Secondary Logo

Journal Logo

Assessing Factors Affecting Fecal and Urinary Diversion

Hovan, Holly Marie

Journal of Wound Ostomy & Continence Nursing: September/October 2019 - Volume 46 - Issue 5 - p 459–460
doi: 10.1097/WON.0000000000000572
Getting Ready for Certification
Free

Holly Marie Hovan, MSN, APRN, CWOCN-AP, Cleveland VA Medical Center, Ohio.

Correspondence: Holly Marie Hovan, MSN, APRN, CWOCN-AP, Cleveland VA Medical Center, 10701 East Blvd, Cleveland OH 44106 (hollyhovanrn@gmail.com).

The authors declare no conflicts of interest.

Deciding to become certified in a specialty is a significant commitment, a mark of professionalism, and a designation as an expert clinician. The Wound Ostomy Continence Nursing Certification Board (WOCNCB) has been identified as the gold standard for certification, certifying over 8600 nurses in the past 40 years (wocncb.org). Offering multiple certifications targeting the scope of practice, the WOCNCB is unique in only certifying nurses in the wound, ostomy, and continence (WOC) and foot/nail specialties, not other disciplines.

Preparing to become certified involves a variety of considerations, which include planning, time management, organization, cost benefit, a study plan, etc. Additionally, preparing for a certification exam may involve a bit of stress or test anxiety. Providing these sample questions and rationales helps with exam preparation, and reduces anxiety surrounding examination preparation and studying. Refer to WOCNCB Web site (https://www.wocncb.org) for information.

Back to Top | Article Outline

PRACTICE QUESTIONS

1. The WOC nurse is providing education to a new ostomate. The patient is comfortable discussing sexual intimacy and asks for tips on concealing a pouch. The WOC nurse suggests pouch covers, minipouches, and different types of underwear. Which stage of the permission (P), limited information (LI), specific suggestions (SS), and intensive therapy (IT) PLISSIT model is the WOC nurse addressing?

  1. Intensive therapy
  2. Limited information
  3. Permission
  4. Specific suggestions

Outline location: 020101

Cognitive level: Recall

Back to Top | Article Outline

ANSWER D: Specific Suggestions

The PLISSIT model encompasses 4 levels of response to issues with sexual health. The Permission stage focuses on exploring the patient's needs related to intimacy and sexual relationships. The Intensive Therapy stage focuses on the WOC nurse recognizing psychological, interpersonal, or physical needs, and making appropriate referrals as necessary. The Limited Information stage is also considered the understanding stage, and focuses on increasing the patient's knowledge in areas such as sexuality, treatment, and body image changes. Open-ended questions should be used, along with active listening, empathy, and reassurance. The correct answer, The Specific Suggestion stage involves providing resources, support, and reassurance. This is illustrated in the question previously.

1. Carmel JE, Scardillo J. Rehabilitation issues and special ostomy patient needs. In: Carmel JE, Colwell JC, Goldberg MT, eds. WOCN Society Core Curriculum: Ostomy Management. Philadelphia, PA: Wolters Kluwer; 2016:151–152.

2. Dixon KB, Dixon P. The PLISSIT model: care and management of patients' psychosexual needs following radical surgery. Lippincotts Case Manag. 2006;11(2):101–106.

2. The most common late complication of an ileal reservoir/pouch (postileal pouch anal anastomosis [IPAA] surgery) is ____________, and the treatment for this is ____________.

  1. Blood in the stool, transfusion
  2. Leakage of stool, barrier cream
  3. Loose stools, fluid replacement
  4. Pouchitis, antibiotics

Outline location: 020102

Cognitive level: Recall

Back to Top | Article Outline

ANSWER D: Pouchitis, Antibiotics

Pouchitis is an acute inflammatory process of the pouch that occurs in 25% to 40% of patients, making it the most common late complication of IPAA surgery. The exact cause of pouchitis is unclear. Symptoms of pouchitis typically resolve within 24 hours, and the entire 2-week course of antibiotics should be completed. Pouchitis symptoms include abdominal cramps, increased stool frequency, watery diarrhea, urgency, fatigue, leakage of stool, and may or may not include blood in the stool. It is usually successfully treated with a 2-week course of antibiotics (metronidazole or ciprofloxacin). Transfusion, barrier cream, and fluid replacement are supportive therapies for the symptoms of pouchitis, but antibiotic therapy is the standard treatment for this specific complication.

1. Holubar SD. Prevention, diagnosis, and treatment of complications of the IPAA for ulcerative colitis. Dis Colon Rectum. 2018;61(5):533–537.

2. Stein AC, Cohen RD, Rubin M. Inflammatory bowel disease: Crohn's disease and ulcerative colitis. In: Carmel JE, Colwell JC, Goldberg MT, eds. WOCN Society Core Curriculum: Ostomy Management. Philadelphia, PA: Wolters Kluwer; 2016:55.

3. A patient with a permanent colostomy presents with complaints of itching and reddened skin beneath the skin barrier and difficulty getting a good pouch seal. She is currently receiving chemotherapy for lung cancer and also has type 2 diabetes mellitus. Upon appliance removal for assessment, the skin is erythematous with a maculopapular rash accompanied by satellite lesions. The wafer is cut appropriately. What is the diagnosis and topical treatment?

  1. Peristomal candidiasis infection, antifungal powder
  2. Peristomal granuloma, topical silver nitrate to the areas of elevated tissue
  3. Peristomal moisture-associated skin damage, stoma powder
  4. Peristomal psoriasis, topical corticosteroid spray

Outline location: AP Handbook, p. 37

#2 Diagnosis

#5 Skin Infections (bacterial, fungal)

Cognitive level: Analysis

Back to Top | Article Outline

ANSWER A: Peristomal Candidiasis, Antifungal Powder

The skin described in the question stem includes key information about the patient's risk for developing a fungal infection along with a description of the rash. Rashes associated with fungal infections typically begin in moist areas, hence the appearance of erythematous skin with a maculopapular rash accompanied by satellite lesions beneath the pouch barrier. Peristomal candidiasis (Candida) is one type of fungal infection; the specific features (satellite lesions, erythema, and maculopapular rash) are specific to fungal moisture-associated skin damage. In this situation, the stem also gives clues about treatment to include gently cleansing the skin and applying a topical antifungal agent/powder. A skin sealant may be applied over top of the powder as needed. Candida albicans accounts for up to 75% of all Candida skin infections. Peristomal psoriasis is most common in patients with a history of inflammatory bowel diseases and is also genetic. While psoriasis can also be itchy and red, it usually presents in patches. Granulomas are simply a build-up of granulation tissue around the stoma and will present as red bumps.

1. Salvadalena G. Peristomal skin conditions. In: Carmel JE, Colwell JC, Goldberg MT, eds. WOCN Society Core Curriculum: Ostomy Management. Philadelphia, PA: Wolters Kluwer; 2016:176–184.

2. Alvey B, Beck D. Peristomal dermatology. Clin Colon Rectal Surg. 2008;21(1):41–44.

4. The pediatric WOC APRN in the neonatal intensive care unit (NICU) is consulted on a preterm, formula-fed, neonate. Over the course of the day, the neonate begins to experience oliguria, deteriorating laboratory and vital signs, and periods of apnea. The WOC APRN immediately implements interventions and a treatment plan, including making the neonate nothing by mouth (NPO) and ordering radiographs, recognizing the most common surgical emergency in the neonate as:

  1. Anorectal malformations
  2. Duodenal atresia
  3. Jejunoileal atresia
  4. Necrotizing enterocolitis (NEC)

Outline location: AP Handbook, p. 37

#4 Implementation

#2 Provide patient education specific to medical diagnosis and surgical procedure

a. Medical diagnosis (eg, cancer, bowel or urinary dysfunction, genetic and congenital disease, and necrotizing enterocolitis)

Cognitive level: Application

Back to Top | Article Outline

ANSWER D: Necrotizing Enterocolitis

Necrotizing enterocolitis is characterized by necrosis of the mucosal and submucosal layer of the gastrointestinal (GI) tract, and it is the most common surgical emergency in the neonate. It usually affects preterm infants who are in the NICU. The exact cause is unclear but it is thought to be associated with the immature GI tract. One theory is hypoxemia of the bowel occurs and bacteria invade the bowel wall, which leads to overall deterioration of the intestinal mucosa. The condition is 6 to 10 times more common in formula-fed infants than those who are fed breast milk. Assessment includes radiographs, which may show a normal gas pattern, mild ileus, dilated loops of bowel, or pneumoperitoneum. Gastrointestinal findings may include gastric residuals, bloody stools, absent bowel sounds, abdominal wall distension, and palpable loops of bowel. Often, the infant is made NPO, IV antibiotics are initiated, radiographs are ordered, a nasogastric tube may be placed to decompress the stomach/intestines, and in severe cases, surgery will be performed for bowel perforation or worsening clinical picture. Though anorectal malformations, duodenal atresia, and jejunoileal atresia are also intestinal complications presenting at or very near to birth, they are not the most common surgical emergency in the neonate.

Back to Top | Article Outline

REFERENCES

1. McIltrot K. Assessment and management of the pediatric patient. In: Carmel JE, Colwell JC, Goldberg MT, eds. WOCN Society Core Curriculum: Ostomy Management. Philadelphia, PA: Wolters Kluwer; 2016:158–164.
    2. Christian VJ, Polzin E, Welak S. Nutrition management of necrotizing enterocolitis. Nutr Clin Prac. 2018;33(4):476–482.
    © 2019 by the Wound, Ostomy and Continence Nurses Society.