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Peristomal care: preventing complications

Maureen Benbow
MSc BA HERC RGN
Senior Lecturer University of Chester

Many patients with stomas have no associated skin problems, but for those who do it adds to the stress of adapting to the stoma.(1) Each year 70,000 to 100,000 people in the UK have colorectal urological surgery resulting in stomas,(2) the most common of which is a colostomy.(3) Of this number, most will be aged 60 years or over. Some stomas will be formed for short periods, but others will be placed for decades or life, as in Crohn's disease. The overall rate of peristomal skin complications ranges from 18% to 55%, but there is no standardised classification system or details of the types of skin complications.(4)

Ostomies
An ostomy is a surgically created, artificial opening in which a portion of diseased tissue is removed and a false exit is made to allow waste to be expelled. This may happen in parts of the urinary tract or gastrointestinal tract due to birth defects, disease, injury or other disorders. A colostomy may be formed when a portion of large bowel is brought to the abdominal wall, while an ileostomy refers to the connection of a portion of small bowel to the abdominal wall. Urostomies divert the flow of urine from the diseased or injured bladder. Colostomies are further classified according to the section of bowel brought out through the stoma: for example, sigmoid colostomy involves the sigmoid colon. Although many colostomies are permanent, following, for example, abdominoperineal resection for colorectal cancer, some are formed temporarily to allow healing of a diseased or injured portion of bowel. Following healing, the bowel can be rejoined and normal function resumed. Tracheostomies, either temporary or permanent, may also be formed to bypass diseased or injured tissue or for assisted ventilation in intensive care settings.
Along with tracheostomies for patients suffering from head and neck cancer and other conditions, support is frequently needed with feeding. This may be provided by the insertion of a percutaneous endoscopic gastrostomy (PEG) tube, which provides an artificial connection between the stomach and the abdominal wall via a tube through which patients are fed a liquid diet. Leakage of caustic gastric contents may cause skin problems due to poor placing of the tube, tube migration or improper positioning while feeding.(5)

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The consistency of the output
The consistency of the output from a colostomy depends on the level of bowel from which it originates. The consistency of the stool will be loose if the colostomy comes from the ascending or transverse portion of the bowel, while lower down the colon the stool will be formed as more liquid has been absorbed in the colon. Ileostomy usually involves removal of the entire colon and rectum, with part of the small intestine being brought to the surface. The waste has a liquid consistency because the normal function of absorption in the colon is lost.
Ileal conduit is the most common type of urostomy, where a small segment of the ileum is separated from the small intestine to form a pouch to which the ureters are connected. The small intestine is reconnected so that bowel movements pass normally and one end of the excised bowel is closed. The other end is brought to the abdominal wall in the right iliac fossa to create the stoma; this procedure may also be performed using the colon (colon conduit). An external plastic pouch is attached to the skin to collect urine from the ileal conduit. A urostomy is almost always permanent in adults.(6)
A tracheostomy is a surgically created opening in the neck into the trachea into which a tube is placed to provide an airway and to facilitate removal of secretions from the lungs.(7) Fistulae are common complications of head and neck cancer surgery because of infection, radiation or poor surgical technique.(8)
The combination of oral saliva contamination, fistula output, lymph gland erosion and wound exudate contributes to the potential for infection and skin complications as there is often a large volume of fluid found around the tracheostomy. This makes head and neck surgery wound care-intensive.(8)

Preoperative considerations

To avoid the risk of postoperative complications associated with alterations in peristomal skin and tissue integrity, care should be taken in the selection of the stoma siting. This will include clinician assessment of the physical characteristics and psychological needs of the patient, their capacity for learning about and coping with their new situation, and selecting the best anatomical stoma site.(9) Special consideration with regard to siting, access, visibility and the ability to self-care must be afforded to those patients who are overweight or wheelchair users.
Psychosocial preparation, education and support is essential. Once placed, the stoma must be carefully measured to ensure choice of the best-fitting pouching system. A properly fitted pouch system will be comfortable, maintain a secure seal and move well with the patient.(9)
A major educational requirement is that of teaching patients to regularly inspect the peristomal skin for signs of breakdown, mechanical injury (due to shear/pressure, early mucocutaneous separation), disease-related lesions (pyoderma gangrenosum, varices, malignancy) or immunological disorders.(10)
 
Caring for the stoma
The visible tissue of a stoma should be shiny, moist and a pinkish/red colour; dark discoloration may indicate ischaemia or necrosis and requires immediate medical attention.(3) The peristomal skin must be cared for meticulously.(11) If the skin is burning, itching, painful or eroded, advice must be sought from a stoma nurse. Careful infilling of irregular skin surfaces with pastes, strips or other forms of barrier combined with careful nontraumatic changing of stoma bags when about half full should minimise the risk of skin damage. The type of system used will dictate the frequency with which the whole system is removed and the area cleansed. Unexpected soiling must be investigated as a matter of urgency, not only to reassure the patient but also to prevent peristomal skin complications.

Peristomal skin problems
Prevention and/or early identification of peristomal skin complications are essential components of successful, cost-effective stoma patient management.(9) A well-fitting ostomy system should preclude damage to the surrounding skin from effluent and skin stripping; however, an awareness of the properties of the output will inform skin care regimens. For example, gastric juices contain proteolytic enzymes and hydrochloric acid, which are particularly irritant to the point of digesting the skin surrounding the ostomy.(12) Urine may leak from a urostomy, causing the buildup of crystal deposits on the skin, which require gentle removal with half-strength diluted acetic acid at each appliance change.(11) The output from a tracheostomy may contain enzyme-rich saliva or large amounts of lymph, which, in time, will cause maceration of the skin. Excessive leakage from tracheostomy fistulae or lymph nodes is particularly difficult to manage due to the contours of the face and neck and the size of reservoir needed to catch the leakage.

Maceration and excoriation
Skin becomes macerated when it has become over-hydrated due to long-term exposure to wound exudate, wet dressings or direct leakage from a stoma or wound. Peristomal hyperplasia may occur at the mucocutaneous junction as a result of persistent exposure to effluent over time. Changing the appliance to a better-fitting one combined with appropriate skincare should resolve this problem.(13)
The main skin problem experienced by stoma patients is excoriation of the skin due to leaking urine, saliva or faeces, which may be due to an ill-fitting appliance or weight changes.(11) Excoriated skin is defined as that which has been traumatised, worn away or abraded, often in the presence of maceration due to incontinence.(14) Other problems may be associated with poor technique when changing the appliance, causing trauma to the epidermis on removal, radiotherapy in cancer patients, and changes in the skin integrity due to ageing, stress, illness or dietary problems. Excoriation may present as sore, red and inflamed broken skin around the stoma, while maceration will show as white, soft and soggy skin. Both conditions will weaken the integrity of the skin, predisposing it to further trauma and problems with dressing/appliance adherence.

Skin irritation
Skin irritation is a common problem in patients with ileostomies (34%),(13) which may be secondary to contact dermatitis, mechanical trauma or infections.(15) An allergic reaction or irritation may also progress to irritant contact dermatitis. In all of these cases it is necessary to examine the patient's skin and skin contours, stoma practices, what they use to cleanse the stoma, pastes, powders and appliances until a likely causative agent is found and dealt with. Skin protection can be provided by the use of hydrocolloid wafers, powders or barrier films, to conserve moisture and promote healing. In severe cases, nonadhesive pouching may be a necessary temporary measure.

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Infection    
Lyon and Smith found that 7% of peristomal skin problems were caused by infection, possibly due to the warm, dark, moist environment under hydrocolloid wafers, intermittently contaminated by urine or faeces.(12) The most common infection is folliculitis.(16)
Candidiasis may occur around the stoma, causing pain and irritation, particularly in diabetic and immunocompromised patients. This is more likely where there has been persistent leakage or following a course of antibiotics.(16) Antifungal powder may be indicated to help control leakage and moisture buildup.(15) The cause of the leakage should be identified and corrected if possible. Any existing breach in the integrity of the skin will predispose to infection:for example, psoriasis, eczema and allergic dermatitis. Patients should be assessed for their risk of infection so that proactive management may prevent skin infections. The patient should be educated to identify any peristomal redness, rashes or leakage, which should be reported to and dealt with immediately by the clinician or through referral to stoma care specialist nurses.

Cleaning the stoma and surrounding area
Cleanliness and a positive self-image are important to the wellbeing of the person with a stoma, but overexuberant cleaning with antiseptics of the stoma and surrounding skin is contraindicated. Skin produces its own protective moisturisers, oils and waterproofing, and by removing these the skin becomes exposed to drying out, cracking and the easy entry of bacteria.
The general guidance on washing the peristomal skin is to use only warm water,(12) but a mild, pH-balanced, unfragranced soap used in moderation should not upset the pH or chemical balance of the skin.(17) The pouching system should be removed by supporting the skin and using a soft moist tissue, and the skin cleansed gently with plain water to avoid abrasion.
Chemicals should be avoided unless used for good reason, and the skin should be patted dry before a new system is applied.(10)
 
Conclusion
Peristomal skin complications are the main reason patients with ostomies seek help from healthcare practitioners. Prevention and good management are critical components of ostomy care with regard to quality of life. Risk assessment combined with early, appropriate, onward referral for specialist advice will identify the significant risk factors and contribute to prevention of peristomal skin complications. Documenting the individual's skin problems and the solutions found will help to inform future care.

References

  1. Black P. Holistic stoma care. London: Ballière Tindall; 2000.
  2. Department of Health. Consultation document on the arrangements for paying appliance contractors. Available from http://www.dh.gov.uk
  3. Plant C, et al. Nurs Residential Care 2001;3(6):260-264.
  4. Colwell J, et al. J Wound Ostomy Cont Nurses 2001;28(1):6-17.
  5. Johnson D. Common complications of tube feeding. Available from http://depts.washington.edu/growing/Nourish/Tubecomp.htm#Tube%20feeding%...
  6. Mayo Clinic. Ostomies: what are they and how do they work? Available from http://www.mayo clinic.com/invoke. cfm?objectid= 50A4B9CD-D592-4458-BEE9EA61 FA97FC3B
  7. Fung K. Tracheostomy. Available from http://www.nlm.nih.gov/medline plus/ency/article/002955.htm
  8. Newlands SD. Head and neck lecture for junior medical students. Available from: http://www.utmb.edu/oto/MedicalStudent.dir/Head-Neck/Head-Neck.htm
  9. Erwin-Toth P. Adv Skin Wound Care 2000;13(4):175-180.
  10. Rolstad BS, et al. Ostomy/Wound Manage 2004;50;9:68-77.
  11. Black P. Br J Community Health Nurs 1997;2(5):249-53.
  12. Lyon C, Smith A. Abdominal stomas and their skin disorders. London: Martin Dunitz; 2001.
  13. Leong AP, et al. Br J Surg 1994;81(5):727-9.
  14. Collins F, et al. A-Z dictionary of wound care. Dinton: Quay Books; 2002.
  15. Efron JE. Ostomies and stomal therapy. Available from http://www.fascrs.org/displaycommon.cfm?an=1&subarticlenbr=107
  16. Turnbull GB. The ostomy files: infections of the peristomal skin. Ostomy/Wound Manage 51;6:14-16.
  17. Black P. Br J Community Nurs 2002;7(4):212-7.

Resources
Tissue Viability Society
W:www.tvs.org.uk/ T:01722 429057
E:tvs@dial.pipex.com

Skin Care Campaign
W:www.skincare campaign.org/
 
Wound Care Society
W:www.wound caresociety.org/
T:01480 434401