Continence Certification

Often, the continence component of the tricertification exams is the content area most feared by the new or recertifying CWOC nurse. Some even consider dropping their continence “C” because they feel that continence is not their main clinical focus and thus they will not “pass” the exam. But I challenge each and every one of you to look closely at your clinical practice, and you will see that you practice continence nursing every day. (See the sidebar article “You Do ‘DO' Continence.”) Your continence knowledge base is an essential part of your wound or ostomy practice. A careful review of the areas in the continence exam content outline and some practice examination questions will go a long way to help you keep your continence “C.” There are 80 questions asked on the Continence exam. Questions are categorized as recall, application, or analysis. Here are some practice examples. Which of the following toileting programs would be best for a nursing home resident with severe cognitive impairment who is frequently incontinent but when toileted will void 50% of the time or more? Routine scheduled toileting Habit training Bladder retraining Prompted voiding What type of incontinence is often characterized by daytime frequency, hesitancy, nocturia, and postvoid dribbling? Urge incontinence (UUI) Stress incontinence Overflow incontinence Reflex incontinence What is an initial treatment strategy for a patient with fecal incontinence related to diarrhea? Pelvic muscle exercises Sphincter repair Referral for anorectal manometry Dietary changes Which of the following is the best initial intervention for an independent patient with multiple sclerosis and urinary retention? Indwelling urinary catheter Timed voiding Clean intermittent catheterization (CIC) Pelvic muscle exercises Answers/Discussion Question 1: Answer: A Rationale: Routine scheduled toileting is best for patients with severe cognitive impairment. It is a program of assisted toileting on a fixed schedule. In contrast, habit training is a type of scheduled toileting based upon a patient's usual voiding pattern and, to be successful, needs a patient who is only moderately cognitively impaired and is cooperative with staff efforts to toilet. Prompted voiding also requires higher levels of cognitive functioning, with the goal that the patient will “relearn” how to recognize and act upon the urge to void. Bladder retraining requires a motivated and cognitively intact patient willing to inhibit the urge to void and gradually increase the interval between voiding.1(pp180-182) Question type: Application Content area: Differentiate and manage types of UI/toileting programs (3-B-4-i) Question 2: Answer: C. Rationale: Symptoms of overflow incontinence and urinary retention can overlap with other types of incontinence, but those listed in the question are classic symptoms. Stress incontinence is often characterized by small volume leakage associated with an increase in intra-abdominal pressure, which could include daytime frequency, but often nocturia is not a problem. Some classic symptoms of UUI include involuntary leakage of urine associated with urgency but can also be characterized by frequency and nocturia, but hesitancy is not a problem. Reflex incontinence is an involuntary loss of urine that occurs with diminished or absent sensory awareness of urinary urge, and again, hesitancy would not be a problem.1(p229),2(p102) Question type: Recall Content area: Differentiate and manage types of UI/retention with overflow (3-B-8-d) Question 3: Answer: D Rationale: Assessment and modification of diet would be an initial treatment strategy for a patient with fecal incontinence, with the goal to normalize stool consistency. Biofeedback, sphincter repair, and further diagnostic studies such as anorectal manometry would be appropriate if the incontinence was related to sphincter dysfunction or impaired colonic motility.1(p472) Question type: Application Content area: Types of bowel dysfunction(fecal incontinence (C-3-c) Question 4: Answer: C Rationale: Clean intermittent catheterization is the best strategy to manage urinary retention in a motivated and functionally able patient. Indwelling urinary catheters may be necessary but are not the best intervention due to the high risk for infection and injury. Timed voiding can be used in conjunction with CIC, but if the bladder does not empty, the risk for infection and upper urinary tract damage is high. Pelvic muscle exercises may help if the bladder is overactive but might not help emptying.1(pp237-238),2(pp393,444-446) Question type: Analysis Content area: Differentiate and manage types of UI/retention with overflow (3-B-4-h) References Doughty, DB. Urinary and Fecal Incontinence: Current Management Concepts. 3rd ed. St Louis, MO: Mosby; 2006. Newman DK, Wein AJ. Managing and Treating Urinary Incontinence. 2nd ed. Baltimore, MD: Health Profession Press; 2009. New WOCNCB Exam Provider As of October 1, 2011, a new provider began administering certification exams. The new exam manager, Castle Worldwide, Inc, stands ready to assist you with an online application and registration system. CASTLE provides over 450 exam sites in the US and Canada and over 200 additional international sites. More information is available at www.WOCNCB.org. Helpful WOCNCB Resources The WOCNCB offers a variety of resources to help WOC nurses successfully certify, recertify, and promote the specialty and themselves. Learn more at www.wocncb.org/resources. Resources for Preparing for the WOC Certification Exam Free Sample Test Try a user-friendly online test at http://www.lxr.com/webtest/login.aspx. WOCN Society Review Courses Each year the WOCN Society offers CD-ROMs of a certification review course presented at its national conference. You can buy these online at www.prolibraries.com/wocns/. Become a Certified Foot Care Nurse The WOCNCB offers foot care certification to RNs. No bachelor's degree is required. Learn more at www.wocncb.org/WhyCFCN. Not Recertifying Due to Economic Issues? The WOCNCB created a Benevolence Fund in 2007 to cover exam fees in times like these. Don't let your certification lapse. All inquiries are treated with the utmost confidentiality. Contact the WOCNCB 1-888-496-2622, [email protected] You Do “DO” Continence Donna L. Thompson The WOCN/WCET Joint Conference in Phoenix, Arizona, this past June was a wonderful opportunity to learn and network, to share ideas, and to support each other on a national and international scale. Talking with so many incredibly knowledgeable and experienced WOC nurses was an inspiration. One conversation made quite an impact. A truly expert certified WOC nurse shared, “I really do not do continence.” In a country where incontinence affects nearly 20% of hospitalized patients,1 greater than 50% of nursing home residents,2 and 46% of patients receiving home care services,3 it seemed hard to believe that dedicated, professional CWOC nurses did not believe they “do” continence. With the WOCN Society achieving recognition of our nursing specialties by the American Nurses Association, it is more important than ever that we take ownership of the second “C” in our CWOC credential and own our identity and expertise as wound, ostomy, and continence nurses. The newly published Scope and Standards of WOC Nursing4 identifies that the CWOC nurse may have a number of very specialized continence skills that range from urodynamics to setting up incontinence prevention strategies as simple as effective toileting programs. I charge all of you who carry that second “C” in your CWOC nurse credential to look long and hard at your clinical practice and you will indeed see that you do “do” continence. At the WOCN/WCET Joint Conference, Dorothy Doughty, MN, RN, FNP, CWOCN, FAAN, introduced the session “Redefining Continence Nursing in Acute Care” with the comment, “Continence Care is setting specific.” She was so right. What so many WOC nurses consider as “continence nursing” is what the nurse practitioner (NP) does in the outpatient setting. However, WOC nurses in acute care, long-term care, and home care do indeed “do” continence every day of their practice. It may not be multichannel urodynamics or biofeedback-assisted pelvic muscle rehabilitation; instead, it is solid, basic continence nursing that can make all the difference to a patient's well-being. CWOC Nurses Do Solid, Basic Continence Practice Daily The continence-certified nurse addresses continence issues in many ways: assessments such as bladder and bowel diaries; examination of the external genitalia; testing pelvic muscle strength via a simple digital exam; and neurological evaluations by observing the anal wink and watching how patients walk. Daily, certified WOC nurses assess and intervene for reversible causes of incontinence and address the challenges of incontinence-associated dermatitis (IAD). What a certified WOC nurse would ignore fecal and urinary incontinence in a patient with a sacral wound? A CWOC nurse “does” continence when treating IAD, making recommendations to prevent catheter-related urinary tract infection, ensuring that a postvoid residual is evaluated after a catheter is removed, recommending and managing fecal incontinence with fecal management systems, recommending a scheduled toileting program for a patient with dementia, and seeing that the patient with fecal incontinence is evaluated by the dietician to ensure that there is adequate fiber in the diet. It is the certified WOC nurse who knows when to refer patients to a continence NP or urologist for further evaluation. No, I disagree with so many of those CWOC nurses who say they do not “do” continence; they “do” continence every day of their practice. Certified WOC nurses make a huge difference in the lives of their patients when they implement basic level interventions grounded in their understanding of the complex needs of those patients suffering from incontinence. Who else is going to do it but the nurse who is educated and certified to do so? Yes, you do “do” continence and, for the sake of our patients, please keep doing it. 1. Junkin J, Selekof JL. Prevalence of incontinence and associated skin injury in the acute care patient. J Wound Ostomy Continence Nurs. 2007;34(3):260–269. 2. Centers for Disease Control and Prevention. National Nursing Home Survey. http://www.cdc.gov/nchs/nnhs.htm. Accessed June 25, 2010. 3. Du Moulin MF, Hammers JP, Ambergen AW, Janssen MA, Halfens RJ. Prevalence of urinary incontinence among community-dwelling adults receiving home care. Res Nurs Health. 2008;31(6):604–612. 4. Wound Ostomy Continence Nursing Society. Scope and Standards of Wound, Ostomy and Continence Nursing. Mt Laurel, NJ: Wound Ostomy Continence Nursing Society; 2010.

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