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Ostomy 2.2 > Lessons 23-25: Peristomal Skin Complications > Flashcards

Lessons 23-25: Peristomal Skin Complications Flashcards

1
Q

Principles of Protection

A
  • protect against mechanical trauma
  • protect against irritants
  • protect against allergens/irritants
  • protect against impact of occlusion
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2
Q

Protection against mechanical trauma

A
  • Gentle pouch removal + cleansing
  • Push+pull technique
  • Silicone-based adhesive remover
  • Atraumatic hair removal re: folliculitis
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3
Q

Protection Against Irritants

A
  • Enzymatic drainage = small bowel, pancreatic, and gastric
  • Size opening in wafer accurately
  • Use of filler protects
  • Change leaking pouch promptly
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4
Q

Protection Against Allergen

A
  • allow adhesives to dry fully before application
  • watch for s/s of sensitivity/allergy
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5
Q

Protection Against Impact of Occlusion

A

Reduction in levels of skin lipid
- Dry skin
- Itching
- Peristomal breakdown
- Reacts poorly to management

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6
Q

Liquid Skin Barriers

A
  • Protective film over skin
  • Not needed under hydrocolloid barrier
  • Can be used with adhesive-only pouches
  • Commonly used for crusting procedure
  • Alcohol and alcohol-free
  • Wipes or sprays
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7
Q

Solid Hydrocolloid Barriers

A
  • Protection against urine and stool
  • Improved pouch seal due to conformability

Options
- Solid barrier ring or wafer
- One or two piece
- Paste strips
- Barrier rings
- Squeezable paste

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8
Q

Adhesive Products

A
  • Used to improve pouch seal
  • Spray or stick applicator
  • Paint-on is latex based
  • Watch for allergies
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9
Q

Primary Goals for WOCN

A

Primary goal = prevention
- Pre-op stoma marking
- Secure pouching system
- Post-op follow-up with adjustments PRN
- Ongoing patient + caregiver education
- Crusting for minor skin issues

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10
Q

Differential Assessment - Key Questions

A
  • Usual frequency of pouch change + products used
  • Procuring procedure + any problems
  • Onset of problem + associated factors
    — Leakage?
    — Antibiotic use?
    — Change in pouching system?
    — Diagnosis of IBD or rheumatoid arthritis
    — Onset as a solitary painful ulcer?
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11
Q

Differential Assessment - Key Observations

A
  • Pouching system in use
  • Exposed peristomal skin
  • Any breakdown extending beyond pouching system
  • Evidence of undermining or leakage
  • Inspection of barrier upon removal
  • Evidence of saturation or patterns of leakage
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12
Q

Differential Assessment - Location + Distribution of Damage

A

Inferior, medial, or lateral to stoma = irritant dermatitis

Damage matching pouching system = allergic dermatitis

Solid maculopapular rash with satellite lesions = yeast dermatitis

Patchy breakdown = mechanical breakdown

Defined crater under rigid pouch element = pressure injury

Solitary, crater-like painful ulcer = pyoderma gangrenosum

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13
Q

Differential Assessment - Manifestations

A

Itching = yeast rash or allergic dermatitis

Burning pain = irritant dermatitis

Tenderness = skin loss

Constant severe pain = pyoderma gangrenosum

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14
Q

PMASD - Maceration

A
  • Overhydration of skin
  • Vulnerable to mechanical trauma + penetration by irritants/pathogens
  • Most common with urostomy + ileostomy

Presentation
- Skin soft, moist, and light in color
- Areas of involvement match areas of softening/overhydration

Management
- Crusting procedure
- Assure correctly fitting pouch seal with no undermining
- Add adhesives PRN
- Extended wear barrier
- Antiperspirants to pouching surface
- Manage external moisture

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15
Q

PMASD - Pseudoverrucous Lesions

A
  • Wart-like lesions caused by chronic overhydration
  • Likely with urostomy or high-output fecal diversion

Presentation
- Wet, wart-like lesions on stoma/peristomal skin
- Areas of involvement match overhydrated barrier
- Itching, tenderness, bleeding
- Episodes of pouch leakage

Management
- Silver nitrate to flatten raised/irregular lesions
- Crusting procedure
- Assure secure seal that prevents undermining
— Convexity, belt, adhesive, barrier rings PRN
— Consider extended wear
- Appropriate frequency of change with correct sizing
- Assure urine is dilute OR stool is thick

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16
Q

PMASD - Irritant Contact Dermatitis

A
  • Erythema with patch skin loss due to prolonged contract with urine or stool
  • Common with ileostomy

S/S
- Erythema
- Denuded skin adjacent/inferior/lateral to stoma
- Area of damage matches areas of erosion on used barrier
- Itching, tenderness, burning pain
- Frequent episodes of leakage

Management
- Dry skin thoroughly
- Crusting procedure
- Hydrocolloid dressing over area
- Pouch seal that prevents undermining
- PRN thickening of stool

17
Q

PMASD - Yeast Dermatitis

A

Maculopapular rash caused by Candida albicans

Risk factors
- Peristomal moisture
- Antibiotics
- Steroids
- Diabetes
- Immunosuppression

Presentation
- Solid rash with district satellite lesions
- Itching + tenderness
- May have rash in other areas

Management
- Crusting with anti-fungal powder
- Miconazole or Nystatin
- Systemic antifungal if resistant or widespread
- Manage peristomal moisture

18
Q

PMASD - Allergic Contact Dermatitis

A

Inflammatory response to component of pouching system
- ?sensitivity reaction vs true allergy

Presentation
- Matching areas of involvement to agent causing inflammation
- Erythema +/- blisters
- Intense pruritus with tenderness
- Difficulty maintaining pouch seal

Assessment
- Assess products used and pt’s procedure of pouch application
- correlate areas of involvement with products used
- Patch testing PRN

Management
- Eliminate irritants from pouching system
- Trial hydrocolloid alternatives
- Topical antihistamines
- Keep pouching system as simple as possible

19
Q

PMARSI - Folliculitis

A

inflamed/infected hair follicle d/t traumatic removal
- 2° staph or strep infection

Presentation
- Erythematous, pustular lesions corresponding to hair follicles
- Tenderness + pain with pouch removal

Management
- Cleanse with AMD soap
- Topical antibiotic cream or gel PRN
- Culture + systemic abx if not responding

Education
- Shave in direction of hair growth
- Reduce frequency of shaving
- Use electric shaver
- Consider depilation

20
Q

PMARSI - Mechanical Damage

A

Patchy areas of skin loss due to aggressive removal of pouch or barrier

Factors
- Fragile skin
- Incorrect use of adhesives and tackifiers
- Improper application + removal
- Abnormally frequent pouch changes

Presentation
- Defined patchy area of skin loss in area not exposed to urine or stool
- May present as blister or skin tea
- Usually along edges of pouching system

Management
- Crusting or hydrocolloid use
- Education re: adhesive use
- Education re: frequency of pouch change
— Use of releases and removers
— Releases = silicone based
— Removers = solvent based

21
Q

Peristomal Pressure Injuries

A
  • Full thickness ulcerations caused by pressure
  • Common with patient with peristomal hernia with rigid/convex pouch

Presentation
- Isolated, well-defined, full-thickness tissue loss
- Area of tissue loss not exposed to stool or urine
- Patient reports tenderness/pain to area of ulceration

Management
- Dressing based on depth and exudate
- Use of flat or all-flexible pouch
- If hernia reducible = use of binder to maintain reduced state
- If hernia irreducible = binder PRN for support + use of all flexible pouch

22
Q

Bacterial Infection

A

Development of purulent fluid collection beneath skin
- Caused by bacterial invasion of suture skin or open inflamed area

Presentation
- Erythematous, edematous lesion
- Purulent drainage
- Possible systemic signs of infection

Management
- Surgical consult re: I+D of abscess pocket +/- drain placement
- Systemic Abx
- AMD dressing
- Increased frequency of pouch change to manage exudate

23
Q

Peristomal Pyoderma Gangrenosum

A

Presentation
- Solitary or multiple lesion
- Partial or full thickness wounds
- Location is variable
- Wounds acutely painful
- Purulent drainage
- Dermal destruction
- Borders irregular with purple colour
- Pathergy - exacerbation d/t minor trauma

Management
- Pain management
— Oral analgesics +/- lidoderm patches
— Lidocaine gel for pouch changes
- System anti-inflammatories
— Steroids +/- biologics
— Dapsone or doxycycline
— Intralesional steroids
- Topical anti-inflammatories
— Triamcinolone or tacrolimus
— AMD absorptive dressing
— Hydrofera Blue
— Silver Alginate
- Adhesive releaser for atraumatic removal

24
Q

Caput Medusae

A

Peristomal varicella caused by portal hypertension

Presentation
- Purple discolouration around stoma
- May seen dilated vessels on stoma or peristomal skin
- No denudation
- No pain
- No itching

Management
- MD aware
- Correction of underlying portal hypertension
- Avoid rigid convexity to prevent peristomal skin trauma
- Atraumatic pouch removal
- Manage minor bleeding
— Silver nitrate or hemostatic agents
— Alginates
— Manual pressure
— Ice

25
Q

Mucosal Transplantation

A

Island of intestinal mucosa transplanted to peristomal skin during surgical maturation
- Bowel inadvertently sutured to epidermis

Presentation
- Irregular mucocutaneous suture line
- Persistent “fingers/islands” of wet mucosal tissue interspersed with tissue
- No pain
- No response to crusting

Management
- Modifications to pouching system PRN
— cut barrier to clear mucosal islands
— Use paste to prevent undermining
- If no leakage, no treatment required

26
Q

Peristomal Granulomas

A

Inflammatory response to foreign body - usually mucocutaneous sutures

Presentation
- Raised, erythematous lesions
- Bleed easily
- Tender to touch
- Problems with pouch seal

Management
- Gently probe lesions to remove sutures
- Cauterize with silver nitrate
- Crusting PRN +/- absorptive dressings
- Pouch modifications
- Surgical consult for refractory issues

Ostomy 2.2 (15 decks)

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