Ostomy care: Pouching System, products and accessories

Peristomal breakdown is common incidence ranges from 29%-63%, a recent study shows that they account for over 30% of outpatient visits.

Peristomal skin is subject to mechanical threats including abrasions, pressure injury and repeated removal of adhesive products.

Most harmful threat is the effluent coming from the stoma.

Proper stoma location, and ensuring proper fit of ostomy products is the most important intervention in preventing skin breakdown.

WOCN should ensure they adequately educate patients post-operatively so that they are capable of taking proper care of their stomas and peristomal skin.

  1. Patient history- know your patient!
  2. What pouching systems and products are being used?
  3. Assess pouching system in place- security, areas of leakage, tension
  4. Assess peristomal skin in good lighting.
  5. Assess the stomal mucosa.
  6. Measure any present wounds, rash, take pictures if possible

PERISTOMAL MOISTURE ASSOCIATED DAMAGE

MASD is a broad category of skin complications defined as inflammation and erosion of the skin adjacent to the stoma, associated with exposure to effluent such as urine or stool (Colwell). Especially common in patients with Ileostomies.

It includes: irritant dermatitis, maceration, pseudoverucuous lesions. 

Assessment reveals erythema, superficial skin loss, stinging pain, difficulty getting pouch to adhere.  If chronic hyperkeratosis and scarring can cause stoma stenosis especially with urostomies.  Management involves correcting cause of leakage or moisture and using appropriate pouching systems.

MACERATION

  1. Soft, moist skin, lighter in color than surrounding skin
  2. Usually caused by cutting wafer hole bigger than stoma.
  3. REDUCING further moisture damage is KEY!
  4. Consider products with convexity, night bags, skin barriers.

Pseudoverrucous lesions

Exuberant growth of benign papules- look like warts, may have different skin coloring than rest of skin, may be itchy or bleed.

Chronic condition caused by prolonged exposure to liquid stools or urine- a type of irritant dermatitis. Management involves REDUCING MOISTURE!

Silver nitrate may be used to smooth out surface for better seal, stoma powder.

Lowering urine PH- fluid intake or cranberry pills useful if urine encrustations present.

If no improvement refer to urologist.

CONTACT DERMATITIS

 Hypersensitivity to chemicals
 Contact Dermatitis is RARE.
 Management involves identifying and removing allergen.
 Topical corticosteroids can be used to reduce inflammation- make sure they do not impair pouch adhesion
 Dermatology consult for a patch test.

ABSCESS
 Acute abscesses typically seen 2 weeks post-op usually foreign body.
 May be due to IBD or pyoderma gangrenosum.
 Assess for signs of systemic infection.
 Obtain cultures
 Consultation of other disciplines indicated.
 Treatment often requires drainage, ABX, and proper peristomal skin care.

 Hair follicle inflammation develops typically due to injury or infection.  Shaving peristomal hair and pulling of hair when taking off adhesives- major culprits.

FOLLICITIS  Gram positive bacteria- Staphylococcus and Streptococcus usually causing infection.  Assessment reveals tenderness, redness and pustules.  Obtain cultures if difficult to differentiate cause as fungal or foliculitis.  Treatment involves decreasing frequency of shaving or injury, topical use of antibacterial soaps, topical ABX gel .