The Standard of Care

The "standard of care" changes as health care
and nursing research determine the effectiveness of approaches to care.

 

 

 

 

Hygenique Plus - The Standard of Care

Hygenique™ Sitz Bath was designed by a nurse to promote wound healing, provide pain relief, and reduce surface contaminants in the perineal area.

Promotes Wound Healing

Hygenique™ Sitz Bath's continuous warm water cleansing therapy concentrates heat and stimulates blood flow to the perineal wound or episiotomy. This local hyperthermia increases subcutaneous perineal tissue temperature and oxygen tension, thus significantly promoting the wound healing process.

  • Episiotomies
  • Fissures
  • Peri-anal abscesses
  • Anal lesions
  • Vaginectomies
  • Fistulas
  • Hemorrhoidectomies
  • Vaginal tears/trauma

    Decreases Peri-anal Pain

    By providing a gentle, therapeutic cleansing and soak, as well as local hyperthermia to the perineal wound, the patient will feel a relaxation of the internal an'al sphincter muscle, thus decreasing pain due to perineal trauma.

  • Episiotomies
  • Itching
  • Incisions
  • Perineal trauma
  • Hemorrhoids
  • Burning
  • Chronic diarrhea pain
  • Pain from infections
  • Puritius ani

    Reduces Surface Contaminants

    Hygenique's glycerin cartridge and warm water cleansing therapy gently debride loosely attached devitalized tissues; reduce surface contaminants such as residual blood, urine, and fecal matter; and provide a surfactant and emollient to help maintain the proper PH level without drying out the tissue.

  • Chronic diarrhea
  • Reduces potential for skin breakdown which can lead to infection for immune-suppressed patients
  • Incontinence
  • Reduces potential for infection
  • Reduces the risk of urinary-tract infections

     

    References:

    McCulloch, J. (1995). Physical Modalities in Wound Management, Ultrasound, Vasopneumatic devices and Hydrotherapy. Ostorny Wound Management, 41(5), 30-32, 34, 36-37.

    Rabkin, J.M. and Hunt, T.K. (1987). Local Heat Increases Blood Flow and Oxygen Tension in Wounds. Archives of Surgery 122(2), 221-225.

    Shafic, A- (1993). Warm-Water Bath in Anorectal Conditions: The Thermosphincteric Reflex. Journal of Clinical Gastroenterolo&L 16(4), 304-308.

     

    APPLICATIONS HOSPITAL WIDE - For Diagnoses and Procedures of the Perineum

    Treatment
  • Postpartum
  • Gynecology
  • AIDS
  • Radiation / Oncology
  • Med-Surg
  • Voiding Stimulation
    Pain Relief
  • Gastroenterology
  • Postpartum
  • AIDS
  • Med-Surg
  • Radiation / Oncology
  • Gynecology
    Prevention
  • Preterm Births
  • Surgical Infections Perineum
  • Neonatal Infection
  • Nosocomial Diarrhea
  • Urinary Tract Infection

    Treatment: Promotes Wound Healing

    Hygenique™ Sitz Bath's continuous warm water cleansing therapy concentrates heat and stimulates blood flow to the perineal wound. This local hyperthermia increases subcutaneous perineal tissue temperature and oxygen tension, thus significantly promoting the wound healing process.

    (1) Local Heat Increases Blood Flow and Oxygen Tension in Wounds. Archives of SurgeEy, Rabkin, J.M. and Hunt, T.K. (1987), pages 122 (2), 221-225.

    (2) Physical Modalities in Wound Management, Ultrasound, Pasopneumatic devices and Hydrotherapy. Ostomy Wound Management, McCulloch, J. (1995). 41(5),30-32, 34,36-37.

    (3) Minimizingjactors that impair wound healing; a nursi . ng approach. Ostomy Wound Management, Krasner, D., vol. 41, pages 22-6, 28, 30.

    (4) Wound healing. Advanced Dermatology Waldorf, H., 1995, vol. 10, pages 77-96; discussion 97. Department of Dermatology, Harvard Medical School, Boston, MA.

    (5) Using Wound Care products to promote a healing environment. Critical Care NqE~jn North America. Maklebust, J., June 1996, vol. 8, pages 141-158.

    (6) Perineal manifestations of HlV infection. Diseases Colon Rectum, Orkin, B.A-, April 1992, vol. 4, issue 35. Division of Colon and Rectal Surgery, (5porge Washington University Medical Center, Washington, D.C.

    Pain Relief: Decreases Perineal Pain

    Hygenique™ Sitz Bath provides a gentle, therapeutic cleansing and soak, as well as local hyperthermia to the perineal wound. The patient will feel a relaxation of the internal anal sphincter muscle, thus decreasing pain.

    (1) Warm-Water Bath in Anorectal Conditions: The Thermosphincteric Reflex. Journal of Clinical GastroenterolozL Shafic. A. (1993). 16(4), 304-308.

    (2) Anal sphincter complex; endoanal MR imaging of normal anatomy. Radiology Hussain, SM., Dec. 1995, vol. 197, pages 671-7. Department of Radiology, University Hospital Rotterdam.

    (3) Anorectal disorders;five common causes ofpain, itching and bleeding. Postgraduate Medicine. Metcalf, A., Nov. 1995, vol. 98, pages 81-4, 87-9, 92-4. Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Lk

    Prevention: Reduces Surface Contaminants

    Hygenique™ Sitz Bath's glycerin cartridge and warm water cleansing therapy gently debride loosely attached devitalized tissues; reduce surface contaminants such as residual blood, urine, and fecal matter; and provide a surfactant and emollient to help maintain the proper PH level without drying out the tissue.

      (1) Bacterial vaginosis in pregnancy: an approach for the 1990's. Obstetrics & Qynecology Survey, 1995, vol. 50, pages 482-8. University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, USA-

      (2) Risk of preterm delivery in pregnant women with group B streptococcal urinary infections or urinary antibodies to group B streplococcal and E. coli antigens. British Journal Obstetrics Qynecology, McKenzie, H., Feb. 1994, vol. 101, pgs. 107-13. Department of Obstetrics and Gynecology, Ninewells Hospital, Dundee.

      (3) Preterm labor. emerging role ofgenital tract infections. Infectious Agents Diseases Dec. 1995, Andrew, W.W., vol. 4, pages 196-211. Department of Obstetrics and Gynecology, University of Alabama at Birmingham.

      (4) Effect of vaginalfluid on adherence of type I piliated Escherichia coli to epithelial cells. Journal of Infectious Disease, Gaffney, R-A, Dec. 1995, vol. 172, pages 1528-35. Department of Urology, Northwestern University Medical School, Chicago, IIL.

      (5) Role of warm water bath in inducing micturition in postoperative urinary retention after anorectal operations. Urology International, Shafik, A., 1993, vol. 50, pages 213-7. Department of Surgery and Research, Faculty of Medicine, Cairo University, Egypt.

      (6) Clinical and molecular epidemiology ofsporadic and clustered cases ofnosocomial Clostridium difficile diarrhea. American Journal Medicine Jan. 1996, Samore, M.11, vol. 100, pages 32-40, Division of Infectious Diseases, New England Deaconess Hospital, Harvard Medical School, Boston, MA.

     

     

     

     

     

     

     

     

     

     

    COMPARISON OF PERSONAL

    HYGIENE TECHNIQUES

    A COMPARISON OF THE Hygenique Plus SITZ BATH / BIDET

    SYSTEM TO A PERI-BOTTLE, BAG-TYPE SITZ BATH, AND PERSONAL

    HYGIENE WIPES FOR PERINEAL CARE

    Microbiology performed at:

    PTI Technologies, Inc.

    Newbury Park, California

    Microbiologist: John A. Simonetti

    Date of Report: July 14, 1997

    Purpose of the Study

    Vaginal infections often contain bacteria that are normal inhabitants of the intestinal tract. Some of the rnicro-organisms cited in literature most frequently are Escherichia coli (E. Coli) and group B Streptococcus. These pathogens have been indicated as one of the causes for urinary tract infections. By reducing the number of types of bacteria in the perineal region, the number of pathogens will also be reduced; and with thern, we believe that the probability for cross-contamination of the vaginal area with bacteria is also reduced. This study was undertaken to compare various hygiene practices for perineal care to see which is the most effective in reducing the number of bacteria in the perineal region.

    Introduction

    Different perineal cleaning techniques were used following bowel movements by a female test subject. Following the personal hygiene technique, the perineal area was then rinsed using a squirt bottle filled with a sterile solution containing nutrients to support the growth of bacteria (TSB). This "post hygiene" wash liquid was allowed to fall into a sterilized basin and was subsequently transferred to a sterile Erlenmeyer flask, removed to a laboratory, and evaluated for the presence of micro-organisms. The number of bacteria in the post-hygiene TSB wash signifies the efficacy of the personal hygiene step; that is, the lower the bacteria numbers in the post-hygiene wash liquid, the more effective the person hygiene technique.

    Materials

    QTY

    Description

    4
    Flasks containing 250-ml sterile tryptic soy broth (TSB)
    18
    Sterile tryptic soy agar (TSA) Petri dishes
    6
    Sterile 500-ml -wide-mouth Erlenmeyer flasks for sample collection
    6
    0.2 micron membranes
    1
    Premoistened towelette (Tucks brand)
    1
    240-cc peri-bottle
    1
    HygeniqueTm Sitz Bath/Bidet
    1
    Conventional sitz bath (Futuro)
    8
    Test tubes containing 9.9-ml TSB for dilution
    1
    Incubator set at 37 degrees Celsius
    1
    Autoclave
    1
    Vortex
    1
    47-nim filter funnel with vacuum source
    4
    Sterile squirt bottles
    4
    Sterile containers for catching wash solution

     

    1.0 Perineal Wash Procedures

    After a bowel movement, the subject was instructed to perform one of the following procedures:

    1.1 Wipe perineum from the front to the back with toilet paper.

    1.2 Wipe perineurn from the front to the back with toilet paper. Follow with 250-ml of warm water applied from a peri-bottle.

    1.3 Wipe perineum from the front to the back, with toilet paper. Follow with the use of a personal hygiene (Tucks) moistened towelette.

    1.4 No toilet paper. Two minute warm water wash applied with Hygenique™ Sitz Bath.

    2.0 Evaluation of Washed Perineal Area

    After each of steps 1 - 4 above, a sterile wash bottle filled with a sterile TSB was used to spray the TSB over the perineal area; and the TSB wash was collected in a sterile plastic basin. The TSB wash was then transferred to a sterile screw cap Erlenmeyer flask and transferred to the laboratory. Samples from each of the steps above were evaluated for the presence of bacteria by using the following method:

    2.1 100 - ml of the sample was filtered through a sterilizing grade membrane filter, and the filter was placed on the surface of the TSA in a Petri dish. The purpose of this collection method was to collect bacteria from a large volume of liquid in case the bacteria counts were very low. A 0.2 micrometer filter is capable of collecting all bacteria on its surface, and the cells are capable of growing into visible colonies suitable for counting purposes.

    2.2. 1 - ml sample was removed from the sample container, plated directly on the surface of the TSA Petri dish, and spread using a sterile glass rod (standard spread plate technique). The purpose of this and following dilutions is to achieve countable quantities of bacteria, even if the levels are very high.

    2.3 The original sample was diluted using a 100 - fold dilution in sterile TSB, and 0. 1 - ml was removed and plated as in step 2.2.

    3.0 Sitz Bath

    Water Sample

    After a bowel movement, the subject was instructed to '%kripe the perineal area with toilet paper and perform one of the following procedures:

    3.1 Hygenique™ Sitz Bath Sitz Bath / Bidet

    3.2 Conventional bag-type sitz bath

  • After a ten-minute sitz bath, a water sample was removed and evaluated for bacterial contamination. See test results 3.1 and 3.2
  • Results

    The results are listed in Table I and photographs of several of the sample dilutions in Figure 1. Wash procedures 1.1, 1.2, and 1.3 had very similar numbers of bacteria which were present in concentrations of approximately 3 x 107. This data suggests that there is not much difference between the cleaning methods of toilet paper used alone, toilet paper used in conjunction with a peri-bottle, and toilet paper used in conjunction with a personal hygiene wipe (50% witch hazel). There was a very large reduction of bacteria, however, after the use of the Hygenique™ Sitz Bath ( see 1.4 ). The bacteria numbers were approximately 100 times less than writh the peri-bottle or personal hygiene wipe. This means that the quantity of bacteria was reduced, by the Hygenique™ Sitz Bath, not only two or three, or ten times, but over 100 times or two orders of magnitude.

    Table 1: Bacteria Levels in TSB Rinse Liquid after Personal Hygiene

    Wash Procedure
    Number of Bacteria (Colony-Forrriing Units)
     
    Estimated Total Bacteria per: 100-ml TSB
    0. 1 - ml
    Undiluted
    0. 1 - ml
    1/100 Dilution
    1.1 Toilet paper only
    30,000,000
    TNTC
    300
    1.2 Toilet paper and peri-bottle
    10,000,000
    TNTC
    100
    1.3 Toilet paper and personal hygiene wipe
    24,000,000
    TNTC
    240
    1.4 Hygenique™ Sitz Bath only --no toilet paper
    112,000
    112
    2
    3.1 Hygenique™ Sitz Bath sitz water
    0
    0
    0
    3.2 Bag-type sitz water
    1,000,000
    TNTC
    2

    TNTC = too numerous to count

    Toilet Paper Only
    0.1 ml perineal rinse liquid
    number of bacteria : TNTC
    ( estimated total bacteria 30,000,000 3 X 10 7 )
     
    Toilet Paper and Peri-Bottle
    0.1 ml perineal rinse liquid
    Number of Bacteria : TNTC
    ( estimated total bacteria 10,000,000 or 1 X 10 7 )
     
    Bag-Type Sitz Bath water sample
    0.1 ml perineal rinse liquid
    number of bacteria : TNTC
    ( estimated total bacteria 1,000,000 1 X 106)
     
    Toilet Paper and Personal Hygiene Wipe
    0.1 ml perineal rinse liquid
    Number of Bacteria : TNTC
    ( estimated total bacteria 24,000,000 or 2.4 X 10 6 )
     
    Hygenique only no Toilet Paper
    0.1 ml perineal rinse liquid
    number of bacteria :
    112
    ( estimated total bacteria 112,000 1.2 X 105)
     
    Hygenique Sitz bath Water Sample
    Number of Bacteria : 0
    ( estimated total bacteria 0 )
     

     

    NOTE:

  • Bacteria colonies were reduced by over 250 times with the use of Hygenique™ Sitz Bath when compared to toilet paper alone.
  • Bacteria colonies were reduced by over 100 times with the use of Hygenique™ Sitz Bath when compared to toilet paper and a peri-bottle.
  • Bacterial colonies were reduced by over 200 times with the use of Hygenique™ Sitz Bath when compared to toilet paper and a personal hygiene wipe.
  • Bacteria colonies were not detected w th the use of the Hygenique™ Sitz Bath Sitz Bath System.


  • Conclusion

    Although these results only come from a single test subject, they show conclusively that some personal hygiene techniques are significantly more effective than others. Much of the logic for understanding the mechanisms of how Hygenique™ Sitz Bath works is simple common sense. The water mechanically removes debris and bacteria. The results show particularly that the Hygenique™ Sitz Bath is more effective than a peri-bottle, personal hygiene wipe ( 5 0% witch hazel ) and conventional sitz bath in removing microorganisms from the perineal area. A reduction in bacteria from this area reduces the probability of cross-infection to the vaginal area with enteric pathogens. Although this study did not differentiate between enteric and normal inhabitants of the skin, it does show that the total number of bacteria was reduced; and we hypothesize that enteric organisms as well non-nal flora would be reduced in numbers with the use of Hygenique™ Sitz Bath.

    The Hygenique™ Sitz Bath Sitz Bath water was notable in that there was no detectable bacteria present ( 3. 1 ). This is likely due to the presence of chlorine in the tap water and that the water is constantly being replaced with new fresh clean water. The conventional sitz bath water, however, did contain a large number of bacteria; i.e., over a million. This discounts the fact that chlorinated water alone killed the bacteria in the Hygenique™ Sitz Bath Sitz Bath ( 3. 1 ); the replenished fresh water was probably responsible for the killing or removing of the microorganisms.

    Bibliography: available upon request.

     

     

     

     

    TECHNOLOGY ASSESSMENT FOR PERINERAL CARE

    with Emphasis on the Postpartum Period

    and the Effect on Patient Outcomes

     

     

    Submitted by:

    Andermac,, Inc.

    Yuba City, California

    Manufacturer of

    Hygenique Plus Sitz Bath/Bidet

     

     

    Introduction

    The following information will give the researcher an overview of some of the common practices that are currently being used in the treatment of perineal, trauma/care and their drawbacks to patient care/outcomes. As part of the discussion, we will introduce the new standard of care, the Hygenique Plus Sitz Bath/Bidet, a superior perineal cleansing and wound treatment system. With the information presented in this package, you will be better informed to make a decision based on medical, clinical, and laboratory testing when choosing a treatment system for perineal care.

    Desired Outcomes for Perineal Care

    1. Provide a cleansing method which will reduce surface contaminants' to help in the prevention of infection.

    2. Provide a wound treatment system to help promote the wound healing process.

    3. Provide pain relief.

    4. Provide the patient with a method to help stimulate voiding before catheterization.

    5. Provide the patient with an effective method of treatment to continue perineal care throughout his/her recovery period.

    6. Provide the standard of care

     

    Common Practices for Perineal Care and Their Associated Problems

    1. Hygiene Wipes ( premoistened towelettes )

    2. Community Sitz Bath (tub approx. 3x3 ft., water delivered to patient at a steady flow)

    3. Peri-Bottle (squirt bottle, holds 240-cc)

    4. Bag-Type Sitz Bath (plastic basin, hooks up to plastic bag holding approx. 2000-cc gravity feed 5 ft.)

    5. Whirlpool Tubs (bathtubs with water jets to provide whirlpool action)

    6. lce Packs (ice or cold gel wrapped in sealed pouch)

    7. Anesthetic Sprays and Ointments (topical products containing an anesthetic)

     

    Hygenique Plus

     

    The Hygenique Plus personal whirlpool sitz bath/bidet system prevents cross-contamination and allows for treatment of perineal trauma such as postepisiotomy edema, hemorrhoids, and pain in the perineurn and anal areas both in the hospital and at home. This system easily connects to a single-spouted water faucet for home use or to a delivery system in the patient's room. Used as a whirlpool sitz bath, the unit provides continuous water-flow heat therapy at a constant temperature and relief for tender tissues. With the flow-through door, the unit may be used as a bidet for self-administered gentle cleansing. The Hygenique Plus is the only sitz bath system available that provides the patient with contaminant-free soaking.

    Hygenique Plus was designed to promote wound healing, provide pain relief, and reduce surface contaminants in the perineal area.

    Promotes Wound Healing

    Hygenique™ Sitz Bath's continuous warm water cleansing therapy concentrates heat and stimulates blood flow to the perineal wound. This local hyperthermia increases subcutaneous perineal tissue temperature and oxygen tension, thus significantly promoting the wound healing process.

    Decreases Perianal Pain

    Hygenique™ Sitz Bath provides a gentle, therapeutic cleansing and soak, as well as local hyperthern-~a to the perineal wound. The patient will feel a relaxation of the internal anal sphincter muscle, thus decreasing pain.

    Reduces Surface Contaminants

    Hygenique™ Sitz Bath's glycerin cartridge and warm water cleansing therapy gently debride loosely attached devitalized tissues; reduce surface contaminants such as residual blood, urine, and fecal matter; and provide a surfactant and emollient to help maintain the proper pH level without drying out the tissue.

    Hygenique Plus Benefits

     

    Postpartum Nursing Care Practices: Perineal Trauma

    Episiotomy/Perineal Swelling, Bruising

    Nursing Interventions

    Rationale

    Use sitz baths (100-104 F) for 15 to 20 minutes three to four times a day. Heat increases circulation to the perineum, thereby promoting oxygenation and nutrition of tissues. It, therefore, promotes healing, which reduces discomfort.
    Cleanse perineal area after each elimination. Perineal cleansing reduces risk for infection, which causes discomfort. Cleansing from front to back reduces introduction of intestinal-tract microorganisms.
    *Wash hands before and after perineal care, elimination, and use of heat Cleansing the hands reduces microorganisms, which could be transferred to the perineum.

     

    Hemorrhoids

    Nursing Interventions

    Rationale

    Instruct client in taking a warm sitz bath for 15 to 20 minutes three times a day. Warm sitz baths and cleansing warm water sprays are helpful for relieving pain and discomfort due to hemorrhoids. A sitz bath temperature of 105'F is comfortable for most women, although the patient's personal preferenceshould be followed. Sitting in the bath for about 20 minutes is usually adequate for most patients. If the patient uses a sitz tub rather than a personal sitz bath system, use caution when assisting her out of the tub; the warmth of the bath may causesufficient vasodilation, which increases the risk for dizziness or fainting.

     

     

    Risk for Uterine Infection (Endometritis) Related to:

    The most common pathogens responsible for postpartum infections are those that inhabit the lower genital tract and bowel; however, pathogens may also be exogenous in nature. After birth, portads of entry for bacterial invasion include the placental site, the perineum, the episiotomy, an incision or laceration, the vagina~ the urinary tract, the breast, and the lymphatic system along the uterine veins. Common organisms include Streptococcus, Escherichia coli, Staphlococcus, Clostridia, Klebsiella, and Neisseria gonorrhoeae. Most infections are caused by a combination of anaerobic bacteria.

    Risk for Urinary Tract Infection Related to:

    Nursing Interventions

    Rationale

    The patient should be taught self-care measures to reduce the risk for infection. This includes teaching her to ,vNipe the perineum from front to back after voiding and defecation. This decreases the risk for contamination with microorganisms from the anus to the vagina. Warm water using a bidet or other irrigator device should be used to rinse the perineum after elimination.

    Frequent assessment of bladder distention is essential during the postpartum period. Catheterization should be used only after other interventions have proven unsuccessful, because catheterization increases the risk for bladder infection.

    Run water, pour warm water over perineum, or have patient void in shower.
    With trauma, swelling, and decreased distention, there is a tendency toward urinary retention. Urinary retention increases the risk for infection. The patient should void at least I 00-rnl per voiding. With trauma and urinary tract changes, the bladder may become distended. In addition, renal plasma flow remains elevated in the first week after delivery, which increases bladder filling. (Nichols 1997; Zwelling 1997)

     

    Risk for Infection: Vagina, Episiotomy/Perineum, Breasts (Mastitis) Related to:

    Nursing Interventions

    Rationale

    Educate patient in how to do perineal cleansing. This includes cleansing from front to back and rinsing with water after each elimination.
    Cleansing the perineum reduces the number of microorganisms present. In addition, it removes lochia, moisture that provides an environment favorable for the growth of microorganisms.
    Instruct client to wash hands before and after perineal cleansing and changing perineal pads.
    Washing hands reduces microorganisms that can be introduced to perineal pads or the perineum.
    Instruct patient to use a sitz bath or apply hot packs for 15 to 20 minutes three times a day.
    Warm heat increases circulation, which promotes healing. It also reduces discomfort.
    Instruct patient to wash hands before breast-feeding.
    Milk ducts open directly onto nipple. Microorganisms on the hands may be introduced into the breasts through handling associated with breast-feeding.

     

     

     

    Hygenique™ Sitz Bath Applications - For Diagnoses and Procedures of the Perineum

    Hospital/Departments

     

    Incentives to Change Current Practice

    The Standard of Care

    The "standard of care" changes as health care and nursing research determine the effectiveness or ineffectiveness of approaches to care. Hospital policies and procedures set standards of care. The standard of care is expected to be based on the professional literature and reviewed at regular intervals so that they remain current.

    (Nichols 1997; Zwelling 1997)

    Conclusion

    This technology assessment has included references from various technical publications, professional literature, textbooks, university studies, and laboratory testing. The information presented clearly shows the benefits that Hygenique Plus , the new standard of care, can have on patient care/outcomes.

     

    References

    Comparison of Hygenique Plus Sitz Bath Bidet to a peri-bottle, bag-type sitz bath and personal hygiene wipes for perineal care. Simonetti, J.A., July 1997, PTI Technologies, Newbury Park, CA.

    Maternal-Newborn Nursing: 7heory and Practice. Nichols, F.H. and Zwelling, E., 1997. W.B. Saunders Company.

    Local Heat Increases Blood Flaw and Oxygen Tension in Wounds. Archives of Surge1y Rabkin, J.M. and Hunt, T.K. (1987), pgs. 122 (2), 221-225.

    Physical Modalities in Wound Management, Ntrasound, Vasopneumatic Devices and Hydrotherapy. Ostomy Wound Management, McCulloch, J. (1995), pgs. 41 (5)) 30-32, 34, 36-37.

    Minimizing jactors that impair wound healing; a nursing approach. OstomyWound Management, Krasner, D., vol. 41, pgs. 22-6, 28, 30.

    Wound healing. Advanced Dermatology, Waldorf, H., 1995, vol. 10, pgs. 77-96; discussion 97. Department of Dermatology, Harvard Medical School, Boston, MA.

    Using Wound Care products to promote a healing environment. Critical Care Nursing North America, Maklebust, J., June 1996, vol. 8, pgs. 141-158.

    Perineal manifestations of HIV infection. Diseases Colon Rectum, Orkin, B.A., April 1992, vol. 4, issue 35. Division of Colon and Rectal Surgery, George Washington University Medical Center, Washington, D.C.

    Effect of vaginal fluid on adherence of type l piliated Escherichia coli to epithelial cells. Journal of Inffectious Diseases Gaffhey, R.A., Dec. 1995, vol. 172, pgs. 1528-35. Department of Urology, Northwestern University Medical School, Chicago, IL.

    Role of warm water bath in inducing micturition in postoperative urinary retention after anorecial operations. Urology International, Shafik, A., 1993, vol. 50, pgs. 213 -7. Department of Surgery and Research, Faculty of Medicine, Cairo University, Egypt.

    Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridum difficile diarrhea American Journal Medicine, Jan. 1996, Samore, M.H., vol. 100, pgs. 32-40, Division of Infectious Diseases, New England Deaconess Hospital, Harvard Medical School, Boston, MA.

    Warm-Water Bath in Anorectal Conditions: The Thermosphincteric Reflex. Journal of Clinical Gastroenterology Shafic, A. (1993). 16(4), 304-308.

    Anal sphincter complex; endoanal MR imaging of normal anatomy. RadiologyHussain S.M., Dec 1995, vol. 197, pgs. 671-7. Department of Radiology, University Hospital Rotterdam.

    Anorectal Disorders, five common causes of pain, itching and bleeding. Postgraduate Medicine. Metcalf, A., Nov. 1995, vol. 98, pgs. 81-4, 87-9, 92-4. Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA.

    The virulence of E. Coli strains isolated in urinary infections. Bacteriology Virology Parasitology & Epidemiology. David, E., Jan. 1993, vol. 41, pgs. 57-61.

    Episiotomy and body image. Modern Midway, Sept. 1996, vol. 6, pgs. 18-19.

    Factors related to perineal trauma in childbirth. Journal of Nurse Midwifery Jul.Aug. 1996, vol. 41, pg. 269.

    An overview of urinary incontinence in adults: assessments and behavioral interventions. Clinical Nursing Specialty, Beckman, N.J., Sept. 1995, vol. 9, pgs. 241-7, 274.

    Anorectal disorders. Emergency Medical Clinician North America, Janicke, D.M., vol. 14, pgs. 757-88. Department of Emergency Medicine, State University of New York at Buffalo, Millard Filhnore Hospital.

    Anal Itching: Strategies to Stop the Scratching. Fleiss, P.M., M.D., Universily of Southern California School of Medicine.

    NRS 414 Research Utilization. Rosenfeld, A. RN, PhD., 1994, University of Portland School of Nursing .