Most patients are distressed to learn they need ostomy surgery to divert stool, urine, or both. Adapting to ostomy surgery can be difficult at best, even with today’s advanced technology and the wide assortment of ostomy supplies available. While recovering from the surgery itself, patients must learn how to contain or control feces or urine and how to minimize odor—without feeling like a social outcast.
This article reviews three types of ostomy surgery—colostomy, ileostomy, and urostomy. Subsequent articles will discuss ostomy management and treatment of stomal and peristomal skin complications. (more…)
Document if the diversion is an intestinal or urinary ostomy, whether it’s temporary or permanent, and the location— abdominal quadrant, skin fold, umbilicus. (SeeDescriptor reference.)(more…)
Moldable skin barrier effective for elderly patients with ostomy
A study in Gastroenterology Nursing reports that compared to a conventional skin barrier, a moldable skin barrier significantly improves self-care satisfaction scores in elderly patients who have a stoma. The moldable skin barrier also caused less irritant dermatitis and the costs for leakage-proof cream were lower.
As a wound care specialist, you have learned about many skin conditions, some so unusual and rare that you probably thought you would never observe them. I’ve been a nurse for 38 years, with the last 10 years in wound care, and that’s certainly what I thought. But I was wrong. Let me tell you about my challenging patient with an unusual skin condition.
No one wants an ostomy, but sometimes it’s required to save a patient’s life. As ostomy specialists, our role is to assess and intervene for patients with a stoma or an ostomy to enhance their quality of life. We play an active role in helping patients perform self-care for their ostomy and adjust to it psychologically, starting even before surgery. (more…)
Keeping clinicians up to date on clinical knowledge is one of the main goals of the Wild On Wounds (WOW) conference,held each September in Las Vegas. Each year, I present the opening session of this conference, called “The Buzz Report,”which focuses on the latest-breaking wound care news—what’s new, what’s now, and what’s coming up. I discuss innovative new products, practice guidelines, resources, and tools from the last 12 months in skin, wound, and ostomy management. (more…)
Have you ever had an idea for improving patient care that you wanted to market? You may have lacked confidence or know-how, as I once did. But one patient, a crafty idea, and a trip to Walmart put me on the path to becoming a successful nurse entrepreneur. (more…)
This issue’s resources include patient tools and new guidelines.
Improving patient safety
Research suggests that adverse events affect patients with limited English proficiency (LEP) more frequently, are commonly caused by communication problems, and are more likely to result in serious harm compared to adverse events affecting English-speaking patients. Your hospital can take steps to reduce risks of adverse events for patients with LEP with “Improving patient safety systems for patients with limited english proficiency: a guide for hospitals,” from The Disparities Solutions Center, Mongan Institute for Health Policy at Massachusetts General Hospital, Boston, and Abt Associates, Cambridge, Massachusetts. (more…)
By Gail Hebert, RN, MS, CWCN, WCC, DWC, LNHA, OMS; and Rosalyn Jordan, BSN, RN, MSc, CWOCN, WCC, OMS
Imagine your physician has just told you that your rectal pain and bleeding are caused by invasive colon cancer and you need prompt surgery. She then informs you that surgery will reroute your feces to an opening on your abdominal wall. You will be taught how to manage your new stoma by using specially made ostomy pouches, but will be able to lead a normal life.
Like most people, you’d probably be in shock after hearing this. More than 700,000 people in the United States are living with ostomies. Every year, at least 100,000 ostomy surgeries are done, preceded by a conversation much like the one above. So how do patients recover from the shock of learning about their pending surgery—and then return to a full life? (more…)
By Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, WCC, OMS; and Judith LaDonna Burns, LPN, WCC, DFC
About 1 million people in the United States have either temporary or permanent stomas. A stoma is created surgically to divert fecal material or urine in patients with GI or urinary tract diseases or disorders.
A stoma has no sensory nerve endings and is insensitive to pain. Yet several complications can affect it, making accurate assessment crucial. These complications may occur during the immediate postoperative period, within 30 days after surgery, or later. Lifelong assessment by a healthcare provider with knowledge of ostomy surgeries and complications is important. (more…)
By Rosalyn Jordan, RN, BSN, MSc, CWOCN, WCC, and Marci Christian, BBE
Any patient with a fecal or urinary ostomy may experience complications on the skin surface around the stoma. These complications may occur lifelong, although they’re more common during the first 5 years after the initial ostomy surgery. Causative factors include infection, trauma, certain diseases, and chemical irritation; most of these problems stem from the pouching system or pouch leakage.
Peristomal skin complications can cause a wide range of signs and symptoms, from skin discoloration to polyp-like growths, from erythema to full-thickness wounds. They can lead to discomfort, pain, poor self-image, social isolation, and impaired quality of life, not to mention additional care costs.
Incidence and types of these complications are hard to compare or contrast across multiple patients. Until recently, no standardized assessment or documentation tools were available to characterize or define complications. For this reason, reported rates ranged widely, from 10% to 70%. And because no designated common language or categories related to peristomal skin complications existed, documentation was inconsistent.
In the late 2000s, a group of nurses experienced in caring for ostomy patients worked with the World Council of Enterostomal Therapists to develop a resource called the Ostomy Skin Tool, which clinicians can use to categorize and describe peristomal skin complications in a consistent, objective manner. The tool also provides a common language for documentation.
The Ostomy Skin Tool has three major assessment domains—discoloration (D), erosion/ulceration (E), and tissue overgrowth (T), known collectively as DET. The DET combined rating ranges from normal, rated 0, to the worst condition possible, rated 15. Mild DET complications are documented as less than 4, moderate as less than 7, and severe as 8 or higher. (See Using the Ostomy Skin Tool by clicking the PDF icon above.)
The tool describes four categories of peristomal complications:
• chemical irritation
• mechanical trauma
• disease-related complications
• infection-related complications.
Chemical irritation
Chemical irritation can stem from irritants (as in contact dermatitis) or allergic reactions (allergic dermatitis). The most likely cause of chemical dermatitis is effluent leakage (feces or urine) from the colostomy, ileostomy, or urostomy, in which effluent comes in contact with peristomal skin. Other potential causes include contact with soap, certain adhesives, and adhesive removers.
The major treatment of chemical irritation is identification and removal of the offending agent, followed by patient and caregiver education on the new pouching procedure the patient must use. Follow-up assessment also is recommended. In a 2010 study that followed 89 patients for 1 year after ostomy surgery, about 50% of subjects experienced peristomal skin complications, most of them from pouch leakage. Another investigator estimated that 85% of ostomy patients experience pouch leakage at some time during their lives. Pouch leakage usually occurs when stool is extremely liquid (for instance, ileostomy effluent). Other causes of pouch leakage include wearing a pouch more than half full of effluent and abdominal contours that aren’t level. Besides changes in the pouching system, treatment may entail adding products to the pouching system or removing certain agents.
Some patients experience allergic dermatitis in reaction to products used in the pouching system (such as skin barriers, belts, pouch closures, or adhesives). However, allergic dermatitis is rare. One 2010 study suggested allergic reactions to these products occur in only about 0.6% of patients with peristomal skin irritation. Most major ostomy product manufacturers provide a patch test on request to help identify allergic conditions. Once the offending product is discontinued, allergic dermatitis should resolve rapidly.
Mechanical trauma
Mechanical trauma usually results from either the pouching system itself or its removal. It also may result from harsh or multiple skin-barrier removals, pressure from convex rings or pouches, and abrasive cleansing techniques. Some researchers believe the stronger the adhesive barrier and the more often a pouch is changed, the greater the risk of epidermal damage.
Mechanical trauma may present as a partial-thickness ulcer caused by pressure, shear, friction, tearing, or skin stripping. Patients with fragile skin are susceptible to mechanical trauma, so less aggressive pouching systems may be preferred for them. Of course, if the pouching system is changed, the patient or caregiver needs to learn about the new system.
Disease-related complications
Disease-related peristomal complications may be linked to preexisting skin conditions, such as psoriasis, eczema (atopic dermatitis), or seborrheic dermatitis. Hyperplasia also may occur. This overgrowth of cells, which may appear as gray or reddish brown pseudoverrucous lesions, usually is linked to urinary ostomies, although it can occur with fecal ostomies as well. Vinegar soaks are the recommended treatment, in addition to a change in the pouching system and corresponding patient education.
Occasionally, other disease-related complications occur, including primary adenocarcinoma of the peristomal skin and peristomal pyoderma gangrenosum, a painful and problematic condition that presents as peristomal ulcers. Ulcer borders are well-defined with a bluish purple coloration at the edges. Infection must be ruled out, as this condition usually is linked to an autoimmune condition. Treatment includes pain management and, in most cases, a topical corticosteroid. Crohn’s disease also may manifest as a peristomal skin ulcer.
Infection-related complications
Infection-related complications may be bacterial or fungal. Two common peristomal skin infections are folliculitis and Candida fungal infections. An infection of the hair follicle that causes pustules, folliculitis usually stems from traumatic hair pulling in the peristomal area during pouch removal. It may warrant a prescribed antibiotic, along with patient teaching regarding proper hair removal using an electric razor.
Candida infections may arise because peristomal skin provides a warm, dark, moist environment that promotes fungal growth. These infections appear as erythema with pustules or papules and satellite lesions. Treatment usually involves antifungal powder and use of the crusting technique to secure the pouching system. (See Using the crusting technique by clicking the PDF icon above.)
Management
Many complications are well advanced by the time patients seek assistance, perhaps because they don’t understand the significance of their symptoms and think they can manage the problem themselves. In some cases, they don’t know where to turn for assistance. Commonly, the complication progresses to the point where the patient goes to the emergency department or (particularly during the immediate postoperative period) needs to be readmitted for treatment. The best way to manage peristomal skin complications is to prevent them in the first place. (See Preventing peristomal skin complications by clicking the PDF icon above.)
Patient education
Over the past 20 years, hospital stays for ostomy surgery patients have decreased from about 2 weeks to less than 5 days. Reduced stays decrease the time available for caregivers to teach patients and family members how to empty and change the pouch. They need alternative education covering (among other topics) how to recognize peristomal skin complications and when to seek help. Not only do these complications require vigilant self-observation, but many patients don’t understand their implications or how rapidly they can worsen. In some cases, the first symptoms are itching and redness under the skin barrier. Fortunately, some patients may know or remember that itching, burning, stinging, reddened, or weeping peristomal skin requires professional attention. They can avoid serious complications by seeking assistance early, such as right after noticing pouch leakage.
Early treatment can reduce the cost of treatment. In a 2012 study, researchers estimated care costs related to peristomal skin complications for a 7-week treatment period, using the Ostomy Skin Tool as a reference. Severe complications (those with a DET score above 8) cost six times more to treat than mild cases (those with a DET score below 4) and 4.5 times more than moderate cases.
Along with early intervention by a trained ostomy care specialist, self-assessment by ostomy patients promotes a better quality of life, reduces pain, and may decrease care costs. Clinicians’ use of the Ostomy Skin Tool to assess and document peristomal skin complications promotes more reliable, objective, comparable assessment data for reporting.
Selected references
Al-Niaimi F, Lyon CC. Primary adenocarcinoma in peristomal skin: a case study. Ostomy Wound Manage. 2010;56(1):45-7.
Burch J. Management of stoma complications. Nurs Times. 2011;107(45):17-8, 20.
Jemec GB, Martins L, Claessens I, et al. Assessing peristomal skin changes in ostomy patients: validation of the Ostomy Skin Tool. Br J Dermatol. 2011; 164;330-5.
Jones T, Springfield T, Brudwick M, Ladd A. Fecal ostomies: practical management for the home health clinician. Home Healthc Nurse. 2011;29(5):306-17.
Martins L, Samai O, Fernandez A, et al. Maintaining healthy skin around an ostomy: peristomal skin disorders and self-assessment. Gastrointest Nurs. 2011;
9(2):9-13.
Martins L, Tavernelli K, Serrano JLC. Introducing a peristomal skin assessment tool: The Ostomy Skin Tool. World Council Enterostomal Therapists J. 2008;28(2):3-13.
Meisner S, Lehur P, Moran B, et al. Peristomal skin complications are common, expensive, and difficult to manage: a population based cost modeling study. PLoS One. 2012;7(5):e37813.
Omura Y, Yamabe M, Anazawa S. Peristomal skin disorders in patients with intestinal and urinary ostomies: influence of adhesive forces of various hydrocolloid wafer skin barriers. J Wound Ostomy Continence Nurs. 2010;37(3):289-98.
Ratliff CR. Early peristomal skin complications reported by WOC nurses. J Wound Ostomy Continence Nurs. 2010;37(5):505-10.
Shabbir J, Britton DC. Stomal complications: a literature overview. Colorectal Dis. 2010;12(10):958- 64.
Wound, Ostomy, Continence Clinical Practice Ostomy Subcommittee. Peristomal skin complications: Best practice for clinicians. Mt. Laurel, NJ; 2007.
The authors work for RecoverCare, LLC, in Louisville, Kentucky. Rosalyn Jordan is director of clinical education and Marci Christian is a clinical associate product specialist.
