Encountering Ostomies in Acute Care: Peristomal Skin Changes.

ABSTRACT: Up to 80% of individuals with an ostomy experience a peristomal skin complication, which can result in significant healthcare issues. All clinicians working with patients with stomas need to be aware of the signs and symptoms of peristomal skin complications and basic strategies to address the most common cause of skin complications: leakage of stool or other effluent onto the skin. Use of an evidence-based, standardized instrument to guide peristomal assessment and selection of appropriate interventions can improve patient outcomes and increase meaningful collaboration between all members of the healthcare team. This case study addresses dilemmas of care during a non-ostomy-related hospitalization.

Antibiotic Knowledge, Beliefs, and Behaviors: Testing Competing Hypotheses Using an Urban Community Sample.

Antibiotic use and misuse continue to be a worldwide concern with the increasing rate of antimicrobial resistance, lack of new antibiotics in the pipeline, and rising health care costs. Despite studies that attempt to distinguish between factors associated with antibiotic use and misuse (e.g., knowledge and beliefs and provider-patient communication), few studies have tested comparative hypotheses related to antibiotic use behavior. This study 1) compares two theoretical models (health belief and patient-centered communication) to learn which best represents the pathways associated with antibiotic use; and 2) describes urban consumers' knowledge, beliefs, and behaviors regarding antibiotic use. Interviewers completed 505 intercept surveys across six clinic- and community-based sites in Southeast Michigan. Structural equation modeling was utilized to compare two competing theoretical models predicting antibiotic behavior. Findings support the assertion that a patient-provider communication model fits the data better than the null model. Descriptive statistical analysis explicated participant knowledge was mixed. While many participants knew correct general facts about antibiotics, 35% of the sample put forth that they believed that antibiotics cure colds and flu and over half (57%) endorsed the belief that antibiotics are good for treating infections caused by viruses. The implications for theory and practice are discussed including the need for clinicians to target communication strategies for the populations that they serve.

A Descriptive Study Using an Intercept Survey: Knowledge, Attitudes, Beliefs, and Behaviors About Systemic Antibiotic Use in Adults Who Reported a Wound Within the Previous Year.

PURPOSE: This project examined knowledge, attitudes, beliefs, and behaviors about systemic antibiotic use for persons who reported a wound within the previous year. DESIGN: Secondary data analyses of 505 adults from a cross-sectional, prospective, intercept survey where every fifth adult was randomly approached to participate. SUBJECTS AND SETTING: Twenty-six participants (5.15% of the parent sample) stated having a wound within the previous year. METHODS: Participants were "interviewed" using the Facilitators and Barriers to Consumer Use of Antibiotics questionnaire that included demographics, health, information sources, antibiotic knowledge, attitudes, beliefs, and behavior questions. Hierarchical agglomerative cluster analysis was used to find clusters of items on the attitude, beliefs, and behavior questions. RESULTS: Sample demographics included 15 women and 11 African Americans, and 17 had some college education. Knowledge about antibiotics had a mean correct score of 10 out of 15 (67%) questions. Higher antibiotic knowledge was significantly related to higher education (rs = 0.69, P < .001). There were 2 attitude and beliefs clusters: most participants (>85%) recognized the need for medical supervision of antibiotic use (cluster 1), and beliefs about the need for antibiotics to prevent illness or treat wounds varied in 27% to 62% of participants (cluster 2). There were 4 behavior clusters: almost all participants 96% (cluster 1) filled and took the antibiotic if prescribed; greater than 71% (cluster 2) disagreed with unapproved methods of obtaining antibiotics; greater than 87% (cluster 3) used prescribed antibiotics correctly; and 36% of participants heard about antibiotic resistance through television or radio or Internet (40%) (cluster 4). CONCLUSIONS: Knowledge about antibiotics was low, while attitudes were positive. These findings support the need for research and evidence-based information on the role of antibiotics in wound care.

Nonviral Injection-Related Injuries in Persons Who Inject Drugs: Skin and Soft Tissue Infection, Vascular Damage, and Wounds.

GENERAL PURPOSE: To explore skin and soft-tissue infections and vascular damage in persons who inject drugs and relate these changes to wound development and care. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Review the issues surrounding wound infections in persons who inject drugs.2. Describe the risk factors and manifestations of wound infections in persons who inject drugs.3. Summarize the treatment options for wound infections in persons who inject drugs. ABSTRACT: The number of persons who inject drugs (PWIDs) is increasing. The literature has placed a substantial focus on the association between injection drug use and the transmission of blood-borne viral infections such as HIV and hepatitis C, but there is less extant research on other injuries such as skin and soft tissue infections (SSTIs), vascular damage, and associated wounds. Both SSTIs and vascular injury can result in marked morbidity and mortality and wounds that are slow to heal, likely to reoccur, and lifelong. The aims of this article are to (1) explore SSTIs and vascular damage in PWIDs and (2) relate these changes to wound development and care. Providers must address the health and psychosocial problems of PWIDs; take physical, psychosocial, and substance use histories; and develop multifocal plans of care. Finally, care must be provided in a nonjudgmental manner.

Forgiveness and Spiritual Distress: Implications for Nursing.

Spirituality, spiritual distress, and forgiveness are constructs relevant to nursing diagnoses and care planning. Forgiveness has significant implications, as it contributes to the spirituality of the individual and has been linked to positive and negative health outcomes. In clinical practice, forgiveness facilitation, grief work facilitation, and spiritual growth facilitation are evidence-based nursing interventions to address Spiritual Distress. Need exists to enhance spiritual distress and forgiveness within nursing curricula, patient assessment, and research designs.

Long-Term (up to 21 Years) Follow Up after Biological and Mechanical Aortic Valve Replacement in Younger Patients.

BACKGROUND: Despite the limited durability of biological aortic valves, increasing numbers of younger patients are choosing to receive them, due mainly to the lack of a need for permanent anticoagulation. Few data exist, however, regarding the outcomes of valve replacement in patients aged <55 years, and additional data are required in this patient population. METHODS: Between 1993 and 2014, at the authors' institution, a total of 448 patients (237 males, 101 females; mean age 45.8 ± 8.0 years) underwent aortic valve replacement (AVR) with either a mechanical prosthesis (M1 group, n = 318) or a biological prosthesis (B1 group, n = 130). The mean follow up was 8.5 ± 5.8 years (range: 4 days to 20.8 years) in the M1 group, and 4.9 ± 4.6 years (range: 2 days to 21 years) in the B1 group. The entire collective (EC) (n = 448 patients) was compared and analyzed with a selective collective (SC) (n = 109 patients) after exclusion of patients with concomitant procedures or comorbidities (M2 group, n = 74; B2 group, n = 35). RESULTS: Early mortality was greater after biological AVR in the EC (6.1% versus 1.9%), but in the SC no early deaths were observed after both primary and redo procedures. The reoperation rate was greater after biological AVR in both collectives. The late mortality, survival and endocarditis rates were comparable in both collectives. Bleeding occurred more often in the EC after mechanical AVR. CONCLUSIONS: Biological AVR in patients aged <55 years provides satisfactory outcomes, whereas reoperations were performed less commonly in patients with mechanical valve substitutes. In selective patients, AVR can be performed with zero mortality.

The Perceived Control Over Pain Construct and Functional Status.

INTRODUCTION: Belief in one's ability to control pain is a significant predictor of health outcomes and is related to improved functional status. The purpose of this study was to introduce a novel formulation of the construct, Perceived Control Over Pain and to test its effects on functional status. METHODS: Participants (N = 301) were primarily African American (92%); and were adults with low income attending a primary care clinic and reporting pain within the past 2 weeks. A cross-sectional design was used with confirmatory factor analysis and structural equation modeling. The Perceived Control Over Pain construct consisted of four measures-two specific measures of control over pain and two general measures of control over life events. Perceived Control Over Pain has not been defined in this way previously. RESULTS: Mean worst pain scores for the past week were 8.4, where "0" (no pain) to "10" (pain as bad as you can imagine). The model demonstrated good construct validity for the components of pain, Perceived Control Over Pain and functional status. Mediation by Perceived Control Over Pain was partial but strong, accounting for a reduction of 29% in the effect of pain on functional status. DISCUSSION: In minority populations with low income, factors such as perceived control over pain and its effect on the outcome of patient function need to be considered. Improving Perceived Control Over Pain has the potential for improving patients' feelings of life control and purpose or meaning in life, and psychological and physical functioning for adults living with pain.

Falls, Balance Confidence, and Lower-Body Strength in Patients Seeking Outpatient Venous Ulcer Wound Care.

PURPOSE & ABSTRACT: To provide information about a quality improvement project examining falls in persons seeking outpatient wound care. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Describe the scope of the problem and the related quality improvement project. 2. Delineate the results of the project and their implications for treatment of patients with venous ulcers. OBJECTIVE: The authors aim to examine fall occurrence and fall injuries in persons seeking outpatient wound care and to compare falls, balance confidence, and lower-body strength in persons with injection-related venous ulcers (IRVUs) versus persons with venous ulcers (VUs) related to other risk factors besides injection drugs (VUs-other). DESIGN: This quality improvement project used a cross-sectional, comparative design. Participants responded to demographic questions, the Activities-specific Balance Confidence (ABC) Scale, fear of falling, fall numbers, and injuries and performed the 30-second chair-rise test. SETTING: Outpatient wound service. PATIENTS: Patients (N = 106; mean age, 59.94 years) included men (66%) and women. RESULTS: Sixty patients reported falling; 47 were recurrent fallers. Twenty patients stated they were injured, but did not go to an emergency department. A higher number of total falls was significantly related to more comorbidities. Total falls were significantly related to fear of falling and ABC Scale scores. Those with VUs-other had significantly more comorbidities and higher body mass index values than those with IRVUs. Those with IRVUs were comparable to those VUs-other on number of falls and fear of falling, respectively. Those with IRVUs (7.30) performed significantly more chair rises than those with VUs-other (4.72). Persons with IRVUs had significantly higher ABC Scale scores (63.24%) than those with VUs-other (49.38%). CONCLUSIONS: Falls are a common occurrence in persons seeking outpatient wound care. Despite greater strength sufficient to perform more chair rises among those with IRVUs, fall rates were comparable to those of weaker individuals with other types of VUs. With the high occurrence of falls during the project, long-term risk for fall injury would be high. Further research is needed to clarify interactions between VU risk and patient factors such as strength, age, agility, and impaired cognition.

Sleep Quality: A Pilot Study Comparing Patients With and Without Injection-Related Venous Ulcers.

PURPOSE: The purposes of this study were to (a) compare sleep quality of persons with and without injection-related venous ulcers (VU) and (b) examine associations between global sleep quality with age, sex, comorbidities, pain, nutrition, physical health rating, fatigue, emotional problems, health-related quality of life, attitude toward physical activity, and number of ulcers. DESIGN: This study used a cross-sectional design. SUBJECTS AND SETTING: The participants included 31 patients with VU and 30 without VU (men [n = 35] and women; mean age = 54 years) who were attending an indigent clinic for wound care or general health. METHODS: Participants were recruited from an urban clinic when they came for primary care or wound care. Questionnaires were administered at that time and included the Pittsburgh Sleep Quality Index (PSQI), Mini Nutrition Assessment, Patient Reported Outcomes Measurement Information System (PROMIS) questions about general physical health, fatigue, emotional problems, and quality of life, Brief Pain Inventory worst pain rating, Positive Attitude and Motivation for Physical Activity Scale, wound assessment, and demographic factors. RESULTS: The 2 groups did not differ on the PSQI in terms of time going to bed, minutes to fall asleep, time awakening, hours slept, and time in bed. Those with VU compared to without VU took more medications to help sleep (P≤ .03). There were no significant differences in PSQI correlations across groups. All study variables except age, gender, and quality of life were significantly related to Global sleep disturbance score. A higher number of comorbid conditions, worse pain, poorer nutrition, poor physical health rating, greater fatigue, more emotional problems, and poor attitude toward physical activity were related to greater sleep disturbances for all participants. Both groups had mean Global PSQI scores greater than 5 (with VU = 7.83 and without VU = 8.2), indicating sleep problems. CONCLUSIONS: Study findings suggest that sleep disturbances may be a concern in persons with VU and are related to many variables. Assessing sleep along with other aspects of wound care may provide a more comprehensive assessment of factors affecting a person with a VU.

The effect of ankle range of motion on venous ulcer healing rates.

Limitation of ankle movement may contribute to calf muscle pump failure, which is thought to contribute to venous leg ulcer formation, which affects nearly 1 million Americans. We therefore wished to study ankle movement in patients with venous leg ulcers and its effect on healing. Using goniometry, we measured baseline ankle range of motion in venous leg ulcer patients from a Phase 2 dose-finding study of an allogeneic living cell bioformulation. Two hundred twenty-seven patients were enrolled in four active treatment groups and one standard-care control group, all receiving compression therapy. Goniometry data from a control group of 49 patients without venous disease, from a previous study, was used for comparison. We found patients with active venous leg ulcers had significantly reduced ankle range of motion compared with the control group (p = 0.001). After 12 weeks of therapy, baseline ankle range of motion was not associated with healing, as there was no significant difference between healed and nonhealed groups, suggesting that ankle range of motion is not important in venous leg ulcer healing or, more likely, is overcome by compression. However, patients with venous ulcers located on the leg (as opposed to the ankle) had significantly higher ankle range of motion for plantar flexion and inversion (p = 0.021 and p = 0.034, respectively) and improved healing with both cell bioformulation and standard care (p = 0.011), suggesting that wound location is an important variable for ankle range of motion as well as for healing outcomes.

The Pieper-Zulkowski pressure ulcer knowledge test.

OBJECTIVE: To describe the development and initial testing of the Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT). DESIGN: Cross-sectional, instrument testing. SETTING: Hospital association pressure ulcer educational program conference. METHODS: Pressure ulcer research and guidelines from the last 5 years were examined for test item content. The initial PZ-PUKT had 115 items; response options were "true," "false," and "don't know." Registered nurses (N = 108) were randomly divided into 2 groups to take either the 60 prevention/risk and staging items or the 55 wound description items. Analyses of these responses resulted in 72 items, which were administered in total to a second cohort of 98 nurses for reliability. RESULTS: Cronbach's α was .80 for the 72-item PZ-PUKT. Cronbach's α values for the subscales were as follows: staging, .67; wound description, .64; and prevention/risk, .56. The mean correct scores were as follows: total, 80%; prevention, 77%; staging, 86%; and wound description, 77%. Nurses with wound care certification scored significantly higher on the PZ-PUKT than did nurses with other clinical certifications or with nurses who lacked certification. CONCLUSIONS: The PZ-PUKT has updated content about pressure ulcer prevention/risk, staging, and wound description. Reliability values are highest for the total test. Further use of the instrument in diverse settings will add to reliability testing and may provide direction for determination of a passing cutoff score.

A comparative study of the five-times-sit-to-stand and timed-up-and-go tests as measures of functional mobility in persons with and without injection-related venous ulcers.

PURPOSE: To provide information on the Five-Times-Sit-to-Stand (FTSTS) and Timed-Up-and-Go (TUG) tests in persons with injection-related venous ulcers (VU+) and persons without venous ulcers (VU-). TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: OBJECTIVE: To examine functional mobility using Five-Times-Sit-to-Stand (FTSTS) and Timed-Up-and-Go (TUG) tests in persons with injection-related venous ulcers (VU+) and compare these findings to persons without venous ulcers (VU-). DESIGN: Cross-sectional, comparative design. SETTING: Outpatient clinic.PARTICPANTS: Participants (n = 61) were 31 persons VU+ and 30 persons VU-; 57.4% men; mean age, 54 years; 93% African American. MAIN OUTCOME MEASURES: Five-Times-Sit-to-Stand, TUG, physical activity, quality of life, comorbidities, falls, and body mass index. RESULTS: Participants VU+ were 36.8% slower on completion of the TUG test (P = .012) and 26.5% slower on completion of the FTSTS test (P = .081). Five-Times-Sit-to-Stand and TUG were strongly correlated with each other, r = 0.93, 0.87, P < .001 for VU- and VU+, respectively. Test-retest reliabilities for the FTSTS and TUG tests were high (intraclass correlation coefficient = 0.89-0.94) for the VU+ and VU-. Within each group, correlations of FTSTS and TUG were similar for each of the variables examined. Across groups, correlations showed that the time to complete FTSTS and TUG increased as a function of comorbidities in the VU+ group; the correlations in the VU- group were not significantly different from zero. CONCLUSIONS: The VU+ group exhibited poorer physical performance than the VU- group. The high correlation between FTSTS and TUG and the similarity of correlations with other variables suggest that these physical performance measures may be interchangeable in their ability to predict physical functioning in these clinical groups despite differences in test demands. Clinicians need easy-to-perform reliable clinical tests such as FTSTS and TUG to assess mobility of aging injection users with venous ulcers.

Psychosocial needs of cancer patients living in the Adirondacks: a needs assessment.

As the national conversation on solutions to healthcare factors such as affordability and access is likely to intensify, health inequities continue to persist in rural areas. National studies suggest a growing, aging, rural population impacting the revenues of local healthcare facilities, as well as contributing to complexity of care. This paper examines factors influencing the health of rural citizens in upstate New York and offers the results of an initial needs assessment looking at the psychosocial healthcare needs of cancer patients living in the Adirondack Park region. Patients were surveyed regarding their perceptions of psychosocial needs and experiences as a cancer patient. Psychosocial factors while acknowledged as important influences on recovery and healing remain an underdeveloped intervention toward improving the quality of cancer care. Recommendations are made based on the results to enhance the quality of life for this vulnerable population.

Testing a fall risk model for injection drug users.

BACKGROUND: Fall risk is a critical component of clinical assessment and has not been examined for persons who have injected illicit drugs and are aging. OBJECTIVES: The aim of this study was to test and develop the Fall Risk Model for Injection Drug Users by examining the relationships among injection drug use, chronic venous insufficiency, lower extremity impairments (i.e., decreased ankle range of motion, reduced calf muscle endurance, and leg pain), age and other covariates, and the Tinetti balance and gait total score as a measure of fall risk. METHODS: A cross-sectional comparative design was used with four crossed factors. Standardized instruments were used to assess the variables. Moderated multiple regression with linear and quadratic trends in age was used to examine the nature of the relationship between the Tinetti balance and gait total and age and the potential moderating role of injection drug use. A prespecified series of models was tested. RESULTS: Participants (n = 713) were men (46.9%) and women with a mean age of 46.26 years and primarily African American (61.7%) in methadone treatment centers. The fall risk of a 48-year-old leg injector was comparable with the fall risk of a 69-year-old who had not injected drugs. Variables were added to the model sequentially, resulting in some lost significance of some when they were explained by subsequent variables. Final significant variables in the model were employment status, number of comorbidities, ankle range of motion, leg pain, and calf muscle endurance. DISCUSSION: Fall risk was associated with route of drug use. Lower extremity impairments accounted for the effects of injection drug use and chronic venous insufficiency on risk for falls. Further understanding of fall risk in injection users is necessary as they age, attempt to work, and participate in activities.

Doctoral education for WOC nurses considering advanced practice nursing.

Advanced practice nursing education is at a crossroads. Societal changes, increased health care demands, and leadership nursing organizations have identified the need of a doctor of nursing practice (DNP) degree as the advanced practice degree. WOC nurses need to examine DNP programs when considering returning for an advanced practice degree. This article explores nursing education at the doctorate level and areas the WOC nurse should consider when making a decision about attending a program. The WOC nurse needs to understand the similarities and differences of the doctor of philosophy and the DNP, issues about each program and its completion, personal factors, and the application process. Although selecting a doctoral program is a daunting experience, the education will provide opportunities for the WOC nurse to excel as a scholar, thus influencing the profession and the practice.

Itch: association with chronic venous disease, pain, and quality of life.

PURPOSE: The purpose of the study was to examine the symptom of itch and its relationship with chronic venous disease, pain, and quality of life. DESIGN: The study used an exploratory, cross-sectional design. METHODS: One hundred and sixty-one participants completed demographic, health, substance abuse, itch, and pain questionnaires and the SF-12v2 Health Survey to measure health related quality of life. RESULTS: Participants were mostly men (n=95, 59%), African American (113, 70.2%), and had a mean age of 44.19 years. A history of injection drug use was reported by 91.4%. Using the clinical score of the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) Classification of the worst leg, the most common classification was Class 3, edema without skin changes (45.9%); 18.6% had severe venous disease (Classes 5 and 6). Eighty-eight participants (54.7%) reported itch somewhere on their body with 74 of them (45.9%) reporting itch on the legs or feet. Fourteen participants who reported itch of their legs or feet had wounds on the legs or feet. A positive correlation between magnitude of reported itch and CEAP clinical classification was noted (0.26, P =.025). This relationship was not strictly linear with itch increasing at a faster rate at higher levels of the CEAP classification. Persons with leg or feet itch had poorer health related quality of life, more comorbidities, and higher leg pain than those without itch. Because the SF-12v2 Health Survey is norm based, persons with itch were more than 1 standard deviation below the mean for the United States for their mental and physical health scores. CONCLUSIONS: Itch on the legs or feet is a clinically relevant problem that is related to the level of venous disease. Persons with lower extremity itch have higher pain ratings and lower quality of life.

C-reactive Protein Levels in Plasma and Chronic Venous Ulcer Exudate of Persons Who Inject Drugs: A Pilot Study.

BACKGROUND: Persons who inject drugs (PWID) in the groin, legs, and/or feet are at high risk for chronic venous ulcers (CVUs). The plasma C-reactive protein (CRP) level is a marker of systemic inflammation. OBJECTIVE: This pilot study examined CRP levels in plasma and CVU exudate of PWID. The aims were to (1) compare levels of CRP in plasma and exudate; (2) examine if the CRP level in exudate changed over 4 weeks with wound treatment; and (3) examine the relationship of the exudate CRP level with CVU area, CVU age, number of CVUs, and number of comorbidities. MATERIALS AND METHODS: Persons who inject drugs seeking wound care were enrolled in this Institutional Review Board approved prospective, longitudinal, descriptive study. A blood sample was collected on the first visit (week 1); the plasma was then separated. Wound exudate was collected on swabs during the first visit (week 1) and 4 weeks later (week 4). All samples were stored at -80° C. Samples were eluted from swabs using mass spectrometry grade water then aliquoted for CRP analysis. RESULTS: The participants of the study included 14 PWID (mean age, 62.14 ± 4.52 years; mean number of comorbidities, 5.71 ± 1.90; and mean number of ulcers 2.07 ± 1.07 that were present for a mean of 7.96 ± 11.91 years without healing). C-reactive protein level in plasma was a mean of 6.47 ± 8.56 mg/L, with lower levels found in wound exudate but highly correlated (rho = .925). Exudate CRP levels decreased from week 1 to week 4, and the 2 were highly correlated (rho = .895). Exudate CRP level week 1 was not significantly related to wound area, wound age, number of ulcers, or number of comorbidities. CONCLUSIONS: Plasma and exudate CRP levels were highly correlated. Exudate CRP levels decreased across time. Future large-scale wound healing studies should examine CRP levels over a longer duration and as they correlate to wound healing.

The impact of vascular leg disorders on physical activity in methadone-maintained adults.

Chronic venous disorders (CVD) and peripheral arterial disease (PAD) may affect diverse physical activity domains. How CVD and PAD and other relevant variables affect physical activity was examined in 569 opioid-addicted adults. Both CVD and PAD were significantly inversely related to daily walking, sports, and active living. Effects remained significant in the latent variable regression after controlling covariates. Overall activity was very low; most participants walked less than a half mile daily and rarely engaged in sports. Motivation for physical activity was the strongest predictor (ß = .55) of daily physical activity. Health-care professionals promoting physical activity for injection users should consider the vascular health of their legs and motivational variables in addition to general health.