In the recent Review of 2010 Evidence for WOC and Foot Care Nursing Practice, a supplement to the July/August 2011 issue of the Journal of Wound, Ostomy and Continence Nursing,1 2 cited studies supported the role of WOCNCB certified nurses as key agents in identifying and initiating treatment for patients with bowel dysfunction. WOCNCB certified nurses often do not recognize the impact their unique knowledge and skills exert on the care of patients with fecal incontinence (FI) and related bowel dysfunction. Their perception of the specialty role is limited to containment and skin protection. Though these aspects of the role are important, they are only a fraction of what the skilled CWOCN can do to help patients with elimination problems.
Fecal incontinence, the involuntary loss of gas or stool, affects between 10% and 15% of the adult general population.2 Often called the “silent affliction,”3 FI impacts quality of life and can lead to social isolation.4 Embarrassment and fear prevent seeking prompt treatment that would significantly improve quality of life. The consequences of this underreported and often undertreated problem are far reaching and impact individuals in all areas of their lives.
Fecal incontinence is a common problem that increases with age.5 A study conducted by the Mayo Clinic reports that nearly 7% of women in the third decade of life experience FI, with the incidence increasing to 22% and more by the sixth decade of life.6 These findings are supported by an Australian study recently published in Menopause,7 which showed FI affecting 1 out of 5 of the community-dwelling women.7 Menopause and complicated obstetric deliveries have also been identified as risk factors for FI.8 The prevalence of FI in the nursing home population exceeds 50% and a significant number of these patients experience dual incontinence.2,9 With FI affecting such a large number of patients, it is important to remember that it is a symptom of a complex problem with multiple contributing factors10 and a condition uniquely suited to the skills and expertise of the WOCNCB certified nurse.
Depending on experience and educational preparation, the certified nurse's involvement may range from basic to advanced interventions. WOCNCB certified nurses may begin by implementing initial interventions that focus on skin protection and containment. Then, based upon skilled assessment and specialized knowledge, they develop plans of care that include interventions to further address reversible factors that contribute to FI such as education and counseling regarding dietary and fluid modifications, bowel training, strategies to improve and strengthen the muscles of the pelvic floor, and working with the healthcare team in medication modification. An advanced practitioner with specialized testing might develop comprehensive treatment plans that may include all of the prior mentioned interventions plus recommend or assist with more advanced strategies such as rectal irrigation, biofeedback and electrical stimulation, or neuromodulation of the anal sphincter with sacral nerve stimulation. Sacral nerve stimulation is a newer intervention initially used in the treatment of urinary incontinence and now accepted as a safe and effective method of treating functional defects of the anal sphincters.11
The specialty of continence nursing is not unlike our other specialties: New research is continuously added to the evolving evidence base, which, in turn, leads to the development of new products and devices. As an expert and leader in continence nursing, the WOCNCB certified nurse has the ability and responsibility to disseminate current research, make recommendations, and apply and manage optimal treatment strategies in partnership with all members of the healthcare team. Expertise in the specialty and sensitivity to the unique needs of the individual places the WOCNCB certified nurse as a stellar example of excellence in nursing.
The FI questions at the end of this article are similar to those actually found on the WOCNCB's continence exam. The question topics are taken from the Content Outline, Continence-Section C: Types of Bowel Dysfunction. The sample questions, answers, and rationales will help you prepare for the exam or serve as a self-test of your knowledge in the continence specialty.
1. WOCNCB. Review of 2010 evidence for WOC and foot care nursing practice. J Wound Ostomy Continence Nurs. 2011;38(4S):S3–S14.
2. Bliss DZ, Norton C. Conservative management of fecal incontinence. Am J Nurs. 2010;110(9):30–38.
3. Johanson JF, Lafferty J. Epidemiology of fecal incontinence: the silent affliction. Am J Gastroenterol. 1996;91(1):33–36.
4. Heymen S. Psychological and cognitive variables affecting treatment outcomes for urinary and fecal incontinence. Gastroenterology. 2004;126:S146–S151.
5. Melville JL, Fan M, Newton K, Fenner D. Fecal incontinence in US women: a population-based study. Am J Obstet Gynecol. 2005;193(6):2071–2076.
6. Bharucha AE, Zinsmeister AR, Locke GR, et al. Prevalence and burden of fecal incontinence: a population-based study in women. Gastroenterology. 2005;129(1):42–49.
7. Botlero R, Bell RJ, Urquhart DM, Davis SR. Prevalence of fecal incontinence and its relationship with urinary incontinence in women living in the community. Menopause. 2011;19(6):685–689.
8. Bohle B, Belvis F, Vial M, et al. Menopause and obstetric history as risk factors for fecal incontinence in women. Dis Colon Rectum. 2011;54(8):975–980.
9. Leung FW, Rao SS. Fecal incontinence in the elderly. Gastroenterol Clin North Am. 2009;38(3):503–511.
10. National Institute for Health and Clinical Excellence. Faecal incontinence: the management of faecal incontinence in adults. http://www.nice.org.uk/nicemedia/live/11012/30548/30548.pdf. Published 2007. Accessed September 7, 2011.
11. Lim JT, Hastie IA, Hiscock RJ, Shedda SM. Sacral nerve stimulation for fecal incontinence: long-term outcomes. Dis Colon Rectum. 2011;54(8):969–974.
Continence—Section C: Types of Bowel Dysfunction
Question 1. A 60-year-old diabetic patient has been recently hospitalized and was treated with antibiotics. What is the most likely underlying cause of recent onset of FI?
- Aging changes
- Clostridium difficile infection
- Diabetic autonomic neuropathy
- Pelvic floor muscle dyssynergia
Question 2. What would be an appropriate initial treatment for a patient with FI associated with 1 to 2 loose stools a day?
- Pelvic floor muscle exercises
- Application of a perianal pouch
- Modification of the diet
- Administer an antidiarrheal medication
Question 3. A cognitively impaired patient with a history of chronic constipation presents with daily FI of soft formed stools not associated with bowel urgency. The nurse notes a strong circumferential anal contraction on digital exam. What type of bowel dysfunction is most likely?
- Fecal impaction
- Sensory dysfunction
- Irritable bowel syndrome
- Impaired rectal sphincter
1. Doughty DB, Jensen LL. Assessment and management of the patient with fecal incontinence and related bowel dysfunction. In: Urinary & Fecal Incontinence Current Management Concepts. 3rd ed. St Louis MO: Mosby; 2006:458–460.
Answers to Sample Questions
Answer. B-C difficile infection
Content outline: C-2
Cognitive level: Recall
Rationale: Clostridium difficile infection, which can occur after antibiotic therapy, is the most likely cause of FI in this patient. High-volume diarrhea, such as what is experienced with patients infected with C difficile, can overwhelm normal mechanisms to contain and control stool.
Dyssynergia of the pelvic floor muscles is an obstructive defecation disorder. Constipation is the most common complaint among these patients. Diabetic autonomic neuropathy plays a dominant role in the development of gastrointestinal motility problems and disordered defecation and is associated with chronic diarrhea, not necessarily acute diarrhea as in this case. The prevalence of FI in the frail elderly is high due to multiple factors such as dementia, compromised mobility interfering with prompt toilet access, and weakness of the external anal sphincter. It is possible that the patient could have a weak sphincter that would be overwhelmed by the frequent diarrheal stools, but the question stem does not lead clearly to this option.
1. Bliss DZ, Doughty DB, Heitkemper MM. Pathology and management of bowel dysfunction. In: Urinary & Fecal Incontinence Current Management Concepts. 3rd ed. St Louis MO: Mosby; 2006:445–451.
2. Lacy BE, Weiser K, De Lee R. The treatment of irritable bowel syndrome. Ther Adv Gastroenterol. 2009;2(4):221–238.
Answer. C-Modification of the diet
Content outline: C-4-b
Cognitive level: Application
Rationale: Modification of the diet is the most appropriate initial treatment. Establishment of normal stool consistency is considered the first step in restoring normal bowel function and fecal continence. Foods and beverages are common causes of changes in stool consistency. If, after stool consistency is normalized, the incontinence continues, pelvic floor muscle exercises would be an appropriate intervention by helping to strengthen the anal sphincter and thus improve fecal continence. The perianal pouch is a temporary measure to contain high-volume liquid stool in order to protect the skin until the underlying cause has been successfully treated and stool returns to a normal consistency and frequency. Antidiarrheal medications would be an effective course of action if the FI was characterized by diarrhea.
1. Doughty DB, Jensen LL. Assessment and management of the patient with fecal incontinence and related bowel dysfunction. In: Urinary & Fecal Incontinence Current Management Concepts. 3rd ed. St Louis MO: Mosby; 2006:471–479.
2. Bliss DZ, Doughty DB, Heitkemper MM. Pathology and management of bowel dysfunction. In: Urinary & Fecal Incontinence Current Management Concepts. 3rd ed. St Louis MO: Mosby; 2006:443–451, 476.
Answer. B-Sensory dysfunction
Content outline: C-1-c
Cognitive level: Analysis
Rationale: The patient's symptoms and history best fit a diagnosis of sensory dysfunction. Both key findings of normal stool and the absence of bowel urgency indicate an inability to recognize the presence of stool in the rectum. Cognitive impairment as well as long history of constipation with chronic rectal distension can cause a loss of the ability to recognize or sense rectal filling and urge. The normal findings during rectal exam do not support impaired sphincter function nor does the patient present with classic symptoms of a fecal impaction such as fecal soiling due to liquid stool oozing around the obstructing mass, absence of bowel movement for at least 3 days, nausea, vomiting, and particularly in the elderly, change in mental status. The patient symptoms are also not consistent with the ROME III criteria for IBS, which include characteristics such as a change in stool consistency or frequency.
Advanced Practice Certification: The Highest Recognition of Achievement in WOC Nursing
The value that advanced practice education brings is widely recognized, whether the nurse is an APRN, Clinical Nurse Specialist (CNS) or Nurse Practitioner (NP). However, the aging of the population brings a greater need for advanced practice nurses who specialize in wound, ostomy and continence (WOC) nursing. Aging skin, increasing prevalence of diabetes with complication of lower extremity ulcers, the co-morbidity of obesity, and issues related to fecal and urinary incontinence will increase the demand for advanced practice WOC practitioners.
In anticipation of this need, the Wound, Ostomy and Continence Nursing Certification Board (WOCNCB) is happy to announce the inaugural offering of WOC certification at the Advanced Practice (AP) level by examination. The anticipated launch date of the exams is June, 2012.
This unique credential is already recognized internationally as The Gold Standard for Certification® in this highly specialized practice area that exceeds typical advanced practice. The WOCNCB AP credentials signify a commitment to excellence in the areas of wound, ostomy, or continence nursing. Current certificants report that their advanced practice credential is a source of great pride, gives them leverage when negotiating salary and compensation packages with an employer, serves as a marketing tool when establishing a professional clinical practice, and provides evidence of tenacity, dedication, inquiry, and mastery of critical thinking skills.
Advanced practice certification from the WOCNCB is considered The Highest Recognition of Achievement in WOC Nursingsm. Passing the psychometrically sound and legally defensible advanced practice specialty exam(s) will communicate to the public, potential patients, professional peers (especially physicians and surgeons), and prospective employers a higher level of knowledge and skill in these specialty areas.
If you are not currently certified by WOCNCB, you must meet the following requirements to be eligible for the AP exam(s):
- Hold a current RN license
- Have completed a MSN or higher nursing degree program to become an Advanced Practice clinician (ex. Nurse Practitioner or Clinical Nurse Specialist)
- Document basic wound, ostomy, or continence knowledge by completing a Wound, Ostomy, Continence Education Program, or possess current entry-level WOCNCB certification in the specialty for which AP certification is desired, or meet the Experiential Pathway requirements.
If you are an AP nurse and currently hold a WOCNCB wound, ostomy or continence certification, you may submit an AP portfolio to upgrade your entry-level credential to an AP level through August 15, 2012. After that date, you must take one or more AP exams, and the portfolio will be used for AP recertification only. Complete eligibility details are available at http://www.wocncb.org/become-certified/advanced-practice/eligibility.php.
As an AP nurse, you have already demonstrated your commitment to professional development and personal achievement. Continue along your pathway to excellence by receiving the highest achievement in WOC nursing: Advanced Practice Certification from the WOCNCB.