The primary goal of the “Getting Ready for Certification” feature articles is to assist the candidate to successfully pass a particular certification examination. The WOCNCB certification examination format is multiple-choice; test-takers select the correct answer from 4 options. Although the answer is right before the test-taker's eyes, making the correct choice is built on thorough content knowledge and understanding and effective test-taking strategies. The focus of this column is choosing between 2 options. Example questions are from the “Ostomy Detailed Content Outline number 0202604: Assess and Manage Continent Fecal Diversion; Educating Patients and Caregivers on Management Techniques.”1 A thorough understanding of the construction of continent fecal diversions and the implications for the patient is imperative to correctly answer this section of examination questions. These principles include (1) operative procedures (eg, ileal pouch anal anastomosis [IPPA], Koch Pouch), (2) management (eg, staged operative procedure, intubation, mucous discharge, lavage), and (3) management of complications (eg, pouchitis, valve failure, obstruction).
Effective multiple-choice test performance begins with a careful reading of the stem of the question and anticipating the correct answer prior to reading answer choices. Anticipation of the answer helps focus on the specific content addressed in the question and eliminate answer choices that do not apply. The correct answer can then be chosen from remaining selections. Read the question stem again and choose the answer that is most correct and has the clearest applicability to the question stem. Consider the following 3 questions with rationales to assist with this strategy for choosing the correct answer.2
WOCNCB examination handbook. http://www.wocncb.org/pdf/WOCNCB_handbook.pdf.
Harrington C. It's show time: tests, papers, and presentations. In: Student Success in College: Doing What Works! Boston, MA: Wadsworth, Cengage Learning; 2013:204–214.
Question 1 Recall
A patient with an IPPA complains of diarrhea, tenesmus, pelvic discomfort, and low-grade fever. Which of the following is the MOST likely cause?
- Recurrent colitis
- Fistula formation
- Pouchitis. Pouchitis is a common postoperative complication following IPAA and is the most common complication for patients with ulcerative colitis. The symptoms include diarrhea, rectal tenesmus or feeling of incomplete emptying, pelvic discomfort, low-grade fever, malaise, and anorexia. Pouchitis is, therefore, the most likely cause of these symptoms in a patient with IPAA.
- Appendicitis. Although diarrhea, low-grade temperature, and anorexia are also symptoms of appendicitis, abdominal pain is more severe and increases with time.
- Recurrent colitis. Ulcerative colitis is not likely to recur after the colon is removed. A proctocolectomy is considered a surgical cure. However, this answer may be appealing to those who are unclear on the differences between ulcerative colitis and Crohn's disease.
- Fistula. Symptoms of a fistula include fever and malaise, but there is a more localized tenderness, induration, and pain around the anal area. Ulcerative colitis and Crohn's disease have similar symptoms and presentations. However, the diseases are inherently different and surgeries have a completely different focus. A proctocolectomy is frequently curative for patients with ulcerative colitis and may be disastrous with Crohn's disease if the disease recurs in the pouch. The goal of Crohn's disease is to save bowel and avoid surgery.
Colwell JC, Goldberg MT, Carmel JE. Rectal and Urinary Diversions: Management Principles. Chicago, IL: Mosby; 2004:75 and 95.
National Digestive Diseases Information Clearinghouse. Appendicitis [electronic version]. National Digestive Diseases Information Clearinghouse (Publication No. 13-4547). http://digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/#symptoms. Published 2013. Accessed January 2014.
3. Bartlett JC, Gerding DN. Clinical recognition and diagnosis Clostridium difficile infection. Clinic Infect Dis. 2008;46(suppl 1):S12–S18.
Buckmire M. Anal abscess/fistula. American Society of Colon & Rectal Surgeons. http://www.fascrs.org/patients/conditions/anal_abscess_fistula/. Published 2012. Accessed January 2014.
Question 2 Analysis
A patient with a Koch Pouch reports intubating the pouch 4 to 5 times a day. What recommendation should the WOC nurse give the patient?
- Increase intubation to 6 to 8 times a day.
- Decrease intubation frequency to avoid valve slippage
- Indicate that this is a normal intubation schedule.
- Avoid intubation and apply a drainable pouch.
c. Indicate that this is a normal intubation schedule.
Rationale. With each question, it is important to form the potential answer in one's mind and then scan the 4 choices to see if this answer is provided. As the choices are scanned, the 2 least likely choices can be excluded. In the example given previously, the 2 least likely answers are as follows: (a) Increase intubation to 6 to 8 times a day. There are no diversions that require intubation this frequently. The second least likely answer is as follows: (d) Avoid intubation and apply a drainable pouch. The test taker needs to know that a Koch Pouch is a continent diversion and requires intubation. The choices remaining are as follows: (b) decrease intubation frequency to avoid valve slippage and (c) indicate that this is a normal intubation schedule.
The test taker needs to be familiar with the construction of continent diversions, including (1) the bowel segments required to construct the diversion, (2) the continence mechanism, and (3) the antireflux mechanisms used in urinary diversions. In the case of the Koch pouch, the continence mechanism is usually created by intussusception of a portion of the bowel into the pouch. Continent ileostomies were most commonly created during the 1970s and are no longer the first choice in most cases for UC and FAP. There may be times during the career of the COCN when these patients are encountered. It is important to be familiar with the construction of these pouches as well as their management. The COCN may be the only person in the facility familiar with the management of a continent fecal diversion.
Doughty D. History of stoma creation and surgical advances. In: Colwell J, Goldberg M, Carmel J, eds. Fecal and Urinary Diversions Management Principles. St Louis, MO: Elsevier Mosby; 2004:10.
2. Beck D. Continent ileostomy: current status. Clin Colon Rectal Surg. 2008;21:62–70.
Question 3 Application
For management of ulcerative colitis, a patient has undergone the final stage of IPAA. You instruct the patient to expect increased episodes of stool. Further instructions include:
- Protect the perianal skin with a barrier cream.
- Clean intermittent catheterization of the nipple valve.
- Use an alcohol-based skin sealant to prevent infection.
- Protect peristomal skin with metronidazole powder.
The correct answer is a. The patient will have increased stool frequency from the anal pouch. The stool frequency may increase up to 7 per day during the first year. This increase in stools from the anus may cause perianal dermatitis. To prevent this complication, the patient is instructed to regularly apply a barrier cream to the perianal area. In addition, the patient can be taught that the stool frequency will decrease with time.
Incorrect answer: b. The IPAA procedure does not require the creation of a nipple valve for stool evacuation. The nipple valve is created when a continent ileostomy is performed for those patients with ulcerative colitis and poor anal sphincter control.
Incorrect answer: c. This answer is incorrect because alcohol-based skin sealants can further irritate the perianal tissue that is irritated and excoriated from increased stool activity.
Incorrect answer: d. The ileostomy stoma has been eliminated during the final stage of the IPAA procedure, and the patient is now expelling stool from the anus. Therefore, the chance of peristomal skin irritation has been eliminated.
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; 2004:92–97.
Chapman G, Sinclair L, Langevin JM, Hocevar B. Surgical alternatives. In: UOAA United Ostomy Associations of America, Inc. Ileoanal Reservoir Guide. http://firstname.lastname@example.org. 2009:20.