Part 3 in a multi-part series reviewing different types of certification and providing tips and practice questions. Read Part 1 Here and Part 2 Here. As someone who holds tricertification, I often feel as though my ostomy patients are the ones in whose lives I am making the biggest difference. Watching them progress, gain confidence in independent ostomy management, and enjoy their lives once again is one of the best feelings to me! An ostomy, whether a planned or an emergency procedure, is life changing. Often, life after an ostomy is referred to as a "new normal."

Going into surgery, many patients are apprehensive, scared, and nervous and may even think "I am never going to be able to leave the house again!" My job is to educate and show these patients that life is different after an ostomy, but it will be okay. Many patients experience an enhanced quality of life after receiving their ostomy because they have less pain, are able to eat foods that maybe they couldn't before, and aren't always on the lookout for the nearest bathroom. They are able to go places and do things that they maybe could not have before... swimming, air travel, hiking, biking, exercise, international travel – ALL possible with an ostomy! The Transportation Security Administration (TSA) even has specific guidelines for travel with an ostomy, thus making things a little less stressful for those who are traveling. United Ostomy Associations of America (UOAA) also provides much information on traveling, lifestyle, support groups, and care.

The 2019 WoundSource Wound Care Certifications Guide
 

There are so many resources available for people with ostomies, but it is our job, as specialists, to be sure that they are aware of these resources. After going home and adjusting to life with an ostomy, I often hear comments from patients such as "my ostomy saved my life!" It is important to remember that an ostomy may be created for several reasons, and education should focus on the preoperative, intraoperative, and postoperative periods. Terminology is also important because ostomies may also be known as fecal or urinary diversions in the literature.

A huge influence in my decision to certify in ostomy care was the desire to make a difference in someone's life and to be able to help an often vulnerable population. When considering certification, it is important to explore the reasons why you want to certify, how you will prepare, and the concepts surrounding maintaining certification. Once you decide to certify, preparation is key. Going into the certification exam prepared, well rested, and nourished and hydrated is important. You want to be able to focus on the questions in front of you versus environmental issues. Many of the testing centers provide noise-canceling headphones and scrap paper for notes – if you're not sure whether yours does, check before going... that way, you'll know what to expect.

Preparation for Ostomy Certification

To recap, before certification:

• Determine why you want to become certified.
• Determine what impact certification will have on your current position.
• Explore the different types of certifications and certifying bodies, requirements for certification, and recertification, along with study materials needed, cost, and preparation time. Reviewing each certifying body's exam preparation handbook is a must!
• Create a timeline from start to finish to map out study times, exam dates, and costs of the study materials, the exam, and renewal fees.
• Research preparation classes and programs or schools for ostomy certification, and determine which most closely align with your goals and vision in terms of becoming certified in ostomy care.

Certification Content Focus

With ostomy certification, anatomy is important, right? We need to be able to explain to our patients how and why an ostomy is created, types of ostomies, location within the intestine and how this will impact output, pouching techniques, and common complications. In addition to the anatomy, we also need to be able to provide advice on lifestyle, emotional support, management, and resources within the community. When studying, be sure to focus on your exam content breakdown or handbook, usually available on the certifying body's website. This is key to be sure that you understand what will be on the exam, feel prepared, and review appropriate study materials before taking the exam. Well… you've made it this far in reading, so it sounds like you may be interested in ostomy certification! Let's try a couple of practice questions with rationales to get you thinking...

Ostomy Certification Practice Questions

Question 1: You're completing preoperative education and ostomy marking for a 22-year-old patient who is scheduled for an ileostomy related to Crohn's disease. What are some important considerations when educating and marking this patient? A. Preoperative education is key, along with marking the patient within the rectus abdominis muscle, examining the abdomen with the patient sitting, standing, and lying down, and marking sites on both sides of the abdomen in case there are changes in the surgical outcome, while being sure to mark #1 as the best site. B. Mark the patient just outside of the rectus muscle, at least 5cm away from the midline (surgical incision), and be sure to assess the abdomen with the patient lying and sitting, while asking questions about occupation and hobbies. C. Ask the patient where they prefer to have their stoma, while marking for a planned ileostomy on the left side and a planned colostomy on the right side. D. Have the patient sit down and assess the abdomen for any folds and creases. Choose a site that is not within a fold or a crease, but place the marking on the underside of the pannus.

Answer and rationale: A is the correct answer. Preoperative education is key for new ostomates because of changes in body image, need to care for their stoma independently if able, lifestyle changes, and overall ostomy management. If a patient is prepared, it makes the transition from hospital to home easier. Assessing the abdomen with the patient lying, sitting, and standing is very important to check for folds, creases, scarring, etc. Be sure to have the patient bend over so that the stoma site is not placed within a fold when the patient bends over. Placing the stoma within a skin fold or in an area that the patient cannot see (on the underside of the pannus) will impede independence with ostomy care and create a potential for the pouch to leak. Stoma markings should always be placed within the rectus abdominis muscle to avoid hernia formation postoperatively, in addition to other complications. Ileostomy markings are typically on the right side and colostomies are on the left because of the body's anatomy. Sites should also be selected on the opposite (non-traditional) side, in case there are changes during surgery or an unexpected outcome. Some other tips or tricks to consider when marking for an ostomy are:

• Ask the patient about hobbies; do they need to wear a tool belt for anything?
• Bring an ostomy pouch to show the patient when marking; consider placing it on the abdomen over top of the premarked stoma location to give the patient a general idea of location and how it will feel.
• Assess the patient's learning style and provide information based on this (written, verbal, hands on, etc.). It is also helpful to provide written information for the patient to refer to while at home in case unexpected questions come up or reinforcement is needed.
• Provide information on support groups, especially those within the community and on the Internet (if the patient has or uses a computer).
• Reinforce that the ostomy nurse is a constant resource and support person for the ostomate, throughout their life.

Suggested Reading

Wound Ostomy and Continence Nurses (WOCN) Society. WOCN Society and ASCRS position statement on preoperative stoma site marking for patients undergoing colostomy or ileostomy surgery. Mt. Laurel, NJ: WOCN; 2014. https://www.ostomy.org/wp-content/uploads/2018/01/wocn_ascrs_stoma_site…. Accessed June 29, 2019.

Question 2: A 68-year-old male patient calls the ostomy clinic with concerns related to his stoma. He states, "I've had my loop colostomy for almost a year and over the last week or so I've noticed that it is sticking out from my stomach more… about 3 inches." What is he most likely describing? A. Parastomal hernia B. Normal changes that occur ~1 year postoperatively C. Stomal prolapse D. Mucocutaneous separation

Answer and rationale: C is the correct answer. Stomal prolapse is when the stoma everts or telescopes itself outward more than expected. Usually, a stoma is "budded" (protrudes outward) ¼–½ inch. However, sometimes the stoma can protrude out farther, resulting in a condition called stoma prolapse. The condition is most common with loop colostomies and can be distressing in terms of appearance and body image, but it is not a medical emergency. Depending on the extent of the prolapse, pouching difficulties, and the impact it has on the patient, a referral to surgery for management options may be warranted. Stomal prolapse is not a normal change that occurs postoperatively. Parastomal hernia is another complication, but it manifests as a bulge next or around the stoma. The intestine bulges through a weak area in the abdominal wall and creates a hernia. Peristomal hernia and parastomal hernia are terms that are used interchangeably to describe this condition. Hernia support belts may be helpful with this condition in terms of providing support; however, hernia repair requires surgical intervention. Mucocutaneous separation is another ostomy complication that occurs when the stoma separates from the surrounding skin (peristomal skin).

This may be related to poor wound healing potential, which may be associated with steroid therapy, malnutrition, prior radiation to the abdomen, or other factors impacting wound healing. Suggested Reading United Ostomy Associations of America (UOAA). New ostomy patient guide. https://www.ostomy.org/wp-content/uploads/2018/05/All-In-One-New-Patien…. Accessed June 29, 2019.

Conclusion

Deciding to become certified in ostomy care is a significant professional achievement and will certainly lend to your success in a career of helping others. Ostomies can be intimidating, and learning to care for them independently is sometimes a challenge. As ostomy nurses, we educate and empower our patients and serve as a really great support system. They rely on us to improve their quality of life and come to us when there are questions or concerns. What better way to be prepared to help and educate others, in addition to experience, is there? As I've often said before... certification is a mark of professionalism and a designation as a specialist in your practice! #GetCertified And I have to say that the hashtags I've seen recently in support of people with ostomies and raising ostomy awareness overall are creative, catchy, and awesome! #OstomyAwareness #NoColonStillRollin' #Stoma #IBDAwareness #Ostomy #Awestomy. Get the word out related to ostomy awareness, a "new normal," and the community support available to new and established individuals who have an ostomy!

Suggested Reading

United Ostomy Associations of America (UOAA). New ostomy patient guide. 2017. https://www.ostomy.org/wp-content/uploads/2018/05/All-In-One-New-Patien…. Accessed June 29, 2019.

Wound Ostomy and Continence Nurses (WOCN) Society. WOCN Society and ASCRS position statement on preoperative stoma site marking for patients undergoing colostomy or ileostomy surgery. Mt. Laurel, NJ: WOCN; 2014. https://www.ostomy.org/wp-content/uploads/2018/01/wocn_ascrs_stoma_site…. Accessed June 29, 2019.

About the Author

Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.