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Ostomy: Continent Fecal and Urinary Diversions

Schaffner, Amy MS, RN, FNP-BC, CNS, CWOCN

Journal of Wound, Ostomy and Continence Nursing: July-August 2009 - Volume 36 - Issue 4 - p 441–443
doi: 10.1097/WON.0b013e3181ab98ee
GETTING READY FOR CERTIFICATION
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Getting ready for an examination is much easier when you know what to expect, isn't it? You can expect that every question on the certification examination for wound, ostomy, and continence nursing will come from the content outline found in the Wound Ostomy Continence Nursing Certification Board (WOCNCB) Candidate Handbook. You can download the handbook for free from the WOCNCB Web site: www.wocncb.org.

In this article, we continue the discussion about ostomy care from the last issue with a focus on continent fecal and urinary diversions. If you look at the Ostomy Care section of the examination outline, you'll see the number 80, which means there will be 80 questions about ostomy care in the examination. Look at subsection D in the content outline: Continent Fecal and Urinary Diversions. Next to this heading is the number 10, which means there will be 10 questions in the examination from this section. Of those 10 questions, there will be 4 recall questions and 6 application-level questions. Although there are no analysis-level questions for this subsection, 1 is included here as a practice example.

  1. What is the suggested catheterization schedule for a continent urostomy during the first week after removal of the postoperative catheter?
    1. Every 2 hours while awake, and every 3 hours at night.
    2. Every 4 to 6 hours around the clock.
    3. Every 5 hours while awake, and every 6 hours at night.
    4. Every 4 hours while awake, and once before bed.
  2. When is it appropriate to teach self-catheterization to a patient undergoing an orthotopic neobladder?
    1. The day of the surgical procedure.
    2. During preoperative teaching session.
    3. Before hospital discharge.
    4. After discharge to the Home Health Agency
  3. A patient with an orthotopic neobladder reports fever, pouch pain, and bacteriuria. The WOC nurse would expect the patient to be treated with
    1. oral antibiotic therapy.
    2. cranberry tablets twice daily.
    3. temporary pouch irrigation.
    4. temporary indwelling catheter.
  4. What is a common complication following Ileal Pouch Anal Anastomosis (IPAA)?
    1. Pouchitis
    2. Pneumonia
    3. Sepsis
    4. Constipation
  5. When teaching a patient about IPAA, the WOC nurse is aware that the most important concern for the patient with an IPAA is
    1. maintaining continence.
    2. chronic pouchitis.
    3. perirectal irritation.
    4. use of incontinence pads.
  6. Following IPAA with loop ileostomy, the WOC nurse instructs the patient to
    1. maintain a high level of fluid intake.
    2. use a standard wear skin barrier.
    3. eat foods to soften the stool.
    4. change the ostomy pouch daily.
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Answers/Discussion

  • 1. (A) This is a straightforward recall question. Recall questions test the recognition or recall of specific information. However, you may still apply logical thinking to answer the question—even if you have no idea of the answer! The rationale for catheterization is to allow gradual expansion of the reservoir and increased length of time between catheterizations. Therefore, shorter time intervals between catheterizations during the first week would be expected. Sometimes there is a word or phrase in the stem of the question that leads to the correct answer. In this case “first week” is your clue!

Content outline location: 2D3a4 recall

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Reference

Tomaselli N, McGinnis D. Urinary diversions: surgical interventions. In: Colwell J, Goldberg M, Carmel J, eds. Fecal and Urinary Diversions: Management Principles. St. Louis, Mo: Mosby; 2004:184–206.

  • 2. (B) It is important to understand that evaluation of patient motivation and functional ability to catheterize is a critical preoperative activity prior to orthotopic neobladder. A discussion of body image changes and emotional challenges would also be part of this teaching session. Although this question has elements of simple recall of information, it requires an aspect of application. Application questions test application of a limited amount of data.

Content outline location: 2D4a2 Application

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Reference

Tomaselli N, McGinnis D. Urinary diversions: surgical interventions. In: Colwell J, Goldberg M, Carmel J, eds. Fecal and Urinary Diversions: Management Principles. St. Louis, Mo: Mosby; 2004:184–206.

  • 3. (A) In this question, you must recognize that these symptoms are characteristic of a soft tissue infection of the pouch known as “pouchitis.” Then the proper treatment must be identified, which in this case is oral antibiotics.

Although analysis items will not be included in this section of the examination, it is provided here for practice with this type of question. It also helps you to be able to differentiate among the 3 types of questions: recall, application, and analysis.

Content Outline Location: 2D3a5 Analysis

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Reference

Tomaselli N, McGinnis D. Ostomies and Continent Diversions. 2004:202.

  • 4. (A) This is a simple recall question. Although all of the complications are possible, only 1 is significant as a “common complication following IPAA.”

Content Outline Location: 2D2a3 recall

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Reference

Kiran R, Fazio V. Inflammatory bowel disease: surgical management. In: Colwell J, Goldberg M, Carmel J, eds. Fecal and Urinary Diversions: Management Principles. St. Louis, Mo: Mosby; 2004:80–101.

  • 5. (A) While any of these answers might give the patient cause for concern, the overarching concern for the IPAA patient is maintaining continence. Although chronic pouchitis might eventually lead to pouch failure and loss of continence, the question requires discernment of the most important concern. The key word in the stem is most, which sets priority. Be sure to answer what the question is asking!

Content Outline Location: 2D2a Application

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Reference

Kiran R, Fazio V. Inflammatory bowel disease: surgical management. In: Colwell J, Goldberg M, Carmel J, eds. Fecal and Urinary Diversions: Management Principles. St. Louis, Mo: Mosby; 2004:80–101.

  • 6. (A) This question requires you to correctly identify a basic safety concern (ie, avoid dehydration and all ensuing complications) when a patient experiences high liquid output from his/her ileostomy.

Foods to thicken, not soften, the stool are recommended. An extended wear (not standard wear) skin barrier is indicated with a high-output pouch and will help ensure intact peristomal skin. Daily pouch changes should be avoided.

Content Outline Location 2D2a2 Application

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Reference

Kiran R, Fazio V. Inflammatory bowel disease: surgical management. In: Colwell J, Goldberg M, Carmel J, eds. Fecal and Urinary Diversions: Management Principles. St. Louis, Mo: Mosby; 2004:80–101.

The pathway to certification is not an easy one. It requires time and effort. However, knowing what type of questions to expect and how to break them down can help reduce test anxiety. In the next J WOCN issue, we will focus on lower-extremity wound questions. Stay tuned!

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Resources for Preparing for the WOC Certification Exam

Whether you are taking the examination for the first time or recertifying by taking the examination again, it is important to prepare to successfully pass the examination. Here are a few resources to help you study:

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Free Sample Test

Try a user-friendly online test at http://www.lxr.com/webtest/login.aspx.

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Self-Assessment Exam

Order a computer-based test from the testing company that produces our exam. Go to www.goamp.com and click first on “E-Store” and then on “Web Tests.” Then select “Health Care” and then “Wound, Ostomy, Continence Nursing.” Each individual practice exam costs $30, which gives you 90-day access.

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WOCN Society Review Courses

Each year, the WOCN Society offers CD-ROMs of the certification review course presented at its national conference. You can buy these online at www.prolibraries.com/wocns/.

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New 2009 Certification Review Manual

The WOC Nursing Education Program at Emory University has a new certification review manual for sale for $65. Go to http://www.surgery.emory.edu/wocnec/order.form.pdf or contact Brenda Michael at brmicha@emory.edu.

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Wound Care Study Guide

The Wound Care Education Program at the Medical College of South Carolina offers a guide for $125. Contact Carol Whelan at 843-792-265 or toll free at 866-637-6835.

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Valuable New Resource for WOC Nurses

First Annual Evidence-Based Practice Literature Review

The WOCNCB is excited to announce that an evidence-based practice literature review will be included as a supplement in the July/August issue of J WOCN. The inaugural issue of what will become an annual feature will encompass articles published in 2007 and 2008 in peer-reviewed journals. The purpose of the review is to distill the literature into a form that can be easily accessed by the nurses in the field and also to serve as a source of current evidence-based practice for the WOCNCB's Examination Committee.

The WOCNCB has seen tremendous growth in the specialty field of wound, ostomy, and continence over the last decade. At the same time, the literature and research in the specialty has grown exponentially. As WOC nurses, we aspire to provide optimal care to our patients, and we know that reliance on evidence-based practice allows us to provide that care and educate others about the value of our practice. However, with the increasingly busy personal and professional schedules of WOC nurses, keeping up to date with the research can be very difficult.

To address this reality, in 2007 the WOCNCB formed an Evidence-Based Practice Committee, a group of clinical experts tasked with identifying key, evidence-based articles in the field of wound, ostomy, and continence nursing. Their 2-year effort has resulted in the 28-page supplement available with the July/August issue of J WOCN.

The literature review is organized by topic: wound, ostomy, and continence. The entry for each article includes the title, authors, complete source citation, and a description of the research study and its results. In addition, a summary called “What Does This Mean to Me and My Practice?” makes the literature review a valuable resource for your practice.

We also hope the literature review will bring value by boosting research. The Evidence-Based Practice Committee found that most of the articles form 2007 and 2008 were based on small studies, and that level A evidence in the specialties was limited. Nevertheless, the evidence-informed literature from small studies is a valuable contribution, and with time and curiosity, larger, randomized studies will be performed that will result in more robust data to support practice in the specialties.

We are proud of our contribution to promoting evidence-based practice in our specialty, and hope you will find the upcoming literature review as informative and helpful as we have while preparing it.

Patricia S. Collins, MSN, RN, ACNS-BC, CWOCN, WOCNCB

Cochairperson of the Evidence-Based Practice Committee, Wound Care Specialist, Department of Inpatient Rehabilitation, Christus St Vincent Regional Medical Center, Santa Fe, New Mexico.

Copyright © 2009 by the Wound, Ostomy and Continence Nurses Society