According to a systematic literature review,1 value added to the health care system by wound, ostomy, and continence (WOC) nurses includes teaching and mentoring, cost reduction, improved efficiency, improved wound outcomes, improved incontinence outcomes, advanced treatments, research, leadership, and quality of life (QoL). The most significant evidence for value added by WOC nurses was for QoL improvement and was further demonstrated through improved incontinence-specific outcomes.
Continence issues reportedly lead to decreased health-related QoL across the life span. The prevalence of incontinence varies by age and sex, and, though not necessarily a sign of aging, the burden of incontinence is expected to rise with a rising population of older Americans.2 Many people do not seek treatment of incontinence due to stigma or a belief that it is a normal part of the aging process.3 Incorporating validated health-related QoL instruments enable certified continence nurses to this key construct of health and improve physical outcomes and QoL outcomes for their patients.
The following questions aim to prepare for continence certification by exam. The questions pertain to Exam Outline Domain 1, Task 5: Assess health-related quality of life of patients with continence issues.
1. 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. [Context Link]
2. Schmuhl NB, Brow KA, Wise ME, Myers S, Mahoney JE, Brown HW. After the randomized trial: implementation of community-based continence promotion in the real world. J Am Geriatr Soc. 2020;68(11):2668-2674. doi:10.1111/jgs.16771. [Context Link]
3. Ermer-Seltun JAM, Engberg S. Wound, Ostomy, and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2022. [Context Link]
PRACTICE QUESTIONS
1. A 73-year-old woman with irritable bowel hesitantly reports occasional bowel leakage. Which of the following strategies can the Certified Continence Care Nurse (CCCN) employ to help reduce her reluctance to share with her health care team?
A. Suggest a referral to a psychologist.
B. Offer body-worn absorbent product information.
C. Communicate consistently and avoid blaming language.
D. Provide a handout of pelvic floor exercises.
Outline location: 010505
Cognitive level: Analysis
ANSWER: C
Rationale: The correct answer for this question is to communicate consistently and avoid blaming language. Fecal incontinence often goes unreported by patients, despite being related to reversible conditions. The misconception that incontinence is a normal part of aging, cultural taboos, and embarrassment are known to keep patients from mentioning incontinence to their care providers. Consistent communication, providing ongoing education, avoiding phrases that imply blame or failure, and stating a commitment to helping address incontinence help establish rapport with the patient.
When reviewing the answer choices, carefully consider what information was provided and the question being asked. The limited information provided gives no insight into the psychological state of the patient, so option "a" is ruled out. While body-worn absorptive products and pelvic floor exercises may be valid management tools for the patient, the question asks the candidate to consider how to improve communication with the patient, making "c" the appropriate selection.
1. Ermer-Seltun JAM, Engberg S, Callan LL, Francis K. Fecal Incontinence: pathology, assessment, and management. In: Wound, Ostomy, and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2022:484-513.
2. Schlogl M, Gordon A. Hearts, Minds and souls-it is time for geriatricians to bring more to continence management. Age Ageing. 2021;50(5):1508-1511. doi:10.1093/ageing/afab088.
2. During her primary assessment, a 64-year-old woman with a body mass index of 30 mentions she has been spending more money than she can afford on body-worn absorbent products over the past year, as she manages her urinary incontinence with the products 24 hours a day. Which validated quality of life (QoL) assessment tool would the continence nurse administer?
A. The Geriatric Depression Scale (GDS)
B. Timed Up and Go Test (TUG)
C. The Mini-Cog
D. The Incontinence Impact Questionnaire-7 (IIQ-7)
Outline location: 010506
Cognitive level: Recall
ANSWER: D
Rationale: The correct answer for this question is the Incontinence Impact Questionnaire-7. The use of body-worn absorbent products for 24 hours a day is associated with decreased QoL due to incontinence-associated dermatitis, difficulty choosing discrete products, difficulty keeping the products in place, and the high out-of-pocket cost associated with 24-hour body-worn absorptive product use.
When considering the answer choices for this question, in-depth knowledge of every assessment tool is not necessary. Through the process of elimination, the testing candidate can rule out which tool is a quality-of-life measurement specifically related to incontinence. While it is possible the patient is experiencing depression related to her symptoms, and a Timed Get Up and Go Test may provide insight for managing contributing factors to her incontinence, they are not directly assessing for quality-of-life, which rules out options "A" and "B." The Mini-Cog is a cognitive assessment; however, no language in the question implies any impairment in cognition, therefore the test candidate knows the IIQ-7 will best assess the affect incontinence has on the patient's quality-of-life.
1. Ermer-Seltun JAM, Engberg S, Nelles K. Primary assessment of patients with urinary incontinence and voiding dysfunction. In: Wound, Ostomy, and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2022:45-64.
2. Grzybowska ME, Wydra D. 24/7 usage of continence pads and quality of life impairment in women with urinary incontinence. Int J Clin Pract. 2018;73(8):e13267. doi:10.1111/ijcp.13267.
3. Pizzol D, Demurtas J, Celotto S, et al Urinary incontinence and quality of life: a systematic review and meta-analysis. Aging Clin Exp Res. 2020;33(1):25-35. doi:10.1007/s40520-020-01712-y.
3. Comprehensive exam of a 50-year-old man with inflammatory bowel disease reveals chronic diarrhea with occasional fecal incontinence. His International Consultation on Incontinence Questionnaire-Bowel Symptoms (ICIQ-B) indicates a poor quality-of-life related to fecal incontinence. Further interview provides evidence that the patient's lifestyle may be contributing to his incontinence. Which of the following information provided during the interview would the continence nurse identify as a reversible risk factor for this patient's fecal incontinence?
A. High fat diet
B. History of back injury
C. Use of body-worn absorbent products
D. Probiotics
Outline location: 010504
Cognitive level: Analysis
ANSWER: A
Rationale: The correct answer for this question is a high fat diet, which is known to increase gastrointestinal motility and risk for fecal incontinence. The certified continence nurse knows fecal incontinence is a common occurrence with inflammatory bowel disease, and that it may be exacerbated by many different factors. The candidate will recognize a history of back injury as a nonreversible risk factor for fecal incontinence, and the use of body-worn absorptive products and probiotics as management tools for fecal incontinence rather than contributing factors.
1. Ermer-Seltun JAM, Engberg S, Callan LL, Francis K. Fecal incontinence: pathology, assessment, and management. In: Wound, Ostomy, and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2022:484-513.
2. Vollebregt PF, van Bodegraven AA, Markus-de Kwaadsteniet TM, van der Horst D, Felt-Bersma RJ. Impacts of perianal disease and faecal incontinence on quality of life and employment in 1092 patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2018;47(9):1253-1260. doi:10.1111/apt.14599.
AP Continence Question
4. A 56-year-old female is seen in the outpatient continence clinic with complaints of urinary urgency, increased daytime frequency, and nocturia, with more than five episodes of urinary incontinence throughout the day and night. After a thorough history, physical examination, and obtaining a urine sample, the advanced practice continence nurse diagnoses overactive bladder (OAB) with urge incontinence. Based on the patient interview, the advanced practice continence nurse determines conservative management has been ineffective and the patient's QoL has declined. What is the most appropriate intervention?
A. Order further urodynamic testing to confirm OAB.
B. Consult urology for further recommendations.
C. Prescribe an antimuscarinic drug.
D. Recommend continued use of containment products with a strict toileting schedule.
Outline location: 010302, 010403
Cognitive level: Application
ANSWER: C
The correct answer is "c." Pharmacologic therapy for OAB should be considered when conservative management proves ineffective. Urodynamic testing is typically not indicated when OAB is suspected based on clinical diagnosis, unless there is an associated neurological condition, history of prior surgery for urinary incontinence, or unclear diagnosis. Consulting a urologist may not be necessary yet as pharmacologic therapy has not been explored and is within the scope of practice of an advanced practice continence nurse. Continued use of containment and strict toileting is also important, but if QoL continues to decline with those interventions already in place, other options should be explored. Antimuscarinic block activation of activation of muscarinic receptors in the detrusor, reducing the detrusor overactivity leading to urgency and urge incontinence. Antimuscarinic drugs may be prescribed for OAB when conservative therapy fails. Common side effects include dry mouth and constipation, and the patient should be educated on these. Evidence suggests that antimuscarinics (along with other anticholinergic agents) may contribute to cognitive impairment in older adults and should be avoided or used with caution in this group.
1. Gandi C, Sacco E. Pharmacological management of urinary incontinence: current and emerging treatment. Clin Pharmacol. 2021;13:209-223. doi:10.2147/CPAA.S289323.
2. Sazsteinlt Wooldridge L. Overactive bladder/urgency UI: pathology, presentation, diagnosis, and management. In: Wound, Ostomy, and Continence Nurses Society Core Curriculum Continence Management. Philadelphia, PA: Wolters Kluwer; 2022:111-133.