Receiving the news that one requires an ostomy placement can be very devastating mentally and emotionally. In addition, learning to manage the ostomy as well as dealing with potential complications can be overwhelming. It is well documented that receiving pre-operative as well as follow-up care from an ostomy expert can reduce hospital stays as well as other complications.1 The Certified Ostomy Care Nurse (COCN®) can not only ease the transition but also provide a valuable resource for the patient throughout the process and for years to come.

The COCN® begins care of the ostomy patient even before the stoma has been created. Studies indicate that patients seen by the COCN® in the pre-operative period have better outcomes not only with their surgical experience but also in the care and management of the ostomy and any complications that may arise.2 During the pre-operative period, being able to ask the COCN® questions as well as voice any concerns during these sessions which help alleviate fears and reduce anxiety for the patient as well as the caregiver. The COCN® can also provide materials and references so that the patient will have these available after the surgery.

Most patients experience some complications related to their ostomy at some point with many occurring in the first year. The COCN® is a valuable resource in assisting with pouching, skin, and elimination issues as well as social anxiety, body image and sexual issues. Many ostomy patients experience fears and doubts about returning to a normal life after receiving an ostomy.3 The COCN® can assist the transition and help alleviate some of these fears.

The most common following surgery for stoma formation is peristomal skin complications.4 These complications can occur at any time, but commonly arise within 5 years of surgery.4 In a systematic review risks factors were defined as type of surgery/emergent or not/preop marking, patients with ileostomy, female sex, patient age (older patients had higher rates), underlying comorbidities, and post operative radiation and/or chemotherapy.4 Peristomal skin complications can range from erythema to eroded skin, which negatively impact the patient’s health-related quality of life, place additional demands on healthcare providers, and increase healthcare costs. This makes prevention an important goal for COCN® to impart on their patients.

The three most common causes of peristomal skin complications are mechanical, chemical, and fungal.5 The most common peristomal skin breakdown is chemical in nature where the peristomal skin encounters stomal effluent, causing inflammation and skin damage if not corrected quickly.6 Mechanical issues are caused by removal of the barrier or pouching product accessories. Peristomal skin that is kept moist is also at increased risk for fungal overgrowth. The COCN® must be prepared to assess for these risks and define an appropriate plan of care to correct the cause.

Becoming certified as an ostomy nurse validates their knowledge and skills that can help the patient in a number of ways. Stoma site marking, selecting a pouching system, managing complications, along with pre and post-operative teaching are examples of the skillset a COCN possesses. Being a COCN® is a very rewarding career as the services providing can make life-changing impacts for the ostomy patient.

REFERENCES 1. Goldberg M, Mahoney M Preoperative preparation of patients undergoing a fecal or urinary diversion. In: Carmel J, Colwell J, Goldberg M, ed. Wound, Ostomy, and Continence Nurses Society Core Curriculum: Ostomy Management, 2nd ed.; 2022:144-161. 2. Rivet EB Ostomy management: a model of interdisciplinary care. Surg Clin North Am. 2019;99(5):885-898. doi:10.1016/j.suc.2019.06.007. 3. Alenezi A, McGrath I, et al. Quality of life among ostomy patients: a narrative literature review J Clin Nurs. 2021;30(21-22):3111-3123. doi:10.1111/jocn.15840. 4. D’Ambrosio F, Calabro E, et al. Peristomal skin complications in ileostomy and colostomy patients: what we need to know from a public health perspective. Int J Environ Res Public Health. 2023;20(1):79. doi:10.3390/ijerph20010079. 5. Berti-Hearn L, Elliott B Ileostomy care: a guide for home care clinicians. Home Health Care Now. 2019;37(3):136-144. 6. McNichol L, Bliss, D, Gray M, Moisture-Associated Skin Damage Expanding Practice Based on the Newest ICD-10-CM Codes for Irritant Contact Dermatitis Associated with Digestive Secretions and Fecal or Urinary Effluent from an Abdominal Stoma or Enterocutaneous Fistula. Journal of Wound, Ostomy and Continence Nursing. 2022;49(3):235-239. Question 1:

The COCN® is obtaining a health history on a patient with a new ostomy. Although all these statements would indicate further follow-up and evaluation, which would be most important to address FIRST?

“My ostomy leaks at times and my skin is starting to break down.” “The skin around my stoma is red with some pus coming out.” “My ostomy sometimes sticks out a lot.” “I have an area around my ostomy that protrudes.”

Content outline: Domain 2, Task 1, 020106

Cognitive level: Analysis

ANSWER: B

Rationale: Peristomal abscesses often occur most often around 2 weeks after placement of the ostomy.1 Signs and symptoms include localized erythema, swelling, and tenderness on the peristomal skin. The patient may also exhibit systemic signs of infection. Treatment needs to begin as soon as possible and includes: drainage of the abscess, antibiotic therapy, and local wound management. Peristomal moisture-associated skin changes (Answer A) can be an issue with pouch adherence as well as skin breakdown and should be dealt with quickly although it is not an emergency.2 It is important to explain to the ostomy patient that the bowel used to create the actual ostomy still has the property of peristalsis and may continue to contract and expand (Answer C). The patient can be taught how to deal with this issue if it is concerning or the expansion begins to fill the ostomy bag. Peristomal hernias (Answer D) sometimes occur after surgery, especially if the patient has weak abdominal musculature or has been lifting too much weight and are not an emergent condition unless the hernia is strangulating the ostomy.

Question 2:

The COCN® is performing pre-operative teaching with a patient in preparation for an end ileostomy procedure. Which of the following statements warrants additional education?

“My ostomy may either protrude or be flush with the skin.” “There will only be one stoma with one opening.” “There will be sutures around my ostomy.” “There will be a plastic rod placed to hold the ostomy in place.”

Content outline: Domain 2, Task 1, 020107

Cognitive level: Knowledge

ANSWER: D

Rationale: Rods are utilized with loop construction to stabilize the loop of intestine and prevent retraction. The normal end ileostomy may protrude 2-3 cm from the skin (Answer A) or may be flush, depending on the amount of ileum available to the surgeon as well as the location.1 There is one stomal opening with the end ileostomy (Answer B) whereas the loop procedure will have one stoma with two openings. Absorbable sutures (Answer C) are utilized to secure the stoma and it is best to make the patient aware prior to the surgery that these will be present.

Question 3:

Which of the following is NOT an acceptable accurate technique for collecting a urinary specimen from an ileal conduit?

Allow urine to drip from the stoma to the collection device for urine specimen collection Connect the pouch to bedside gravity drainage, allow urine to build, and collect the urine specimen from the bag If using a two-piece pouching system remove the pouch from the wafer, collect the urine specimen from the stoma, and reapply a pouch Catheterize the ileal conduit using a straight catheter to collect urine

Content outline: Domain 2, Task 1, 020111

Cognitive level: Application

ANSWER: B

Rationale: When collecting urine from a ileal conduit bacteriuria is almost always present and accurate technique most be used to avoid specimen contamination.2 In a randomized control trial there was no statistically significant difference uropathogen contamination in techniques A, C, and D.1 Removing a one piece pouch and allowing urine to collect from stoma, removing pouch in a two-piece pouching system and allowing urine to collect with the wafer intact, and catheterizing the stoma are acceptable specimen techniques.2 Specimen collection should never be collected from the pouch or bedside gravity drainage.1

Question 4:

The COCN® assesses an individual with moisture associated peristomal skin damage to include erosion of the peristomal skin. After educating the individual on accurate wafer sizing the next best intervention would include:

Begin using antifungal powder with each pouch change Begin using pouching product with convexity with each pouch change Begin using pectin-based powder followed by skin barrier wipe before each pouch change Begin pouch change every 5-6 days

Content outline: Domain 2, task 1, 020106

Cognitive level: application

ANSWER: C

Rationale: When peristomal skin comes in prolonged contact with stool resulting in inflammation and eventual erosion of the peristomal skin. This moisture associated damage creates one of the most common challenges to ensure a good pouch seal. Using the crusting technique (answer C) will help create a dry pouchable surface by applying stoma powder followed by skin barrier wipe to the macerated skin and allowing to dry. The clinical scenario has no indication of fungus being the causative factor. Given the clinical scenario there is no obvious stomal retraction that would benefit from convexity. Expected pouch change would be 3-5 days for most stoma types.

Question 5:

When managing a patient with a high-output ileostomy, which of the following should the COCN-AP consider ordering first?

Order fluid restrictions Order CMP and CBC Order loperamide 4 mg four times daily Order cholestyramine 4 g daily

Content outline: Domain 2, task 1, 020102

Cognitive level: Analysis

ANSWER: B

Rationale: In general the more proximal an ileostomy formation is the higher the risk for malabsorption. While there is no universal definition, output is considered high when the volume exceeds 1200 mL in 24 hours.1 Of the options the first consideration would be to rule out an infectious cause as well as electrolyte imbalance. Fluid restrictions may be recommended as well as hyper or hypotonic fluids once an infectious cause is ruled out. Once infection is ruled out and electrolytes are corrected an antimotility agent like loperamide could be considered followed by an antisecretory agent like cholestyramine if no improvement with loperamide.1