9/10/2018. No financial or off label use disclosures. 1. Describe skin problems for an ostomate and interventions for management

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1 Debra Netsch DNP,APRN,FNP-BC,CWOCN-AP,CFCN WEB WOC Nurse Education Programs: Co-Director & Faculty Ridgeview Medical Center, Wound & Hyperbaric Clinic: NP & CWOCN-AP JWOCN: Clinical Challenges Section Editor No financial or off label use disclosures. 1. Describe skin problems for an ostomate and interventions for management 2. Discuss stomal and peristomal complications management techniques 3. Identify techniques when dealing with a fistula 4. Review different crusting procedure 1

2 Pouching difficulties causes Stoma complications Peristomal complications Topography Top 5 peristomal skin irritation (76%) pouch leakage (62%) odor (59%) reduction in previously enjoyed activities (54%) depression/anxiety (53%) (Richbourg, Thorpe, Rapp. JWOCN 2007: Jan-Feb;34(1):70-9) 20% who experienced difficulties after surgery did not seek help. (Richbourg, Thorpe, Rapp. JWOCN 2007: Jan-Feb;34(1):70-9) 2

3 Most common first couple of weeks postoperative Complications may occur 5 to 10 years later Approximately 20% of patients will require surgical intervention Early : Necrosis Mucocutaneous Junction Separation Late: Parastomal Hernia Prolapse Stenosis Retraction 3

4 Construction of ideal stoma In Ostomies and Continent Diversions: Nursing Management, Hampton, B and Bryant, R eds.,1992, Mosby Preoperative stoma site marking can prevent the majority of stoma complications Good surgical technique Normal BMI Optimize co-morbid disease processes 4

5 defined as a healthy stoma becoming black or dark purple resulting in mucosal death 5

6 incidence 12% to 22% fecal stomas usually within the first 24 hours may skip areas most frequent occurrence in end stoma least frequent occurrence in loop stomas avoid confusion with melanosis coli skeletonization of bowel excessive mesentery tension higher adipose (BMI) end sigmoid colostomy higher risk especially if created for diagnosis of cancer Delayed necrosis: colitis: radiation, ischemic, pseudomembranous surgical technique obese patients lose weight if feasible optimize oxygenation & blood supply 6

7 may occur at different depths (above or extend below fascia) Folkedahl evaluation of extent of necrosis observation if above fascia level superficial debridement Folkedahl Folkedahl Folkedahl Pouching system properly sized to accommodate odor control teach the patient what to expect 7

8 emergent surgery if extends below fascia level Folkedahl stenosis and/or retraction of stoma mucocutaneous junction separation perforation and peritonitis serositis Folkedahl Folkedahl 8

9 defect created by interruption of suture approximation of stoma mucosa to skin early complication induration and/or erythema may be early indicators may be limited area or circumferential fistula formation may occur 9

10 excessive tension on mucocutaneous suture line systemic factors that delay wound healing surgical defect is created too large stoma necrosis involving mucocutaneous junction decreased tension on sutures improve preoperative nutritional status correction of factors interfering with wound healing preoperative weight loss if feasible fill separation with absorptive material correction of systemic factors interfering with wound healing 10

11 Silicone foams Skin barriers Stoma stenosis at skin level Stoma retraction 11

12 narrowing of stoma lumen at fascia or skin level 4% of all stoma types may interfere with output stool ribbon formation large amounts of residual urine in conduit with projectile urine 12

13 infection improper sizing of fascia or skin as stoma constructed scar formation (necrosis, mucocutaneous junction separation) recurrent forceful dilatations of stoma prior irradiation alkaline urine if urostomy excessive weight gain inadequate amount of bowel mobilization disease processes pseudoverrucous lesions 13

14 weight loss prior to surgery proper fitting of pouching system treatment of disease processes avoid excessive weight gain implement measures to keep stools soft low residue diet gentle dilatation (controversial) local surgical correction with fasciotomy and stoma refashioned surgical revision/reconstruction Erythemic area which may be intact, weepy or with shallow ulcerations Causation: Exposure to effluent Exposure to allergan Management: Correct pouching system Remove allergan Absorb moisture until healed 14

15 Epidermis of the peristomal skin is thickened with discoloration being silvery gray, brown, or red. Wartlike papules or nodules are present. Causation: Exposure to effluent Management: Correct pouching system Silver nitrate Surgical debridement At risk: Poor abdominal musculature Too large fascial opening Edematous bowel Heavy lifting Treatment: Surgical repair Management: Hernia belt Hernia belts Keep hernia reduced when standing. Some with prolapse belt others without 15

16 An ulceration which occurs with the use of rigid barrier with a firm abdomen. Causative Factors: Too rigid of convexity Treatment: More flexible convexity Absorptive wound dressing with secondary dressing for pouching. Violaceous borders with painful ulcerations. Frequently with increased bacterial load. Causative Factors: Inflammatory Bowel Disease Cancers (Multiple myeloma) Unknown Treatment: Systemic steroids Topical steroids Treat disease process Antimicrobial, atraumatic dressings A peristomal or stomal ulcer beginning with an inflammatory appearance which rarely may lead to a fistula, when Crohn s is present. Causative Factors: Crohn s disease Treatment: Treat Crohn disease Atraumatic pouching system 16

17 Creases Folds Morbid Obesity 17

18 One complication can lead to another complication Preoperative marking can reduce complications Decrease or have a normal BMI to prevent complications Selection of a surgeon with good surgical technique will reduce complications 18