Peristomal Skin Complications - Northeast Surgical Wound Care

Peristomal Skin Complications - Northeast Surgical Wound Care

By Paula Erwin-Toth, MSN, RN, CWOCN, CNS,
Linda J. Stricker, MSNjED,
WIse
RN, CWOCN, and
Lia van Rijswijk,
RN, MSN, CWCN
Peristomal Skin Complications
Successful treatment can mean
a successful
ostomy.
ination of urine or fecal material can
have a profound effect on the quality of
patients' lives. In patients who experiand stomas
that allowcomplicathe elimence stomal
or peristomal
tions, these effects can be severe.',2 Clinicians playa
crucial role in preventing these complications and in
improving stoma or ostomy patients' quality of life.
One study involving 3,042 stoma patients in Europe
found that although patients' scores on quality-oflife measures improved after hospital discharge, those
who were satisfied with the care they'd received had
higher scores on the Stoma Quality of Life Index
than those who weren't satisfied.'
Peristomal skin conditions are a common complication in patients with stomas. Depending on the
stoma type, rates of peristomal skin problems of
between 30% and 60% have been reported.4-6 The
prevention and management of alterations in peristomal skin integrity offer unique challenges for clinicians and patients. An overview of peristomal skin
complications can be beneficial to nurses caring for
such patients.
Ostomies
CLINICAL CONSIDERATIONS
Successful rehabilitation in people with ostomies is
dependent on a secure, reliable, and odor-proof
pouching system, with containment of effluent. The
system's security is dependent on healthy peristomal
skin and a well-fitted pouch. When either of these
two factors is impaired, nursing care involves interventions that address the underlying causes and create an environment for healing. The combination of
a leaking pouch and peristomal skin conditions can
challenge even the most experienced nurse.
Selection of the pouching system occurs after surgery, and is based on the type of stoma, the patient's
lifestyle, and the patient's abdominal contours.7,8
Postoperatively, mucosal edema diminishes and the
contour of the abdomen usually changes. A pouching system that no longer fits properly can leak,
exposing the peristomal skin to urine or bowel contents and damaging the epidermis.
The importance of skin integrity. Ideally, peristomal skin will look as healthy as any tissue on the
body (such as on the other side of the abdomen);
ioe.com
ajn@waltetskfuwer.cam
likewise, alterations in peristomal skin integrity, such
as infection, can demonstrate classic clinical patterns
of skin conditions seen elsewhere on the body.9, 10
The principles of wound care apply to managing
peristomal skin conditions, which begins with assessment: lesion size, drainage, the presence of devitalized tissue, the condition of the adjacent skin, and
underlying problems associated with the wound.
Nurses must make a careful
accounting of factors within the
patient, such as comorbid conditions,
that can affect healing.
Options for the care of peristomal skin conditions
often involve the use of skin barrier powder and
appropriate wound-care products. Nurses should
also consider how well the pouching system works
for the patient and modification of the pouching
system to help heal the skin lesion.
COMMON
PERISTOMAL
SKIN CONDITIONS
Regardless of stoma type, one skin complication
predisposes patients to concurrent (secondary) peristomal skin issues. The challenge is to determine the
causative factors (see Table 1'0-14). The Cleveland
Clinic stoma registry data (see The Cleveland Clinic
Stoma Registry) and the literature indicate that
most peristomal skin conditions fall into the following general etiologic categories: chemical, infectious,
mechanical, immunologic, and disease related. The
most common conditions are irritant dermatitis,
mechanical trauma, and candidiasis.9-11,15, 16Other
stomal irregularities associated with peristomal skin
problems include the stoma being flush with surrounding skin, a parastomal hernia, and improper
sizing of the pouch aperture. In addition, problems
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,ill
Table
1.
Common Peristomal Skin Conditions
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CLASSIFICATION
CAUSATION
CHARACTERISTICS
TREATMENT
Usually associated with exposure of skin to intestinal effiuent,
Area appears red, moist, and
Product usage and techniques
are reviewed to determine
~
Irritant dermatitis
adhesives from the pouching
system, skin barrier paste,
cleansers, or solvents that
painful; may be localized to
a specific area of leaking or
where the pouch is undermined.
the cause. Pouching system
is revised and refitted
where indicated.
undermine the pouch seal.
Pseudoverrucous lesions
Usually seen with urinary
diversions, these are over-
Irritation leads over time to
First modify the pouching
hyperkeratosis (thickening of
growths of tissue caused by
exposure of skin to an irritant.
outermost layer of epidermis)
system to fit the stoma and
abdominal contours. Some
and acanthosis (thickening of
prickle cell layer of the skin)"
These wart-like lesions bleed
skin barriers melt down rapidly
when exposed to watery
effluent. An extended-wear
easily and are localized to
the area of chronic exposure;
usually gray, white, or reddish
skin barrier provides extra
Alkaline urine, which may
indicate concentrated urine
or bacterial proliferation
(or both!, increases risk
of lesion development."
brown and painful.
protection. "Wear time" of
the pouching system must
be discussed, as patients
with these lesions often don't
change the system frequently
enough. Surgical revision may
be needed. For small, shallow
ulcers, dusting the area with a
skin barrier powder then blotting it with a nonstinging skin
barrier before pouch application provides a healing environment that doesn't interfere
with the pouch seal.
Warm, moist areas create
an environment conducive to
Candidiasis
Candida fungus growth of
Presents as moist or wet
denuded areas with pustules
under the pouching system.
sufficient magnitude to cause
inflommation in the peristomal
skin." Certain conditions or
center and a group of satellite
lesions with an advancing
events predispose patients to
border. Untreated, pustules
candidiasis,
including diabetes
mellitus, immunosuppression,
antibiotic
use, anemia,
surgery,
obesity, increased perspiration,
and leakage under the pouch-
Hallmarks are a bright red
First use a topical antifungal
agent and create a dry environment under the pouching
system. Antifungal powders
work well under pouching
systems and don't interfere
with the pouch seal. Instruct
can coalesce into plaques
potients to thoroughly cleanse
with dry, scaly, or weepy skin.
Patients report pruritus and
and dry the skin during pouch
changes, refit pouching systems that don't work, and
add skin sealants or rol~n
burning or stinging sensations.
ing system.
antiperspirants
if moisture
continues to be a problem
and skin barrier powder
to treat denuded skin.
Cellulitis
The most common cellulitis-
Serious infection affecting the
Because cellulitis involves
causing bacteria are group A
streptococci. Skin normally
deepest or subcutaneous layer
deeper layers of the skin,
of skin, cellulitis of peristomal
patient is at risk for sepsis.
provides an effective barrier to
bacterial pathogen invasion,
but laceration or ulceration of
skin is characterized byerythema, induration, warmth,
Involve primary care physician
in plan of care. Treatment
edema, and intense localized
peristomal skin can leave
pain. Patient may report fever
and chills.
options include revision of
pouching system where indicated and local skin and
exposed lower layers of skin
at risk for cellulitis infection.
wound care with appropriate
dressing. Systemic IV antibiotics
are required in more severe
cases, otherwise oral antimicrobials may suffice. Incision
and drainage
be needed.
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CLASSIFICATION
Folliculitis
CAUSATION
CHARACTERISTICS
TREATMENT
Usually results from traumatic
Hair follicles are inflamed;
Skin barrier powder, aerosol
hair removal during pouch
lesions are painful and moist.
Erythema as pinpoint pustules
antiinflammatory
change, followed by infectious
process; infectious micro-
11
organism is most often
Staphylococcus aureus.
II
product, and
topical antimicrobial powder
as needed for local skin care.
or papules localized at the
hair follicles and pruritus may
Once area is healed, it should
be seen. Patients usually have
be carefully shaved. Use of
adhesive remover and skin
sealant is advised. Review
history of aggressive pouch
removal or shoving the peristarnal skin too frequently, too
closely, or dry.
skin care techniques specific
to the person's needs, reinstruct in safe pouch removal,
and modify pouching system
where indicated.
e
'pidly
'n't
ntly
May be related to acidic
effluent from stoma, undue
Separation of suture line at
Interventions include initial and
junction of stomal mucosa and
tension on suture line, inappropriate pouch system, or pouch
skin. May be superficial or
deep, partial or circumferen-
ongoing assessments-noting
the extent of the problem,
overfilling (causing pulling
on the area). 11 Patients who
tial. When surgeon constructs
the stoma, stoma mucosa is
have diabetes mellitus, are
sutured to subcuticular layer
of skin within the dermis.
and
When this suture line is com-
and the amount of drainage)gentle cleansing, and revision
immunocompromised,
may
dlow
or have
poor visceral protein stores
are at heightened risk.
·ith a
blot-
promised, gap can be seen
belween stoma and adjacent
skin. Problem can involve partial or full thickness tissue loss
skin
licawi-
and encompass part or all of
;ere
mucocutaneous
junction. II
including "prob[ing] the area
of separation to determine
the depth (shallow or deep)
circumference,"13
the pres-
ence of any necrotic tissue,
of the pouching system. Partialthickness separation can be
managed with skin barrier
powder, whereas full-thickness
separation requires an appropriate wound care product,
such as calcium alginate or
hydrofiber with or without silver. To help prevent retraction
of stoma below skin level, mon-
)01
1vi-
ng
rs
itor healing process carefully
and consider addition of con-
e
vexily to the pouching system,
as in an oulwardly rounded
Ict
barrier ring that adds pressure
to skin around the stoma. Scar
tissue can also cause stricture
Jnse
ouch
IS-
(narrowing) of the stoma, which
n
requires consultation far proper
pouch fitting and, sometimes,
surgical revision.
External item or force causes
damage to the stoma ar skin,
Pressure ulcers can involve partial- or full-thickness tissue loss,
Assess the pouching system
for needed revisions, and the
or both, from compression,
laceration, friction, shear, or
lacerations, denuded skin, and
pain, and can lead to cellulitis.
patient's technique for needed
stripping of the epidermis.
Contributing
;ician
factors include
include skin barrier powder
parastomal hernia, weight
gain, or a prolapsed stoma.
for partial-thickness ulcers or
selected wound-care products,
such as calcium alginate or
f
Idi-
hydrofiber with or without silver (with a secondary dressing) to fill the wound and
iate
,iotics
maintain a healing environment without interfering with
~re
mi~
the pouching system, for fullthickness ulcers.
ion
'ins. com
education. Treatment is dependent on ulcer size and can
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CAUSATION
CLASSIFICATION
Mucosal transplantation
(also known as mucosal implants)
Transplantation
of intestinal
epithelial cells into the epidermis during stoma creation; the
needle is brought up through
CHARACTERISTICS
TREATMENT
Small patches of moist, red
mucosal tissue, scattered
Dust islets with skin barrier
around the peri stomal area,
change to absorb moisture
flush with the peristomal skin"
and support an intact pouch
seal. Physician may cauterize
powder with every pouch
all the skin layers, picking up
mucus membrane from the
using silver nitrate or electric
intestinal mucosa and "seeding"
the mucosal tissue into the
cautery. May necessitate more
epidermis (can be avoided by
suturing the bowel mucosa to
changes and increasing pouch
frequent pouching system
aperture to allow islets to be in
opening. Exposed skin should
then be protected with a non-
the subcuticular layer of skin).
water soluble skin product,
such as barrier wipes.
Sensitivity to a specific product
or part of the pouching system,
which causes an inflammatory
Remove the allergen, avoid
Clinical features include erythema; edema; and eroded,
other irritants, and protect the
skin. Modern ostomy products
are designed to be hypoaller-
response seen in the peristomal skin. The initial exposure
weepy, sometimes bleeding
skin with pruritus, stinging,
and burning sensations.
to the allergen causes an
Persistent erythema usually cor-
immune response, which trig-
responds ta the area of skin in
gers the release of antibodies
contact with the specific product. Transient erythema occurs
normally with pouch removal
and is self-limited; it shouldn't
upon subsequent contact with
the allergen.
be confused with persistent
genic. Treatment is aimed at
removing the irritating agent
and using a different pouching
system. Patch testing alternative products can help identify
what the patient can tolerate.
Refer to dermatology if there
are multiple allergies.
allergic contact dermatitis.
Repetitive removal of a pouch-
Presenting clinical features
Treatment varies and includes
ing system can precipitate the
include a localized prolifera-
appearance of psoriasis in
peristomal skin." Its cause
remains unknown but is
tion of the epidermis, with
topical corticosteroids to treat
the immune response, coal tar
believed to have a genetic
component.
discrete erythematous papules
and plaque covered by silvery
white scales, adjacent to the
stoma; interferes with a secure
preparations to reduce proliferation of epidermal cells,
pouching system. Symptoms
can intensify in the immuno-
photosensitizing
antimitotic drugs to reduce
epidermal-cell
replication, or
medications
coupled with ultraviolet light.
May necessitate use of a non-
suppressed.
adherent pouching system to
facilitate the use of topical
medications or skin barriers.
Apply pressure, use hemostatic
agents (such as silver nitrate),
In patients with portal hyper-
Disease involving the liver can
tension, pressure at the portal
cause high venous pressure in
systemic shunt in the muco-
the hepatic mesentery, causing
blood to back up into veins
or both. Cautery or surgical
around the peri stomal skinw.
This produces a bluish-purple
discoloration in the skin and
Remove pouch corefully. Avoid
skin barriers with an aggressive seal. If stoma is relocated,
distended superficial veins.
Profuse bleeding can occur.
varices will eventually recur
around the new stoma unless
cutaneous
junction
increases,
creating venous engorgement.
Ii
11
ligation may be necessary.
underlying liver disease is
treated.
Pyoderma gangrenosum
A rare, chronic inflammatory
disease process thought to be
caused by an altered immune
responseu The condition is
associated with inflammatory
bowel diseases, such as
Crohn's disease and ulcerative
Characterized by welldemarcated red ulcerations
with irregular purplish margins
Management involves systemic
treatment of underlying
disease, including the use of
and purulent-to-sanguineous
drainage. Patients may
systemic and topical corticosteroids, sulfonamides, or
describe the pain associated
immunomodulators. Nursing
care of the ulcers starts with
with this condition as exquisite.
colitis, and arthritis, leukemia,
pain management and main-
polycythemia vera, and multi-
taining a moist wound environment. A reliable pouch seal is
ple myeloma.
crucial to prevent effluent from
leaking into the ulcers.
46
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can arise from improper use or amount of convexity (the use of a barrier ring that's rounded toward
the abdomen [convex], in order to provide support
to the stoma, preventing it from lying flush with
the skin or retracting); convexity is also used "when
deep or uneven topography is evident in the peristomal area" or "when stoma shape and size are variable" (or when both occur).17
A HOLISTIC APPROACH
TO CARE
A holistic approach, by definition, considers the
patient as a whole system. Wound, ostomy, and
continence nurses take a holistic view of the patient
when determining the best approach to wound
management.
The PET model of ostomy care, created by and
named for one of us (PET), involves four elements:
assessment of the patient's intrinsic environment, assessment of the patient's extrinsic environment, topical wound care, and a complete plan of care based
on all of these factors.
Assessment of the intrinsic environment. Intrinsic
in this context means originating within the body.
Nurses must make a careful accounting of factors
within the patient, such as comorbid conditions, that
can affect healing. For example, uncontrolled diabetes can lead to peripheral vascular disease, coronary artery disease, and even tissue ischemia. And
lower-extremity venous insufficiency interferes with
the return of venous blood to the heart, which can
lead to pooling of blood in the ankle and calf area
of the affected leg.
Skin damage can have many possible causes. Radiation, for example, is a conventional treatment
for some types of cancer, but it can also damage skin
cells in the adjacent area. That damage can extend
deep into the cells' nuclei and reach DNA, changing the cells' physiology and leading to the loss of
sebaceous glands, a loss of elasticity with atrophy,
and discoloration.9, 15,18
Bacterial, fungal, and viral organisms can overcome the body's immune system and manifest as
skin complications (a fungal rash within skin folds,
for instance) or impair the wound-healing process.
The important part in this phase of assessment is to
recognize when an infection is present and to treat
it according to organism type.
Skin and wounds require adequate perfusion
and nutrition for normal physiologic maintenance
and tissue repair. Wounds complicated by perfusion
problems can become devitalized and develop nonviable or necrotic tissue. Patients who have poor
nutritional reserves are likely to have delayed healing times. A patient with delayed wound healing
must be assessed for adequate perfusion and nutritional stores.
Another intrinsic factor to consider is the medications the patient is taking. Antiinflammatory agents
ain@wo/terskluwer.com
The Cleveland Clinic Stoma Registry
A snapshot of stoma care and complications.
The
registry with
was ostomies
established
in 1998
to at
gather
prospective
datastoma
on patients
receiving
care
the Cleveland
Clinic's main campus hospital and ambulatory care clinic. When
registered patients return to the hospital or ambulatory care clinic,
an ostomy- or surgical-event form is completed. This indicates an
interaction with the wound, ostomy, and continence nurse (formerly
known as the enterostomal therapy nurse), the surgeon, or both. As
of April 2009 the registry had 10,643 enrolled patients, and since
1998, 21,406 ostomy-event forms and 8,768 surgical-event forms
had been entered into the registry.
The majority (62%) of patients in the registry had an ileostomy. Of
those, more than half were of the temporary loop variety, constructed
to provide proximal diversion to protect a distal anastomosis, primarily an ileal pouch-anal anastomosis (IPM). {Although some centers
only use temporary loop ileostomy in patients at high risk for anastomotic leak, other centers use more-specifically defined criteria to determine the appropriateness of a one-step IPM. Patients who are on
immunosuppressive therapy, are diabetic, have aging sphincters, or
are morbidly obese have a higher risk of postoperative complications,
which may preclude them from receiving a one-step IPM.'9,20
Two percent of the procedures were loop-end ileostomies; unlike a
loop ileostomy, which leads to the distal part of the intestine, a loopend ileostomy ends up at a blind end. Among procedures in the registry, end descending colostomies constituted 13%; end or loop-end
urinary conduits, 9%; and continent ileostomies, loop transverse colostomies, and end sigmoid colostomies approximately 2%. A variety of
other stoma types made Lip the remainder.
Frequency of peristomal skin complications. The most common type of peristomal skin complication listed in the Cleveland Clinic
registry, accounting for 26% of ostomy visits, was irritant dermatitis
resulting from chemical destruction of the skin from effluent. Other skin
complications, appearing at lower rates (4% to 6% of visits), include
pseudoverrucous lesions, candidiasis, allergic contact dermatitis, mechanical trauma, and folliculitis. Stoma complications encountered and
documented, also infrequently, include peristomal ulcers, parastomal
hernias, mucocutaneous separations, and stoma retractions.
and chemotherapeutic agents in particular can interfere with tissue repair because they have an effect
on the wound-healing cascade.lO, 11,13
Finally, nurses must consider the impact of aging
and the effects of stress. As part of the normal aging process, the immune system's protective ability
starts to diminish. Skin repair is slowed, and there's
a greater risk of chronic illness. As the nurse develops a plan of care to manage the wound, optimizing
all internal factors will provide the best chance for
successful healing.
Assessment of the extrinsic environment. Extrinsic in this context means outside factors that have an
effect on the whole. One person may be affected by
many extrinsic factors, but these will affect each
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person differently. The wound, ostomy, and continence nurse needs to consider outside factors that
are significant to the patient's situation. Environmental factors are a priority-management issue. For
example, what are the environmental considerations
if the patient has a pressure ulcer?
• Do the patient's pouching system and accessory
products fall within Centers for Medicare and
Medicaid Services guidelines for ostomy supplies?
If not, why?
'
• What support surface will offer the optimal pressure redistribution and be covered by the payer?
• What if the patient has no insurance?
• How can we offer the patient safe and effective
care while working within organizational policies, predetermined insurance coverage, and the
'patient's own concerns?
To answer these questions, one must take a carefullook at the individual patient and make sure to
include the appropriate interdisciplinary team members in the care-planning process.
Functional deficits are also an important consideration. Say the patient has both pressure ulcers and
ambulatory problems. Treatment will require more
than simply adding a support surface to the bed.
Think about how activities of daily living, such as
transferring, affect the wound.
• Does the patient require a seating device in addition to a specialized bed?
• How will transfers from one department or facility to another be accomplished?
• What type of repositioning schedule will meet
the needs of the patient and be realistic for the
caregivers?
Topical wound care. The selection of a specific
wound treatment can be daunting if the nurse's assessment is incomplete. Treatment isn't based merely
on the depth of tissue injury; rather, it's based on
• a sound understanding of how wounds heal.
• how different categories of wound-care products
work.
• a thorough' assessment of the wound.
• management of intrinsic and extrinsic factors.
Simply put, the dressing is selected in the context
of creating the optimal environment for healing.
Plan of care. The nursing process involves assessment, planning, implementation, documentation,
evaluation, and reassessment. Its goal is to alleviate,
minimize, or prevent actual or possible problems.
And it can be applied in any interaction that involves
a nurse and a patient and in a variety of settings,
including a hospital, the community, a private home,
or a long-term care facility. T
Paula Erwin-Toth is the director, and Linda]. Stricker is the
assistant director, of wound, ostomy, and continence nursing
education at the Cleveland Clinic, Cleveland, OH. Lia van
Rijswijk is a lecturer at Holy Family University School of
Nursing and Allied Health Professions and an adjunct assistant
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professor at La Salle University School of Nursing and
Health Sciences, both in Philadelphia, the clinical editor of
Ostomy Wound Management, and the coordinator of Wound
Wise: lvanrijswijk@holyfamily.edu.
Contact author: Paula
Erwin- Toth, erwinp@ccforg.
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