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Critical Thinking WOCNCB APN Examination

Richbourg, Leanne; Krissovich, Marta

Author Information
Journal of Wound, Ostomy and Continence Nursing: July/August 2013 - Volume 40 - Issue 4 - p 422-423
doi: 10.1097/WON.0b013e31829a2abb

Abstract

Practice Questions

Wound

The AP wound nurse is treating a patient whose breast cancer with liver metastasis includes a fungating malignant tumor on the chest wall. The wound has a covering of soft slough. The patient is bothered by wound odor and copious drainage. Which of the following palliative interventions would be the best to recommend?

  1. Hydrofiber with silver dressings
  2. Debridement of necrotic tissue
  3. Addition of oral metronidazole
  4. Environmental sprays to mask odor

Key: A

Content Outline Location: AP 4-C-1-B

Cognitive Level: Analysis

Rationale

The best answer to this question is hydrofiber dressings, which contain silver, providing drainage management and antimicrobial control. Debridement is not the best answer because of the risk of excessive bleeding. Topical metronidazole is used for fungating tumor management because it reduces the bacterial load in the decaying tissue but it is given topically, not orally. While answer D may be beneficial, it does not address wound drainage.

Relationship of Question to Critical Thinking

This question requires the test taker to analyze the data by breaking it into parts and considering the relationship between them. Since odor from cancerous lesions is secondary to microbial processes on the decaying tissue, one can predict that a reduction of bacteria would lead to a reduction in odor. Anaerobic bacteria produce metabolic end products, which result in a foul odor. The AP nurse must discriminate between available antimicrobial options, as well as routes of delivery (topical, oral, parenteral). Both silver dressings and metronidazole are effective against anaerobes; however, metronidazole is metabolized in the liver and thus it would be an inappropriate medication for this patient to take orally. The copious drainage associated with malignant cutaneous tumors is thought to be contributed to by the interference with the capillary and lymph vessels by proliferating tumor cells. The standard of care for a heavily draining wound is an absorptive dressing; a hydrofiber dressing absorbs heavy exudate and converts it to a gel. With the addition of silver, this intervention would help relieve the patient's complaint. Logical reasoning suggests that since increased vascularity and impairment of blood clotting can cause these types of wounds to bleed easily, debridement would not be the best option.

http://www.worldwidewounds.com/2002/march/Naylor/Symptom-Control-Fungating-Wounds.html

Goldberg MT, Bryant RA. Managing wounds in palliative care. In: Bryant RA, Nix DP, eds. Acute & Chronic Wounds: Current Management Concepts. 4th ed. St Louis, MO: Mosby; 2012:508.

Rolstad BS, Bryant RA, Nix DP. Topical management. In: Bryant RA, Nix DP, eds. Acute & Chronic Wounds: Current Management Concepts. 4th ed. St Louis, MO: Mosby; 2012:289–295.

Ostomy

A patient with an ostomy presents to the advanced practice nurse clinic with complaints of intermittent abdominal pain near the stoma described as a dull ache as the day wears on. Patient denies pain or ache in the mornings. Reports sometimes the pain is sharp during stomal output. Denies any falls or trauma recently. The patient reports a few episodes of leakage under the wafer in the past month and reports a fairly consistent wear time of 3 days. The patient denies peristomal skin breakdown or change in ostomy output. Upon removal of the ostomy pouch system, the advanced practice ostomy nurse notes the peristomal skin is intact and a slight bulge from 6 to 9 o'clock with the patient sitting upright that disappears when the patient is in the supine position at rest. The bulge increases in height with induced cough. The next step taken by the advanced practice ostomy nurse is to:

  1. prescribe a flexible pouch system to mold to body contour changes,
  2. perform a digital exam to assess for a fascial defect with coughing,
  3. order an upper gastrointestinal x-ray film with oral contrast, and
  4. refer the patient to a surgeon for hernia repair consultation.

Key: B

AP Content Outline Location: 2B4

Rationale

The best next step is to assess for a hernia by palpation after the visible inspection presented in the scenario. This is done by digital exam of the stoma, feeling for the fascial defect when the patient coughs or bears down. Answer C would confirm the presence of the hernia but by ordering a retrograde enema with contrast given through the stoma, not taken orally. The AP ostomy nurse should complete the assessment before making decisions about referrals, so answer D would not be the correct answer. Answer A would be a management consideration once the diagnosis is confirmed.

Relationship of Question to Critical Thinking

An AP nurse caring for this patient must begin by collecting (information seeking) as many clinical data as possible and then analyze before determining what next steps are appropriate. The solid theoretical knowledge of the ostomy expert guides the AP nurse to collect a history of the present condition and perform a visual exam followed by a digital exam of the stoma before formulating an appropriate plan of care by predicting consequences of potential options.

Colwell JC. Stomal and peristomal complications. In: Colwell JC, Goldberg MT, Carmel JE, eds. Fecal & Urinary Diversions: Management Principles. St Louis, MO: Mosby; 2004:308–309.

Wound Ostomy and Continence Nurses Society Clinical Practice Ostomy Committee. Peristomal Hernia: Best Practice for Clinicians. Mt Laurel, NJ: WOCN Society; 2011.

Continence

During cystometry, a patient exhibits low bladder compliance. Which option is most important to monitor over time?

  1. Serum creatinine
  2. Postvoid residual
  3. Urinary urgency
  4. Urinalysis with microscopy

Key: A

AP Content Outline Location: 1C2

Rationale

Answer A is the correct choice because low bladder compliance increases risk of ureteral reflux, hydronephrosis, and kidney damage. In addition to attempting to directly address the low compliance and considering upper urinary tract imaging, checking serum creatinine regularly will herald renal function changes and help guide treatment choices. Answer B is not the best choice because postvoid residuals assess bladder emptying and this question is focused on high pressure during bladder filling. Answer C would not be a good choice. While urgency impairs quality of life and might increase as bladder compliance increases, it provides no direct evidence of life-threatening renal decline. Answer D is not correct because urinalysis with microscopy is not the best measure for monitoring renal function.

Relationship of Question to Critical Thinking

This question is an analysis-type question that requires the test taker to analyze patient data in order to choose the best answer. The test taker must consider bladder wall and ureteral and renal function separately in order to better appreciate their normal relationships and the impact when one part of the system goes awry. The question also requires application of standards related to expected bladder pressure responses during filling and laboratory monitoring of renal function. Because none of the answer options would be inappropriate for this patient, this question requires prediction of potential consequences of each option to determine the most important (rank) choice among the options.

1. Abrams P, Andersson KE, Birder L, et al. Fourth International Consultation on Incontinence: Recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence. Neurourol Urodyn. 2010;29:215. http://onlinelibrary.wiley.com/doi/10.1002/nau.v29:1/issuetoc.

2. Cardoza L, Staskin D. Textbook of Female Urology and Urogynecology. New York: Informa Healthcare; 2010(272):323–328.

3. Chapple CR, MacDiarmid SA, Patel A. Urodynamics Made Easy. 3rd ed. London, UK: Churchill Livingstone; 2008(13):79–80.

4. Gray ML. Pathology and management of reflex incontinence/neurogenic bladder. In: Doughty DB, ed. Urinary and Fecal Incontinence: Current Management Concepts. St Louis, MO: Mosby; 2006(201):369–387.

5. US Preventive Services Task Force. Screening for chronic kidney disease: USPSTF recommendation statement. Ann Intern Med. 2012;157:568. http://annals.org/article.aspx?articleid=1355168.

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© 2013 by the Wound, Ostomy and Continence Nurses Society.