Tri-specialty certification reflects a blended specialty practice that incorporates wound, ostomy, and continence nursing expertise. Each triad of the tri-specialty offers unique perspectives to the other 2 sides of the triad. Tri-specialty continence nurses bring a unique contribution to continence nursing based upon wound and ostomy core knowledge and skills. They are the expert in the management of incontinence-skin care including preventative strategies and management of incontinence-associated dermatitis and moisture-related skin damage. In addition, the tri-specialty continence nurse is an expert in the selection, evaluation, and use of body-worn absorptive products1—the management of patients requiring urinary catheterization and facilitating fecal diversion with anal pouching and fecal management systems.
The WOCNCB continence certification examination validates continence knowledge and skills at both the entry level and advanced practice. The certification examination, based upon periodic analysis of current practice (job analysis), includes the unique and critical components of continence nursing practice, which includes tri-specialty expertise in skin care, body-worn absorptive product selection, and patient management as well as care of patients requiring catheterization and fecal management systems. Included here are sample questions that focus on care of patients requiring catheterization and body-worn absorptive products.
1. A 35-year-old man with a sacral spinal cord injury has been sent to the continence nurse to learn self-intermittent catheterization. Which of the following represents the best approach when setting up the catheterization schedule?
- Catheterize twice a day and as needed for feelings of urinary urgency.
- Catheterize every 8 hours and as needed for urinary leakage.
- Catheterize before bed and with the sensation of urinary fullness.
- Catheterize at intervals so that bladder volumes do not exceed 400 mL.
Content Outline: 030502
A primary goal of self-intermittent catheterization is to protect and preserve the upper urinary tract and improve patient quality of life by impacting lower urinary tract symptoms. Catheterized volumes around 400 mL reflect a normal bladder capacity and reduce the risk for urinary tract infection and bothersome lower urinary tract symptoms. When bladder volumes are high, there is increased risk for infection and overflow incontinence. Overflow incontinence negatively impacts patient quality of life and increases risk for moisture-associated skin damage. Individualizing the catheterization schedule based upon catheterization volumes is the best answer choice.
Patients with sacral spinal cord injury or cauda equina syndrome have dysfunction of the bladder, bowel, and sexual function. They often experience compromised sensation of bladder urge and fullness, impaired or absent bladder contractility, decreased or absent motor and sensory function of the lower limbs, buttocks, and perineum. Infrequent catheterization increases the risk for bladder overfilling. It would not be appropriate to develop a catheterization schedule based upon patient sensations of urgency or fullness. Incontinence in a patient with cauda equine syndrome can indicate 2 possible situations. Incontinence might be indicating high bladder volumes and overflow incontinence or may be stress incontinence due to sphincter incompetence. In either case it would not be appropriate to design catheterization intervals based on urine leakage.
2. What is a common cause of indwelling urinary catheter bypassing (leaking)?
- Small catheter size
- 10-mL balloon size
- Bacterial biofilm
- Asymptomatic bacteruria
Content Outline: 030502
A common cause of catheter bypassing (leaking) is catheter occlusion. The flow of urine in the catheter can be obstructed by drainage tube kinking, overfull drainage bag, drainage bag not dependent to the bladder, or obstruction of the catheter lumen by bacterial biofilm. Biofilms are complex structures that are composed of bacteria, host cells, and other cellular by-products and can develop within 3 days of catheter insertion. Catheter biofilms can be thick and mucoid like, causing catheter obstruction. In some cases, such as with proteus mirabilis colonization, the bacteria in the biofilm produce the enzyme urease, which causes alkaline urine. The alkaline urine prompts the formation of ammonium ions and subsequent crystallization of calcium and magnesium phosphate. The crystals become a part of the biofilm causing catheter encrustation and blockage. All patients with long-term indwelling catheters are colonized with bacteria, which may contribute to the formation of biofilms but in of itself will not cause catheter obstruction and bypassing. A catheter inflated with 10 mL is the most common size catheter balloon used for indwelling catheters. Overinflating a balloon may cause catheter rupture or patient discomfort, and improperly inflated balloons (too much or too little) can cause uneven balloon inflation causing the catheter tip to rest on the bladder wall prompting irritation and spasms. Bladder spasms are a common cause of catheter bypassing. Smaller catheter size is not the cause of bypassing. As a general rule, the smallest catheter size possible should be used to allow for adequate bladder draining and minimal patient discomfort.
3. An elderly woman with dementia has been started on a toileting program. She experiences large volume incontinence episodes multiple times a day and will wet the bed at least twice during the night. What body-worn absorptive product would be the best choice for daytime use?
- Pull-up style product
- Cotton underwear
- Incontinence brief
Content Outline: 030203, 030502
Body-worn absorptive products are an essential component of incontinence care. The continence nurse is uniquely qualified to recommend the best product by type and level of needed absorbency. In the scenario posed in this question, the patient is elderly with cognitive impairment that impacts the ability to complete toileting behaviors independently. A key component when implementing a toileting program is to normalize the toileting experience as much as possible. Choosing an underwear-like product has the potential to do just that as well as preserve patient dignity by providing adequate urine containment. Panty-liners and cotton underwear would not provide enough containment for large-volume incontinence episodes increasing risk for embarrassing accidents, discomfort (which can translate into agitation in patients with dementia), and increased risk for moisture-associated skin damage. The incontinence brief, which fits like an infant diaper would certainly contain the urine leakage but would not provide the patient with a dignified containment option. In some cases, an incontinence brief might be an excellent option for nighttime use. Higher quality incontinence briefs are designed with a stay dry upper liner and a core of superabsorbent polymer technology that is very efficient in containing urine, preventing uncomfortable wetness and soiling of bed linens.
4. Six months after radical prostatectomy surgery, a 59-year-old man is experiencing urinary leakage associated with exercise such as weight lifting and fast-paced walking. He reports that the leakage is enough to dampen his underwear. In addition to teaching him pelvic muscle exercises, what body-worn absorptive product should be recommended?
- Guard pad
- Perineal pad
- Insert (liner or booster pad)
- Adult brief
Content Outline: 030203
When recommending the best product for a patient, the continence nurse needs to take into account a number of factors that include patient preference as well as the frequency and volume of the incontinence. In this case the patient most likely has postprostatectomy stress incontinence of relatively small volumes. This type of leakage in men is best contained by the male guard pad, which is designed to allow the penis to rest in the pad as like a protective cup used with sports. The male guard pad has an adhesive strip on the back to secure the pad to close fitting underwear. Most current guard designs are made with SAP (superabsorbent polymer) technology absorbing up to 250 cc of urine. Perineal pads for incontinence come in a variety of shapes and levels of absorbency. These pads also have an adhesive strip that attaches to the underwear but are not designed for male anatomy. Perineal pads as well as feminine hygiene pads are often used by men most likely because other options are unknown. The insert pad or booster pad would not be an appropriate option for this patient. These pads are designed to be used inside another containment product to extend the absorbency of the primary product. The insert pad does not have a leak proof covering; thus, when maximum absorbency is reached, urine can leak through the product wetting clothing and/or bedding. The adult brief provides the greatest level of urine containment. They are designed with refastenable tabs and are applied like a baby diaper. This level of urine containment is not appropriate for the patient in this case.
DeMarinis M, Kaschak TR, Newman DK. Absorbent products for incontinence. In: Newman DK, Rovner ES, Wein AJ, eds. Clinical Application of Urologic Catheters, Devices and Products. Cham, Switzerland: Springer International Publishing AG; 2018:149–172.
Gray M, Kent D, Elmer-Seltun J, McNichol L. Assessment, selection, use and evaluation of body worn absorbent products for adults with incontinence. J Wound Ostomy Continence Nurs. 2018;45(3): 243–264.
Wilde MH, Fader M. Appropriate use of containment devices and absorbent products. In: Doughty DB, Moore KN, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2016:211–213.