Incontinence refers to the involuntary loss of urine or stool and may occur in women and men. A significant number of people are impacted by incontinence mentally, physically, and financially. Incontinence is often underreported and results in many not having access to the available resources they deserve.1 It is imperative to promote awareness related to incontinence and end stigma. Incontinence should not be shameful or embarrassing, and patients experiencing fecal or urinary incontinence, or both, are not alone. Clinicians should feel empowered to educate their patient population about incontinence to ensure they seek the care they deserve.

Living with urinary or fecal incontinence or dysfunction frequently places a great burden on affected individuals, their families, and/or caregivers. The involuntary loss of urine or stool may contribute to skin and wound care complications, which further increases care needs and may complicate care, resulting in individuals being prematurely placed in long-term or skilled nursing facilities.2

Incontinence is frequently believed to be a normal part of aging due to the incidence of incontinence among older adults. Educating the health care community and patients about normal and abnormal aging changes is important, noting that incontinence is not a normal part of the aging process, though older adults often experience it.3 Many resources and supports are available for those experiencing incontinence, including a Certified Continence Care Nurse (CCCN).

The benefits of a Certified Wound, Ostomy, and Continence Nurse (CWOCN) are clearly outlined within literature.4 These benefits include improved patient outcomes as well as a significant educational resource and source of support to health care clinicians. The CWOCN possesses the knowledge and skills required to lead program development, facility-wide education, and foster an environment of awareness while increasing health-related quality of life (QOL) among those experiencing incontinence.4

The following questions serve as exam preparation and review for the continence exam. These review questions pertain to Exam Outline Domain 3, Task 2: Instruct other health care clinicians and providers on care principles and techniques to promote optimal management and prevent complications.

1. A 78-year-old woman with irritable bowel syndrome (IBS) reports increased episodes of fecal incontinence preceded by episodes of crampy abdominal pain. She states, “When the urge comes on, I have to be a near a bathroom, and if I am not, it just leaks out.” The patient has not been formally managed for her IBS in the past, and this is her first visit to the CCCN. What initial step should be suggested for management?

Dietary modification Cognitive-behavior therapy (CBT) Purchasing over-the-counter psyllium to bulk stool as needed Recommending a daily over-the-counter probiotic

Outline location: 030201

Cognitive level: Analysis

Answer: A

Rationale: The correct answer here is A, dietary modification. Modification in diet is typically the first step in self-management of IBS.¹ Foods known to create gas and bloating should be trialed and eliminated, as appropriate; some examples include beans, onions, carrots, celery, raisins, bananas, apricots, prunes, and Brussels sprouts. Some patients also respond well to removing lactose-containing foods.1 A 2-week trial of dietary modification is often recommended and provides insight into the link between dietary intake and symptom severity. Instructing the patient to complete a 2-week food diary and using the Bristol Stool Form Chart as an adjunct are helpful in tracking bowel symptoms and stool elimination patterns. This information can then be used as a baseline for assessment and improvement.1

Cognitive-behavior therapy is helpful in preventing flare-ups and may be delivered in different settings including over the phone, Internet (telehealth), or in person. However, CBT is not an initial good choice to control life-limiting symptoms. Additionally, CBT providers may be difficult to find and the number of sessions required for effectiveness remains to be determined.1

Both psyllium and probiotics are examples of pharmacologic therapy, and while they may be needed, the initial step here should involve changes in diet. Stool-bulking agents such as psyllium may improve intestinal transit time and reduce constipation. However, it is important to remember that many older adults are already at risk for polypharmacy.2 Probiotics are believed to suppress the growth and luminal binding of pathogenic bacteria, thereby improving epithelial barrier function and reducing inflammation; however additional clinical studies are needed.1

2. As the CCCN at your facility, you have noticed an increase in consults for severe incontinence-associated dermatitis (IAD), along with a slight increase in pressure injuries related to moisture. Part of your role includes monitoring the incidence of IAD and tracking outcomes related to skin integrity. Which would be the best initial step to better understand and address this problem?

Review the current incontinence practices and develop a clearly defined algorithm, terms, and documentation requirements with structured protocols and staff education. Encourage staff to exercise autonomy and revise the plan of care for each patient as needed, notifying the CCCN, the patient, and family members with updates. Develop a patient education pamphlet for new admissions; focus your education on the patients and caregivers as discharge planning begins upon admission. Offer an annual or biannual skin education program, including pre- and posttests, along with contact hours, focusing on treatment of IAD and interventions to treat and prevent.

Outline location: 030202

Cognitive level: Application

Answer: A

Rationale: The correct answer here is A. Reviewing current practice, defining a new process, algorithm, and expectations are key when implementing a new product or clinical practice change. Structured protocols addressing reversible causes of incontinence, skin cleansing, and application of a moisture barrier are critical to decreasing IAD in health care.1 Ongoing education and follow-up are also key. Knowledge translation may be an unfamiliar concept to some health care providers but is helpful when closing the gap between literature and applying new knowledge to practice. The CWOCN possesses the knowledge and skills to serve as a change agent and leader in standards of care and evidence-based practice changes.2 Incontinence-associated dermatitis is an avoidable and preventable health care–associated skin injury that impacts QOL greatly and may lead to pain, infection, pressure injuries, and patient dissatisfaction.3 In many organizations, the CWOCN is responsible for outcomes related to skin integrity. Staff look to the CWOCN for clear guidance and education along with mentorship, as the CWOCN is often a role model for bedside caregivers.2 Encouraging staff to individualize incontinence management for each patient would increase variability in skin-cleansing technique and product use and would not be best for patient outcomes. Focused education for patients and caregivers is important. When changing a clinical practice, it is imperative to first engage the bedside caregivers. Lastly, offering annual or biannual education is also important and needed, but when instituting a practice change, algorithms, terms, and documentation requirements should first be established to serve as a clear guideline for bedside caregivers.3

3. You are mentoring a new CWOCN at your facility and discussing differential diagnoses related to IAD to develop a plan of care for an incontinent, bedbound patient in the critical care unit. Incontinence-associated dermatitis, stage 2 pressure injuries, and friction wounds may have similar clinical presentations but are often treated differently. The CWOCN knows that an accurate clinical diagnosis will guide the nursing plan of care. Which statement best describes skin injury by friction?

Friction wounds typically present as intact diffuse erythema, severely eroded skin, or a red rash with pinpoint satellite lesions. Friction wounds initially appear as erythema and progress to an abrasion, usually affecting superficial layers of the skin. Skin injury by friction typically results in tissue necrosis with visible slough or eschar. Friction injuries are usually seen in patients who have both urinary incontinence and fecal incontinence.

Outline location: 030205

Cognitive level: Recall

Answer: B

Rationale: The correct answer here is B. Friction is the resistance to motion in a parallel direction relative to the common boundary of 2 surfaces; wounds initially appear as erythema and progress to an abrasion in the superficial layers of the skin. Forces of friction include incontinence care, shear, or drag against an underlying surface, resulting in tissue layer deformation that leads to skin injury.1 Incontinent patients are at risk for skin injuries by friction due to incontinence care, utilizing friction for skin cleansing. Skin presenting as intact erythema is often related to IAD; in severe cases of IAD, skin may have large areas of denudement or erosion surrounded by erythema.1 A red rash with pinpoint satellite lesions is usually indicative of fungal IAD and may require an antifungal barrier cream to treat.2

Skin injuries by friction typically affect the superficial layers of the skin; therefore, necrotic tissue such as slough or eschar would not be present as these tissue types are noted in full-thickness wounds. Friction injuries may be present in patients with dual incontinence, but this statement does not best describe skin injury by friction. A nursing plan of care to reduce forces of friction and shearing should be employed, along with moisture management and routine pressure injury prevention measures.2

AP Continence Question

1. An 82-year-old male patient is seen in the clinic by the Advanced Practice Certified Continence Care Nurse (CCCN-AP) after being referred by his primary care doctor related to intermittent urinary incontinence with mild skin breakdown in the perineal area. He has recently finished his prescribed course of therapy (chemoradiation) for prostate cancer. He is requesting recommendations for skin care management and states he has a sulfa allergy. Which would be your initial treatment plan for this patient?

Prescribe Silvadene (silver sulfadiazine) cream twice per day to the area as this is likely a result of radiation dermatitis versus true incontinence-related breakdown. Recommend cleansing skin daily with antimicrobial soap and warm water and using standard briefs during the day along with a toileting schedule. Discuss types of body-worn absorptive products (BWAPs) available and prescribe a zinc oxide–based moisture barrier ointment for twice-daily and as-needed use. Refer the patient to urology, given his clinical picture, history of radiation therapy, and concern for long-term management needs.

Outline location: 030204

Cognitive level: Recall

Answer: C

Rationale: The correct answer for this question is C. The CCCN-AP should discuss types of BWAPs available and prescribe a zinc oxide–based moisture barrier ointment for twice-daily and as-needed use. Additionally, education and support should be provided regarding the prevalence of incontinence and the multitude of resources available, especially for older adults.1 Incontinence is not a normal part of aging, and it is important that health care clinicians are educating patients about this. Incontinence is often underreported, resulting in a decrease in access to care and services that could potentially greatly improve QOL.

Silvadene (silver sulfadiazine) cream is appropriate for radiation dermatitis but does not contain a moisture barrier. Additionally, Silvadene cream is contraindicated in patients with an allergy to sulfa drugs. Soap and water can change the pH of the skin and therefore should be avoided. Alkaline soaps may increase the skin's pH, which can cause a rise in pathogenic bacteria, especially in a patient who is already experiencing incontinence. A pH-balanced skin cleanser should be used.2

Prescribing medications or therapies and following up are a routine role of the CCCN-AP. Initial treatment of moisture-associated skin damage secondary to urinary incontinence is within the role and scope of the CCCN-AP. If there is no improvement in the condition of the skin or there appears to be pathology or an underlying cause that cannot be addressed by the CCCN-AP, then a urology consult for further follow-up and treatment recommendations is appropriate.