INTRODUCTION
During the 12 months prior to recertifying, you probably have many questions: Should I recertify by taking the examination? Should I recertify by PGP (Professional Growth Program)? Should I even recertify at all? Limited but consistent evidence suggests that agencies that employ nurses with specialty nursing education and certification have improved health care outcomes. Kendall-Gallagher and associates1 studied specialty nurses staffing in the acute care setting and reported a 10% increase in the proportion of certified baccalaureate nurses positively influenced mortality. Westra and colleagues2 reported results from an Internet-based survey of home health care agencies. Agencies that utilized WOC nurses demonstrated better outcomes for pressure and surgical wounds, improved outcomes for venous ulcers, and a lower incidence of urinary incontinence and urinary tract infections. Obtaining and maintaining specialty certification validates knowledge of WOC nursing, indicate a high level of clinical competence, enhance professional credibility, and potentially support career advancement.
Preparing for recertification is a challenging time for many WOCNCB certified nurses. The thought of taking the certification examination again may provoke fear that the test will not reflect situations and problems not routinely encountered in daily practice. In addition to recertification by examination, the WOCNCB provides another route to recertification that uses evidence of professional growth to validate certification requirements. The PGP provides a framework of professional categories that list multiple qualifying activities. All WOCNCB certified nurses should carefully evaluate both routes to recertification to see which option is best for them. Boxes 1 and 2 summarize the basic steps for preparing for recertification by examination and PGP, respectively.
1. Kendall-Gallagher D, Aiken LH, Sloane DM, Cimiotti J. Nurse specialty certification, inpatient mortality and failure to rescue. J Nurs Scholarsh. 2011;43(2):188-194. [Context Link]
2. Westra BL, Bliss DZ, Savik K, Hou Y, Borchert A. Effectiveness of wound, ostomy, and continence nurses on agency-level wound and incontinence outcomes in home care. J Wound Ostomy Continence Nurs. 2011;40(1):25-33. [Context Link]
QUESTIONS
1. After recent neobladder surgery for bladder cancer, a patient complains of malaise, nausea, vomiting, and lack of appetite. Further assessment reveals dizziness when standing, and the patient reports falls without injury. The patient also reports difficulty emptying the neobladder and passing smaller amounts of urine than usual. What is the most likely etiology of these signs and symptoms?
a. Pouchitis
b. Metabolic acidosis
c. Urinary retention
d. Postoperative bowel dysfunction
Content Outline: Ostomy; Task: 7 020703
Cognitive Level: Analysis
Correct Answer: B
When reviewing the stem of an analysis question, it is important to note not only what specific information is included but also what symptoms are not. The patient describes all the symptoms of metabolic acidosis: lethargy, fatigue, nausea and vomiting, dehydration, and anorexia. Metabolic complications occur in up to 25% of patients after bladder reconstruction using intestinal mucosa. A neobladder is typically created from 50 to 60 cm of ileum. A common result of dehydration is orthostatic hypotension and dizziness, as well as decreased urinary output. Pouchitis, a soft-tissue infection of the neobladder, presents with fever, bacteriuria, hematuria, and pouch pain. While it occurs almost exclusively within the first few months after surgery, the incidence is low. The patient does not report any of the classic symptoms, so choice A is incorrect. The patient does feel he is having difficulty emptying his pouch but has no complaints of abdominal fullness or discomfort, common signs of urinary retention. Tumor recurrence or strictures in the urethra, as well as mucus plugs, can obstruct the outlet of the neobladder. Though the patient has multiple gastrointestinal complaints, they are not consistent with postoperative bowel dysfunction, a syndrome that can occur after surgery on the colon or rectum. Symptoms include rectal urgency, frequent defecation, and loose stools.
1. Herdiman O, Ong K, Johnson L, Lawrentschuk N. Orthotopic bladder substitution (neobladder), part II: postoperative complications, management and long-term follow-up. J Wound Ostomy Continence Nurs. 2013;40(2):171-180.
2. Patel SG, Pariser JJ, Steinberg GD. Urinary stomas: disease states that lead to the creation of a urinary stoma and the use of intestinal segments in urinary diversion. In: Carmel JE, Colwell JC, Goldberg MT, eds. Ostomy Management Core Curriculum. Philadelphia, PA: Wolters Kluwer; 2016:83-88.
3. Tomaselli N, McGinnis D. Urinary diversions: surgical interventions. In: Colwell J, Goldberg M., Carmel J, eds. Fecal and Urinary Diversions: Management Principles. St Louis, MO: Mosby; 2004:184-204.
2. What should be included in the plan of care for patients with a Kock urinary pouch hospitalized for an acute illness and unable to independently drain their pouch?
a. Apply a 2-piece ostomy appliance.
b. Intermittent catheterization of the stoma.
c. Urethral catheterization as needed if unable to void.
d. Daily irrigations with an antibiotic solution.
Content Outline: Ostomy; Task: 7; Skill: A 020700
Cognitive Level: Application
Correct Answer: B
The Kock urinary pouch includes a catheterizable, continent, abdominal stoma. The ileal reservoir is typically emptied every 4 to 6 hours. A continent, cutaneous stoma cannot be effectively emptied by a pouching system, ruling out option A. Urethral catheterization would be impossible after a cystectomy, excluding option C. Stoma irrigation may be necessary to remove mucus in a urinary diversion or larger food particles in a fecal diversion. Tap water or normal saline is typically used, not an antibiotic solution, excluding option D.
1. Patel SG, Pariser JJ, Steinberg GD. Urinary stomas: disease states that lead to the creation of a urinary stoma and the use of intestinal segments in urinary diversion. In: Carmel JE, Colwell JC, Goldberg MT, eds. Ostomy Management Core Curriculum. Philadelphia, PA: Wolters Kluwer; 2016:83-88.
2. Stein AC, Cohen RD, Rubin M. Inflammatory bowel disease: Crohn's disease and ulcerative colitis. In: Carmel JE, Colwell JC, Goldberg MT, eds. Ostomy Management Core Curriculum. Philadelphia, PA: Wolters Kluwer; 2016:37-64.
3. A patient being discharged from the hospital postoperative day 5 after Indiana pouch urinary diversion surgery should be instructed in which of the following?
a. The 24F Malecot catheter will be removed prior to discharge home.
b. Need for self-catheterization every 4 to 6 hours for 2 to 3 weeks initially.
c. Catheter irrigation should be performed 2 to 4 times per day.
d. They will need to carry 2 catheters in a sealable bag with them at all times.
Content Outline: Ostomy; Task: 7; Skill: A 020700
Cognitive Level: Application
Correct Answer: C:
The primary benefit of an Indiana pouch continent urinary diversion is to provide a low-pressure, high-volume reservoir, allowing the patient to intermittently catheterize at reasonable intervals. In the healing period, the patient will be required to irrigate the catheter placed during surgery to ensure that it is draining freely and not plugged with mucus. The frequency of the procedure is titrated to the quantity of mucus present. The 24F Malecot catheter is maintained during the 4- to 6-week healing period to drain the reservoir and reduce pressure on the newly constructed pouch. Self-catheterization is not performed until after the pouch has healed and all postoperative catheters are removed.
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