comfortable sharing thoughts and asking questions in a group of people with similar experiences. Resuming presurgical social events and activities can enhance patients’ adaptation to a new way of life.

Help your patient find a support group at the website of the United Ostomy Associations of America: www.ostomy.org/supportgroups.shtml.

Body-image problems

Ostomates and amputees have to cope not only with changes in physical appearance but with how their body functions and how they feel and perceive their body. They’re keenly aware of their changed appearance and are concerned about others’ perceptions of them. They may feel anxious and depressed related to body image; the degree of anxiety and depression may relate directly to their presurgical body image and activities. Many become anxious and fearful as they adapt to the prosthesis. (See Stages of grief by clicking the PDF icon above.)
Compared to amputees, ostomates may have more concerns about body image with sexual partners, because the stoma is, in a sense, a hidden amputation. In most cases, the stoma and pouch can be obscured visually from others. The amputee, on the other hand, has fewer options for hiding the missing body part.
To help patients cope with body-image problems, care providers must offer education, therapy, and counseling to help the patient accept and successfully adapt to the body-image change. The first step in this process may simply be to have the patient look at the stoma or stump, progressing to participation in prosthesis care.

Sexuality concerns

Many ostomates and amputees have difficulty resuming sexual activity after surgery. Although the stoma usually remains hidden from others, it’s observable to the ostomate and sex partner. Most patients require an adjustment period before they feel comfortable with a sex partner. They may fear that:
• the partner will reject them or no longer find them attractive
• they will experience loss of function and sensation
• they will experience pain or injury of the stoma.

They also may feel embarrassed, causing them to avoid sex. However, counselors can help couples discuss these concerns and resume a satisfactory sexual relationship. Ostomates and amputees and their partners may need counseling to resume a satisfactory sexual relationship. If they continue to have adjustment difficulties, referral to a trained sex counselor or psychologist may be indicated. Several studies show that appropriate counseling can help prevent complications and allow amputees and ostomates to continue to express their affection physically. (See Talking to patients about sexual problems by clicking the PDF icon above.)
Resuming sexual activity may be easier if the ostomate or amputee had a sex partner before surgery. However, males who experience postsurgical erectile dysfunction are less likely than other males to resume sexual activity. Counseling encourages postsurgical patients to focus more on the pleasurable feelings they and their partners feel, rather than on sexual performance. Body-image problems and inadequate sexual adjustment go hand in hand. (See Helping ostomates resume sex by clicking the PDF icon above.)

Team approach to patient education and counseling

In many parts of the country, a designated healthcare team manages amputees’ care and rehabilitation. But until recently, nurses were the only professionals certified to participate in ostomates’ care and rehabilitation. In fact, ostomates may represent a significant underserved population. A 2012 study found many ostomy patients didn’t receive consistent training and counseling from ostomy certified nurses. Only 13% of respondents reported they had regular visits with an ostomy certified nurse; 32% said they’d never received care from an ostomy nurse. Just over half (56%) indicated they saw an ostomy nurse when they thought it was necessary. The study also reported that 57% hadn’t seen an ostomy certified nurse in more than 1 year.
A team with specialized training to address ostomates’ physical and psychosocial needs might be able to provide the specialized care these patients need. The primary medical caregiver or general practitioner would serve as team leader and make appropriate referrals. The team should include a surgeon, ostomy- and amputee-trained nurses, a prosthetist or other healthcare provider trained in selection and fitting of prosthetic equipment and devices that affect function, a physical therapist, an occupational therapist, a social worker, a vocational counselor, a psychologist, caregiver or family members, support groups, and (last but not least) the patient.
The team approach might reduce hospital stays and promote patients’ return to their home environment. It also might encourage independence and enhance the success of long-term adaptation.

Focus on the future

Healthcare providers should encourage ostomates and amputees to focus on the future, not the past. Feeling comfortable with the prosthesis—the amputee’s artificial limb or the ostomate’s pouching system—is essential to adapting to a “new normal” way of life. Maintaining social relationships is important to adaptation as well. Mastering basic skills and adapting to changes in body function help improve the patient’s quality of life. Follow-up visits, phone contact, and access to a team of well-trained healthcare providers for patient education, rehabilitation, and long-term management are crucial to these patients’ successful adaptation and quality of life.

Selected references
Bhuvaneswar CG, Epstein LA, Stern TA. Reactions to amputation: recognition and treatment. Prim Care Companion J Clin Psychiatry. 2007;9(4):303-8.

Bishop M. Quality of life and psychosocial adaptation to chronic illness and acquired disability: a conceptual and theoretical synthesis. J Rehabil. 2005 Apr. www.thefreelibrary.com/Quality+of+life+and+psychosocial+adaptation+to+chronic+illness+and…-a0133317579. Accessed December 20, 2012.

Davidson T, Laberge M. Amputation. Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. 2004. www.encyclopedia.com/doc/1G2-3406200023.html. Accessed December 20, 2012.

Erwin-Toth P, Thompson SJ, Davis JS. Factors impacting the quality of life of people with an ostomy in North America: results from the Dialogue Study. J Wound Ostomy Continence Nurs. 2012;39(4):417-22.

Houston S. Body image, relationships and sexuality after amputation. First Step: A Guide for Adapting to Limb Loss. 2005;4. www.amputee-coalition.org/
easyread/first_step_2005/altered_states-ez.html. Accessed December 20, 2012.

Maguire P, Parkes CM. Surgery and loss of body parts. BMJ. 1998;316(7137):1086-8.

Pittman J, Kozell K, Gray M. Should WOC nurses measure health-related quality of life in patients undergoing intestinal ostomy surgery? J Wound Ostomy Continence Nurs. 2009;36(3):254- 65.

Pittman J. Characteristics of the patient with an ostomy. J Wound Ostomy Continence Nurs. 2011;38(3):271-9.

Racy JC. Psychological adaptation to amputation. In Bowker JH, Michael JW, ed. Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. 2nd ed. Rosemont, IL: American Academy of Orthopedic Surgeons; 1998.

Tunn PU, Pomraenke D, Goerling U, Hohenberger P. Functional outcome after endoprosthetic limb-salvage therapy of primary bone tumours—a comparative analysis using the MSTS score, the TESS and the RNL index. Int Orthop. 2008;32(5):619-25.

Turnbull G. Intimacy After Ostomy Surgery Guide. United Ostomy Associations of America, Inc. Revised 2009. www.ostomy.org. Accessed December 20, 2012.

Turnbull G. Sexuality after ostomy surgery. Ostomy Wound Manage. 2006;52(3):14,16.

United Ostomy Associations of America, Inc. From US to YOU: living with an ostomy, the experience. http://www.ostomy.org/files/asg_resources/UOAA_Nursing_Information_Modules.pdf. Accessed December 20, 2012.

United Ostomy Associations of America, Inc. What is an ostomy? http://www.ostomy.org/ostomy_info/
whatis.shtml. Accessed December 20, 2012.

Rosalyn Jordan is director of clinical education at RecoverCare, LLC, in Louisville, Kentucky.

« 1 … 8 9 10 11 12 »