Referral for surgical repair R/T inability to maintain seal. R/T obstructive symptoms or ischemia

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1 Table 2. Stomal & Peristomal Complications Management Approaches: A Descriptive Study Frequency Count and Critical Comments Peristomal Hernia * Hernia Belt Flexible Pouching system: 1,2 piece with flanges or adhesive coupling Cessation of routine stomal irrigation to avoid perforation surgical repair R/T inability to maintain seal surgical repair R/T obstructive symptoms or ischemia (N = 60) *Most successful choice *Requires careful fitting *Does not fix hernia *Question need for pouch opening in belt for established stomas some support lost (N = 51) *Extremely rare to find 2 piece system that works well *Use convexity rarely; sometimes need but mostly do not (N = 69) *Replace irrigation with stool softener/laxative as necessary *Discontinuation of irrigation depends on degree of herniation (N 93) *Last resort as re herniation is high *Almost never done except in bowel obstruction or ischemia or severe pain (N = 46) *Refer immediately Do not wait!

2 Stomal Prolapse Pouching system accommodating full length and width of stoma Flexible pouching system to protect from trauma Avoid 2 piece pouch with rigid flange or use adhesive coupling with flange Apply pouching system with patient flat to reduce stoma Apply cool compress to stoma to reduce stoma size Use wide properly fitted hernia belt with prolapse flap Sprinkle table sugar on stoma to reduce size surgical repair of ischemic or congested stomal prolapse (N = 31) *Use Pam or similar product to prevent intestinal erosion from pressure *Need to remember that one can use irrigation sleeve or modified high volume pouch *May need to use a wound manager (N = 34) *Use moldable technology *Cut radial slits to allow ability to accommodate bowel/stoma changing size *Combine with other products (e.g., Eakin s seal to increase efficiency) (N=61) *Never say never sometimes 2 piece with flange can work *Adhesive coupling without flange is very safe *Look for trauma on underside of stoma (N = 44) *Very helpful *Lay flat for at least 10 minutes *Difficult to do independently (N = 64) *Helps to combine with applied mild pressure to reduce stoma *Sugar works better *Have not used this How long does compress stay on stoma? What is cool? (N = 49) *Only truly beneficial for a colostomate *Patient compliance an issue *Works better with smaller prolapses *Flap works only if prolapse is reducible (N = 96) Not *What is the evidence base for this? *Have never used this technique *Have only heard about it (N = 44) *Emergent; refer quickly *Patients with metastatic tumors may refuse

3 Stomal Necrosis Use of transparent pouching system for direct visualization Use of a 2 piece pouching system for direct visualization debridement of necrotic tissue as necessary Use of a lubricated clear test tube inserted into stoma Application of nitroglycerine (NTG) patch or ointment peristomally surgery revision if necrosis below fascial level (N = 27) *May be upsetting to patient/family All new ostomies get transparent pouch (N = 45) *Allows direct visualization if pouch removed *Sometimes must use transparent one piece due to contours *Allows access to stoma (N = 61) *Surgeons often wait for necrosis to slough off (auto debride) *Usually debrides if tissue stringy or loose (N = 55) *Must use with flashlight *Limited effectiveness reliability (N = 132) *Have never heard of this *Have never tried *Must have provider (MD, APN) order *Evidencebased support? *How much NTG? *For how long? (N = 77) *Refer when necrosis below fascial level *Refer emergently! *Notify surgeon of any stomal necrosis *Sounds physiologically logical

4 Mucocutaneous separation Filling of separated area with absorbent material (calcium alginate, hydrofiber) (N = 40) *Treat as an open wound *Packing strips and rings can work well *Depth is critical: Shallow use powder Deep use hydrofiber or calcium alginate *Use silver rope (e.g., Aquagel Ag) Covering of separated area with skin barrier of pouching system or strips, durable (e.g. Eakin s) or hydrocolloid dressing (N = 39) *Cover open area with skin barrier above and pouch over it *Really depends on width and depth *Moldable barrier rings work most often Cutting skin barrier opening larger to include separation (N = 84) Not *Must cover exposed wound from effluent Changing of pouching system at frequent intervals depending on undermining areas (N = 36) *Frequent change is usually not appropriate *Frequent change compromises surrounding skin *Frequent should not exceed every hours

5 Stomal Retraction Use of pouching system that incorporates a belt (N = 42) *Combine with convexity *Depends on patient body habitus and acceptance Use of a convex pouching system (N = 55) *Can make convexity with durable barrier rings, strip paste *Effectiveness really depends on body habitus *Use convexity first then add belt *Flexible systems may also work surgical revision if alternate interventions unsuccessful (N = 45) *Usually last resort *Oval appliance or wafer may help *Only refer if stoma is permanent; If temporary stoma, use pouching strategies

6 Stomal Stenosis Use of a low residue (low roughage) diet for fecal ostomies Use of stool softeners for fecal colostomies Increase liquid intake if medically appropriate Use of gentle stomal dilation by physician or trained WOC nurse surgical revision if stomal output obstructed (N = 25) *Can work temporarily *Use only soluble fiber *Low roughage helps to prevent blockage (N = 16) *Usually associated with narcotic use (N = 11) *Can help but must watch intake and output (N = 53) *Helps in short term but not long term *Usually physician/apn does this *In some instances we teach patient to do at appliance change (N = 25) *If no output, then this is emergency referral *If no output for 4 6 hours, instruct go to emergency room

7 Stomal Fistulas surgical revision Use of NPWT to close fistula Use of a pouching system that incorporates both stoma and fistula Use of a pouching system incorporating convexity (N = 52) *Refer only if unmanageable *Referral depends on severity *Usually last resort can refistulize (N = 97) *No experience *Research based? *Fistula needs to be explored first before NPWT (Must know source) (N = 40) *Wound manager of fistula pouch is best *Really depends on location (N = 98) *Has potential to worsen fistula *Use depends on many factors: fistula location, profile *Use with many caveats: Location, output, patient s condition

8 Stomal Trauma Identify and eliminate causative factor(s) Manage bleeding with direct pressure, cool compress No specific topical therapy Observation of traumatized area using transparent pouch (N = 20) *Most common cause of trauma is pouching system (pouch or skin barrier) (N = 43) *Can also use calcium alginate, gelfoam, skin barrier powder *Silver nitrate is effective (N = 54) *For superficial temporary bleeding only *If more prolonged bleeding, may need more active therapies: Silver nitrate, gelfoam, topical thrombin, powder (N = 26) *Two piece pouching system better: Allows visualization and intervention

9 Peristomal Varices Remove pouching system gently and less frequently Managing of underlying etiology per referral Avoiding of 2 piece system with hard flange/faceplate Avoidance of snug clothing Achieve hemostasis with direct pressure Achieve hemostasis with silver nitrate cauterization Achieve hemostasis with epinephrine gauze soaked Achieve hemostasis with calcium alginate dressing and direct pressure injection sclerotherapy (N = 22) *May need to use adhesive remover *May need to switch to soft flexible barrier (N = 20) *Would be for information only usually end stages liver disease or kidney disease (N = 30) *Can use 2 piece pouching system but must have low pressure adaptor to avoid pressing on abdomen *Avoid any firm pouching system (N = 48) *Makes sense but what is snug? (N = 26) *Most common approach used *Teach patient to go to emergency room if bleeding continues (N = 55) *Can use gelfoam, skin barrier powder *Only use silver nitrate if direct pressure is unsuccessful (N = 89) *Haven t used *Haven t heard of this *No experience *Sounds appropriate (N = 32) *Works great *Amount of bleeding affects effectiveness *No experience (N = 72) *No experience *Haven t heard of it *Works in bad patients

10 Peristomal Candidiasis Drying skin thoroughly before pouching system application (N = 12) *Can also use hair dryer on cool setting Use of topical antifungal powder or proparadon that will not decrease adhesive (N = 34) *Best to dab antifungal powder with non sting liquid skin barrier *Silver powder works well *Combine with barrier powder Applying correctly fitted pouching system with good seal (N = 11) *Change system twice weekly trying to stretch wear time increases leaks Ordering or requesting order for oral antifungal (e.g., Fluconazole) (N = 85) *Only if candidiasis is severe or disseminated *Use topical first; if ineffective, then oral therapy *Need to check for allergies/drug interactions Applying pouch cover or pouch with fabric packing to decrease moisture (N = 27) *Only necessary if Candida beyond edges of *Teach to use methods to decrease moisture (e.g., Hair dryer, Interdry Ag) Cleansing of peristomal skin with antifungal skin cleanser (N = 75) *Not experienced with this *Not aware of any antifungal cleansers *Bathe with vinegar solution 5 10%

11 Peristomal Folliculitis Reduce frequency of shaving and use only a clean razor (N = 34) *Use electric razor *Shave in direction of hair growth *Some suggest depilatory cream Recommend electric clipping of hair (N = 23) *Use electric clipper/shaver *Some patients use stoma powder for dry shave Gently remove skin barrier adhesive (N = 16) *Use adhesive remover and rinse off Use of antibacterial soap at pouch change with rinsing (N = 38) *Emphasize rinsing with warm water *May increase dryness and irritation *Regular soap with drying of moisture is adequate

12 Mucosal Transplantation Application of silver nitrate to cauterize mucosal buds (N = 33) *No experience *Not effective *Need provider order *Does not cure the buds permanently surgical excision of transplanted mucosa (N = 60) *Only for extreme cases *Not seen / Not done *Only if silver nitrate does not work re sizing of stoma (N = 69) *Only as last resort for extreme cases *Defer if condition worsens or is unresolved with cauterization

13 Pseudoverrucous Lesions Cut opening to hug stoma Change skin barrier at first signs of erosion Application of silver nitrate to large wartlike lesions Acidification of urine via cranberry juice or tablets, vitamin C tablets, and increased fluid intake (if a urostomy) Application of vinegar soaks to wart like lesions at pouch change (urostomy) Use of acidic (e.g., Colly seal) Use of a convex pouching system to prevent welling of urine (urostomy) Using expanded wear vs. standard barrier (N = 34) *Use moldable system to hug stomas *Use durable seals *Use moldable rings (N = 13) *Increase frequency of pouch change to three times weekly *Use extended (N = 42) *Never use silver nitrate *Use vinegar (acetic acid) soaks for 10 minutes with pouch change *Use Colly seals (acetic acid rings) *Remove moisture (N = 28) *Evidencebased? *Cranberry juice not appropriate *Increased fluid intake very helpful (N = 27) *Prefer using Colly seal *What strength of vinegar? (N = 48) *Not familiar *I haven t used *Best approach (N = 32) *Better to use flat wafer with skin barrier ring or strip paste *Use pouch with antireflux valve *Only need convexity with flat urostomy (N = 19) *Extended barrier should be on all urostomy patients *Must educate about frequency of pouch change

14 Peristomal Pyoderma Gangrenosum Decreasing inflammatory process utilizing topical steroid preparation (spray, paste) decreasing inflammatory process by use of topical immunomodulators (e.g., Tacrolimus) or local Injection (e.g., steroids) administration of systemic medical therapy (e.g., prednisone, cyclosporine, dapsone, infliximab) Application of powder to ulcers Application of silver powder to ulcers Application of foam dressing over ulcers Filling ulcers loosely with hydrofiber or calcium alginate dressing Application of topical anesthetic preparation for pain control Use of biopsy to confirm diagnosis of PG (N = 30) *Use Kenalog spray *Hydrofera Blue foam works great *No paste or gels pouch will not adhere (N = 24) *Have not seen *Have not tried *Use steroid nasal spray (Flonase) works great (N = 20) *If topicals are not effective *Usually referral to physician and/or dermatology *Have no experience (N = 35) *Depends on size of ulcers *Hydrofera Blue works very well *Hydrofiber over tacrolimus works well (N = 41) *Have not used *Hydrofera Blue works better Not Routinely (N = 28) *Gets too damp Hydrofera Blue is better *Silver foam helps work better (N = 28) *Have not used *Usually combine with silver Hydrofera Blue is better (N = 28) *Not tried *EMLA cream *Lidoderm *Lidocaine 2% (N = 65) *Not usually used *Very important *Controversial *Usually for rule out *Biopsy usually for diagnostic

15 Peristomal Suture Granulomas removal of visible suture material (N = 35) *No experience *Will remove suture myself if visible Application of silver nitrate to remove excess tissue (N = 22) * *Usually MD/APN practice level *No experience electric cauterization to remove excess tissue (N = 50) *Rarely needed *Have not used *Never seen *Only if severely problematic

16 Peristomal Irritant Contact Dermatitis Identification and correction of etiologies of skin/ effluent/chemical contact (N = 8) *Most important Use of an extended wear barrier with liquid effluent (e.g., ileostomy, urostomy) (N = 12) *Standard of care *Must address frequency of wafer change Application of topical antiinflammatory product at pouch changes (N = 57) *Not routinely needed; first treat etiology *First correct size opening *Use for limited time only *More appropriate for allergic contact dermatitis Application of light dusting of powder (N = 30) *Use barrier powder with non alcohol liquid skin prep *Use with crusting technique *Best for moist weeping tissue Application of nonalcohol based film (N = 28) *Use with powder *Use crusting technique *Better to use a cyano acrylate like Marathon

17 Peristomal Allergic Contact Dermatitis Identification of and discontinuing of the offending product or agent Application of topical antiinflammatory sprays or products patch testing to determine allergies Application of nonadhesive pouching system Introduction of new ostomy product/agents one at a time (N = 12) *Patch testing is best approach (N = 36) *No creams or ointments *Use Kenalog spray *Use Burow s solution *If severe may need oral steroid (N = 54) *Patch testing done by WOC Nurse in ostomy clinic no referral needed *Can try piece of skin barrier on arm to test reaction (N = 60) *First change to another company s pouching system *Usually for severe cases only *Last resort (N = 12) * *Have patient demonstrate their self care too

18 Peristomal Trauma Identification and elimination of the cause of the trauma (N = 5) * *Careful history can trace back offending cause Applying nonalcohol based film to injured area (N = 20) *Treat area with skin barrier powder first *Cyanoacrylate (e.g., Marathon) better than other liquid s Sprinkling the injured area with skin barrier powder and cover with a thin hydrocolloid (N = 36) * *Use solid barrier wafer or skin barrier washer *Hydrocolloid not as good as extended wear skin barriers (e.g., Eakins) N.B. Bold in comments signifies multiple uses of word * Frequency counts per intervention do not sum to 281; Multiple comments made by each respondent.

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