Fecal incontinence often exerts a negative influence of health-related quality of life (QoL). It is a distressing and often unpredictable problem, frequently associated with stigma. Bowel dysfunction and fecal incontinence can both decrease QoL, negatively impact social interactions, relationships, and dignity. Likewise, chronic constipation has been shown to significantly increase anxiety and depression, resulting in a reduction in both mental and physical domains of QoL. The Certified Continence Care Nurse (CCCN) and Certified Continence Care Nurse-AP (CCCN-AP) play a critical role in helping patients navigate the management of constipation and fecal incontinence, including protecting skin health, counseling patients about use of body worn absorbent products, and managing bowel dysfunction.1 The CCCN is a strong source of support, providing empathy and understanding while educating patients, families, and the general public. The Wound, Ostomy and Continence Nursing Certification Board (WOCNCB) validates specialty knowledge and skill for both first line and advanced practice continence care nurses. Continence care nursing is practiced in all.1 Multiple studies and literature reviews indicate that WOC nurses enhance patient quality of life, reduce costs in hospitals, improve outcomes related to wounds, ostomies and continence, advance treatments, conduct research, and provide leadership and oversight to programs.2 Wound, Ostomy and Continence nurses are not only pillars of support for their patients, but also for the nursing staff and the facilities they serve. Tri-certified specialty nurses serve as experts in the field and liaisons between disciplines, formulating a holistic, evidence-based plan of care for each individual. Integrity, leadership and knowledge are 3 of the core values that guide the professional practice of the WOC nurse role, while integrating art and science to creatively manage wounds, stomas, fistulas, percutaneous tubes and drains, continence problems, and more.3 The following questions serve as exam preparation and review for the CCCN and CCCN-AP exams, specifically focusing on the management of bowel dysfunction and fecal incontinence. These review questions pertain to CCCN Continence Exam Outline Domain 3, Task 2: manage bowel dysfunction and fecal incontinence and the CCCN-AP Continence Exam Outline Domain 4, Task 3: Utilize therapeutic interventions to promote continence management and prevent complications: 040300. REFERENCES Berke C, Conley MJ, Netsch D, et al. Role of the wound, ostomy and continence nursing in continence care: 2018 update. J Wound Ostomy Continence Nurs. 2019;46(3):221-225. doi:10.1097/WON.0000000000000529. Heerschap C, Duff V. The value of nurses specialized in wound, ostomy, and continence: a systematic review. Adv Skin Wound Care. 2021;34(10):551-559. doi:10.1097/01.ASW.0000790468.10881.90. Murphree RW, Jaszarowski K. Professional practice for wound, ostomy, and continence nursing. In: Ermer-Seltun JAM and Engberg S. Wound, Ostomy, and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA. Wolters Kluwer; 2022:1-10. Practice Questions 1. The CWOCN in an acute care hospital receives a consult from a bedside nurse regarding a 77-year-old African American male with irritable bowel syndrome (IBS). He has been having frequent episodes of diarrhea. The nurse describes areas of darker and lighter skin to the bilateral inner buttocks, extending to the perineum, which are painful when performing incontinence care. What is the etiology and treatment plan? A. Irritant contact dermatitis (ICD) due to fecal, urinary, or dual incontinence. Zinc-based barrier cream and pH-balanced cleansing with each incontinence episode. B. Stage 1 pressure injury. Offloading, every 2-hour turns, foam border dressing changed twice weekly and low air loss surface. C. Fungal ICD. Miconazole 2% cream 3 times per day and as needed after incontinent episodes. pH-balanced cleansing with each incontinent episode. D. IBS flare-up. Provide education on diet, stress management, and hydration. Consider consulting GI if there is no improvement over the next 3 days. Outline Location: 030203 Cognitive Level: Recall ANSWER: A Irritant contact dermatitis due to fecal, urinary or dual incontinence, answer A is correct. Irritant contact dermatitis is a localized skin inflammation due to fecal or urinary incontinence. Erythema, or redness of the skin, is typically a key clinical feature of ICD; however, this red coloring of the skin may present differently in different skin tones. On darkly pigmented skin, hypo- or hyperpigmentation (areas of lighter or darker skin) may be a key clinical finding in the assessment of ICD.1 Recognizing and treating changes in skin color and tone are key components for appropriate diagnosis, treatment, and prevention of pressure injuries.1 The prevalence of ICD is often high in hospitalized patients due to decreased mobility, diminished cognitive or motor function, pain, medication effects, nutritional status, and critical illness. Increased age is associated with a higher risk for incontinence although age is not an independent risk factor.1 pH-balanced cleansers help to maintain the acid mantle of the skin, especially in the setting of breakdown from caustic effluent (fecal incontinence). Evidence shows that consistent implementation of a defined skin regimen improves patient outcomes. Topical mineral oil may be used as needed to help remove zinc-based products from the skin while avoiding aggressive cleaning or scrubbing.1 While Stage 1 pressure injuries present as nonblanchable erythema, this presentation is often localized over a bony prominence versus widespread over the perineal area and buttocks.1 Offloading and turning are key components to a successful pressure injury prevention program, although an occlusive or bordered dressing would not be appropriate in the setting of fecal, urinary, or dual incontinence due to the concern for moisture trapping and increased risk of skin breakdown. Therefore, answer B is not correct. Fungal ICD typically presents as satellite lesions or pustules and is accompanied by erythema and often itching in an already moist area. The rash can have a distinct odor. While miconazole 2% cream is an antifungal cream, it does not contain a barrier such as petrolatum, zinc or silicone, and would likely not adequately provide protection against caustic effluent (fecal incontinence).1 When fecal, urinary or dual incontinence is present, it is often best to treat the cause but also ensure that the skin is protected with a barrier ointment and/or containment as appropriate. Since there is no evidence of a fungal skin infection, and the patient is experiencing dual incontinence (in need of a skin barrier cream or ointment), answer C would not be correct. While the patient may be suffering from an IBS flare-up, the immediate concern in this case is correctly assessing and diagnosing the current skin condition and putting appropriate interventions in place to prevent further skin breakdown and/or pressure injury. Providing education and following up on IBS triggers is within the practice scope of the CWOCN but would not be included as the immediate treatment plan for the issue; therefore, answer D is not correct. Ongoing education, follow-up, support and continuity are all important pieces included in the role of the CWOCN. The WOC nurse also collaborates with other health care professionals to provide comprehensive care. Collaboration fosters a culture of communication and trust, bringing awareness to each other’s knowledge, skill sets, and strengths, helping to ultimately improve patient outcomes.2 REFERENCES Bliss DZ, McNichol L, Borchert K, et al. Irritant Contact Dermatitis Due to Fecal, Urinary or Dual Incontinence: It Is Time to Focus on Darkly Pigmented Skin. Advances in Skin 37(11 2022: 1-10. 2. The CWOCN-AP® in the outpatient clinic is consulted for a 40-year-old male patient related to bowel dysfunction, secondary to a spinal cord injury (SCI). He is experiencing neurogenic bowel related to his injury sustained 5 months ago. He is here today as a referral from his SCI physician due to difficulty with bowel care at home and the length of time it takes to complete (over 1 hour). He has failed several conservative therapies but is interested in learning more about transanal irrigation versus a traditional enema. What is the best initial intervention? A. Inform the patient that due to failing some conservative therapies already, he should consider a diverting ostomy. Explain that a diverting ostomy would make bowel care easier and carries little risk. B. Explain the purpose of transanal irrigation. Discuss the advantages of the system over a standard enema, the timeframe to complete and associated risks and benefits. C. Ensure the patient is comfortable and has no immediate needs. Put on a video explaining transanal irrigation and different systems used. Answer any questions after the video is complete and schedule follow-up in 2 weeks to reassess needs. D. Explain to the patient that neurogenic bowel is typically managed through a bowel program, medications, and diet. Provide written and verbal instruction on lifestyle changes and schedule follow-up in 2 weeks. Outline Location: AP 040318 Cognitive Level: Application ANSWER: B Bowel and bladder dysfunction have a profound impact on QoL after SCI and are often associated with anxiety and depression. Approximately 30% of SCI patients are hospitalized on an annual basis with bowel dysfunction being the 9th most common reason for rehospitalization. While initial patient evaluation and management focus on the acute phase of SCI, providing bowel and bladder care should be explored in the sub-acute or chronic phase, taking a multidisciplinary approach.1 The correct answer here is B. It is important to first understand what the patient has been told or understands about transanal irrigation. It is also important to assess the patient’s learning needs and style, and ensure education is provided in a way that is going to be understood. Using the teach-back method is also an effective way to convey information and ensure understanding. Transanal irrigation is seen as a generally safe and conservative way to manage neurogenic bowel and has become increasingly popular over the last several years.2 The purpose of the irrigation is to flush stool from the rectum and colon using a kit with tap water. An advantage of this system over a standard enema is that it has a rectal balloon and a handheld unit which allows the individual to inflate the balloon and control water instillation into the bowel.2 The unit requires minimal strength for hand manipulation which is beneficial for those living with SCI. The timeframe to complete this specific bowel regimen is typically 20-30 minutes. The risk of rectal perforation should also be discussed with the patient prior to using it, ensuring they understand the risks and benefits and are making an informed decision. It is also important to note that transanal irrigation systems are a prescription item and require training from a clinician prior to use.2 When conservative measures are not effective, surgical options may be considered, however, it is important to meet with a trained clinician to ensure that conservative options have first been explored.1 While a diverting ostomy is an option (usually used when most others have failed) to manage neurogenic bowel, conservative options have not been fully explored. Additionally, ostomy surgery does carry risk as it is a surgical procedure. Therefore, A is not the correct answer. Video-based learning is beneficial for visual learners but for those who are not engaged through hearing or seeing information, this may not be an effective teaching tool. It is important to first assess learning needs and style prior to presenting information. Therefore, C is not the best choice. While bowel programs, medications and diet are important first-line therapies for addressing neurogenic bowel secondary to SCI, they are not always effective. Additionally, this patient has already failed some conservative therapies and has met with his SCI physician who is suggesting he explore transanal irrigation. Given the impact that bowel function and continence have on QoL, it is important to explore all evidence-based options which may make bowel care easier and improve QoL while maintaining dignity and promoting independence.2 REFERENCES Kuris EO, Alsoof D, Osorio C, Daniels AH. Bowel and Bladder Care in Patients with Spinal Cord Injury. Journal of the American Academy of Orthopaedic Surgeons. 2022;30(6):263-272. Lonergan Callan L 2022: 484-519. 3. A patient with a history of psychiatric illness presents to the continence clinic after referral from their mental health provider. The patient reports that they were started on Clozapine 2 months ago and have experienced severe constipation with no bowel movements for the past 7 days. After performing a comprehensive medication history, review of systems and physical examination, which of the following would be the most appropriate treatment for the– AP (CCCN-AP) to prescribe? A. Fiber laxative twice daily B. Osmotic laxative once daily C. Stimulant laxative as needed D. Stool softener as needed Outline Location: 040315 Cognitive level: Recall ANSWER: B Clozapine has been shown to be the most effective antipsychotic medication available for treatment of resistant schizophrenia. However, the use of clozapine comes with many serious and potentially life-threatening adverse effects.1 Clozapine has been shown to slow gastrointestinal transit time in 50-80% of patients, resulting in potentially life-threatening complications.1,2 Clozapine-induced gastrointestinal hypomotility (CIGH) results in significantly reduced colonic transit resulting in constipation, paralytic ileus, toxic megacolon and bowel perforation.1,2 When managing constipation, bulk-forming fiber laxatives, along with lifestyle modifications may be appropriate for a patient with normal transit constipation. However, due to the effects of CIGH, and the resulting slow transit, fiber laxatives are contraindicated since increased fiber does not stimulate peristalsis and increases the fecal mass, further exacerbating constipation.2,3,4 Therefore, Answer A would be incorrect. Patients treated with clozapine do not experience constipation the same as the general population, leading to under-reporting and underutilization of laxatives.1,2 As noted by Every-Palmer, et al, “Clozapine-treated patients may not recognize or experience bowel dysmotility in the same way as other people, and may be less likely to spontaneously report it or to request treatment.” Therefore, laxatives administered on an “as-needed” basis have been shown to ineffective. Stimulant laxatives such as Senna have been shown to be effective first-line agents for treating patients with CIGH but should be administered on a routine basis.3 For this reason, answer C would not be correct. The same applies to answer D. Although use of stool softeners have been shown to be an essential component for managing constipation in patients treated with clozapine, they are recommended to be prescribed on a routine schedule and not on an as-needed basis.2 Osmotic laxatives such as polyethylene glycol (PEG) exert laxative effects by drawing water into the bowel lumen, therefore distending the bowel and softening the stool. These agents have been shown to be safe and effective for routine use and are a recommended component of managing CIGH.2,4 Appropriate laxative use is a cornerstone of treatment for patients with slow-transit constipation and hypomotility disorders such as CIGH.4 Of the available answers, the most appropriate answer would therefore be B, osmotic laxative once daily. REFERENCES Every-Palmer S, Inns SJ, Grant E, Ellis PM. Effects of Clozapine on the Gut: Cross-Sectional Study of Delayed Gastric Emptying and Small and Large Intestinal Dysmotility. CNS Drugs. 2019;33(1): 81-91. Every-Palmer, S., Ellis, P. M., Nowitz, M., Stanley, J., Grant, E., Huthwaite, M., 466-469 4. The CCCN is seeing a bed-bound patient with a history of left hemiparesis and aphasia for new-onset diarrhea. His spouse is the primary caregiver and reports that he started having liquid stool approximately 1 week ago and has not had a formed bowel movement (BM) in the past 3 weeks, when his stool was noted to be hard and dry. She rates his current stool as a type 7 on the Bristol Stool Scale and his previous formed BM as a type 1. An abdominal examination reveals hypoactive bowel sounds in all quadrants, a palpable mass in the left lower quadrant with firmness and discomfort with palpation of the abdomen evidenced by the patient grimacing and moaning. Which would be the most appropriate next intervention? A. Perform a digital anorectal exam to check for fecal impaction. B. Provide the caregiver with a bowel diary and collect data for 1 week. C. Apply a rectal pouch for containment of the liquid stool. D. Recommend increasing fluid intake and administering a fiber laxative. Outline Location: 030204 Cognitive Level: Application ANSWER: A Constipation resulting in fecal impaction a which may to of liquid stool as the liquid the and the fecal Fecal impaction often results from chronic constipation secondary to or effects of The increased pressure on the colon by the impaction may to and in the Therefore, when a comprehensive abdominal examination a stool a digital anorectal exam should be the clinician may be to the most appropriate method of Therefore, answer A is the correct answer. The use of a bowel diary is for data regarding and over a of time to in of a treatment plan and evaluation of the of However, due to the acute of the and the for bowel changes if the mass is not the use of a bowel diary at this would not be appropriate. Therefore, answer B would not be correct. fecal are for the of of liquid stool with the of being may be an appropriate for the of the stool but does not the of the fecal impaction. Therefore, answer C would not be correct. modifications including increased fluid intake and fiber are first line treatment for patients with normal transit However, the treatment of constipation be on the specific type of constipation and the cause of the The use of lifestyle to increased fluid and fiber intake may be an appropriate for prevention and management of constipation but in the this does not adequately the presenting of fecal impaction. Therefore, answer D would not be correct.
Hovan et al. (Fri,) studied this question.