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nurs 522 peristomal skin and complications Flashcards

1
Q

Peristomal skin

A

Thicker w/ + TEWL
Warm and moist = + vulnerability to pathogens
Moisture = -regional blood flow

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2
Q

Peristomal MASD

A

Irritant dermatitis, maceration, pseudoverrucous lesion
Chronic = hyperkeratosis and scarring = stoma stenosis
Most common w/ urostomy

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3
Q

Pseudoverrucous lesions

A

Wart-like
Occurs w/ pooling of urine/stool
Alkaline crustations if urine alkaline and concentrated
Associated w/ UTI and renal calculiItching, bleeding, erosion, tenderness
Apply dilute vinegar- urine pH (+ fluid, cranberry juice)
Stoma powder to absorb moisture

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4
Q

Pressure Ulcers

A

Most common if peristomal hernia 2nd to convexity use

Partial or full thickness

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5
Q

Allergic Contact Dermatitis

A

Erythema w/ blisters
Spreads beyond orig contact area
Topical corticosteroid spray
Stoma powder to absorb moisture

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6
Q

Fungal/Candidiasis Infection

A

+ w/ recent antibiotics or if immunosuppressed, DM, corticosteroid, chemo
Begins @ moist area
Topical antifungal w/ barrier film

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7
Q

Folliculitis

A

Inflammation 2nd to injury/infection
Red pustules around follicle
Clip hair or electric razor, depilatory, baby powder
- freq of shaving
Antibacterial soap, topical antibiotic gel

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8
Q

Varices

A

Portal HTN = enlarged venous channels where + pressure meets - pressure
2nd to cirrhosis and primary sclerosing cholangitis
Bluish or raspberry-like stoma
Spontaneous bleeding w/ visible skin changes

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9
Q

Varices: Treatment

A

Apply pressure and use silver nitrate
Use barrier film wipe and 1 piece pouch
0 extended-wear skin barrier
0 convexity or belts
0 rubbing of pouch against mucocutaneous junction
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Beta-blocker or embolization of vessels

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10
Q

Granuloma

A 
Juncture of stoma and peristomal skin
Immunologic response to foreign material (sutures)
Raised, red bumps
Bleeding
Firm or fluid filled
Probe for retained material
Silver nitrate to raised areas
Stoma powder and foam dressing
Convexity
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11
Q

Peristomal Abscess: Acute

A

w/i 2 wks of stoma creation

Purulent material beneath skin 2nd to foreign body (suture), disease process, or infection

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12
Q

Peristomal Abscess of Established Stoma

A

2nd to IBD or pyoderma gangrenosum

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13
Q

Peristomal abscess: tx and s/s

A

Localized redness, swelling, tenderness
Systemic signs of infection possible
Drain fluid, local wound care, systemic antibiotics
+ pouch changes

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14
Q

Pyoderma Gangrenosum

A

Neutrophilic dermatitis
Recurrent, painful ulcerations
= presence of systemic disease (IBD, arthritis, hematologic disorders)
Pathergy
Partial or full-thickness wounds once ulcers open
Dark w/ irregular borders
Purulent exudate

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15
Q

Early Stoma Complications

A

w/i 30 days

Mucocutaneous separation, necrosis, retraction

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16
Q

Mucocutaneous separation

A

Detachment of stoma from peristomal skin and mucocutaneous junction
2nd to tension, infection, and - healing
Partial or complete, superficial or full thickness
Treat as wound (hydrofiber, calcium alginate)
Pouch entire area
Severe separation = retraction
+ risk of stenosis while healing
If fascia involved: fecal effluent may contaminate ABD = peritonitis

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17
Q

Stomal Necrosis

A

2nd tension or inadequate mesenteric vasculature or trauma
Associate w/ obesity & traction on bowel wall
Progressive discoloration pink to black
Dusky/dry w.i hours/days of surgery
Superficial or deep

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18
Q

Stomal Necrosis: Treatment

A
  1. Insert lubricated glass tube into stoma and shine penlight into stoma to determine depth
  2. Intraoperative laser angiography w/ indocyanine green-vascular imaging/real-time assessment of perfusion
  3. Watch and wait. Top layer may slough off if superficial
  4. Debride if below skin level but above fascia
  5. If deeper than fascia, sergeant surgical intervention
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19
Q

Stomal retractions

A 
2nd to tension from short mesentery
Thickened ABD wall
Adhesions and scar tissue
\+BMI 
Inadequate stoma length
Necrosis
Mucocutaneous separation
- Use convexity or belt
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20
Q

Late stomal complications

A

30+ post-creation

Stenosis, prolapse, parastomal herniation

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21
Q

Stomal stenosis

A

2nd mucocutaneous separation, necrosis, retraction
Granulation tissue constricts lumen as healing occurs
Risks: Crohn’s, tumor, + scar tissue, chronic inflammation

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22
Q

Fecal Stomal Stenosis: s/s

A

Small stoma opening
Pain w/ evacuation
Ribbon-like or explosive stool
Explosive, loud gas

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23
Q

Urinary Stomal Stenosis: s/s

A

Freq UTI
Projectile stream
Flank pain

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24
Q

Stomal stenosis: treatment

A 
Use finger to assess size and mobility of opening
Mild, - residue diet
Stool softener
\+ liquid intake
Stoma dilation is temporary only!
If severe, freeze or resite stoma
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25
Stomal Prolapse
Telescoping of intestine through stoma 2nd ABD pressure, obesity, large stomal opening, stoma outside rectus muscle Most common in loop colostomy + length of prolapse = + chance of stomal edema, trauma, ischemia Edemetous and dependent stoma = deep red (vasodilation)
26
Stomal Prolapse: Treatment
``` Palpate w/ pt supine to - prolapse Apply ice Sprinkle sugar on stoma Wear hernia support belt w/ prolapse strap Pouch must accommodate prolapse 1 piece system if large prolapse ```
27
Stomal hernia
Defect in ABD fascia allows bulging of intestine Common @ inguinal ring, umbilicus, esophageal hiatus 2nd + pressure, obesity
28
Stomal Hernia: s/s, tx
Bulging around stoma, difficulty maintaining seal Assess pt supine and coughing Xray Flexible pouching system, 0 convexity, hernia support, spandex, prevent constipation Surgery if obstruction, stenosis, dermatitis, pain
29
Fistula: Initial Indications
Non-specific: fever and ABD pain Definitive: GI secretions into wound or unintentional opening pH of effluent suggests origin of fistula
30
Fistula: Etiologic Factors
Anastomotic breakdown 2nd IBD, Cancer, diverticulitis Complicated by malnutrition, sepsis, hypotension, vasopressors, corticosteroids
31
Spontaneous fistulas
25% 2nd intrinsic intestinal disease (radiation, appendicitis), trauma Resistent to spontaneous closure+ risk w/ pelvic cancer 2nd to radiation
32
Iatrogenic Fistula
75% Anastomotic breakdown Surgical risk factors: - blood supply, poor suturing, lysis of adhesions
33
Fistula Medical Management
``` Spontaneous closure: 6-8 weeks - output Maintain F/E balance Control infection Nutritional support Definition of fistula tract Contain effluent ```
34
Fistula: F/E Balance
8-10 L lost through jejunum w/ 98% reabsorbed (100-200mL excreted) Proximal small bowel = + output Colon = - output H, Cl, Na, K lost - oral and enteral intake H2 antagonist (cimetidine) = - secretions
35
Fistula: Nutritional support
Maintain positive Nitrogen balance TPN and bowel rest 4ft healthy bowel needed for enteral feedings
36
Stomatized Fistula (Pseudostoma)
Anterior bowel wall become adherent to ABD wall Fistula tract undergoes mucosal eversion Permanent opening = surgery needed to close
37
Fistula Effluent
Left transverse/descending: Odorous, semi-formed, - damaging to skin
38
PEG Contraindications
``` Coagulopathy or thrombocytopenia Upper tract obstruction Severe ascites Hemodynamic instability SepsisIntra-abdominal perforation Peritonitis ABD wall infection Severe gas troparesis Total gastrectomy ```
39
G/J tube hypergranulation
2nd to poorly secured tube
40
Nephrostomy Tubes
Through flank skin into renal pelvis | Facilitate drainage post obstruction
41
Biliary Tubes
Through skin to bile ducts Keep drainage bag below waist Weekly dressing change BID 10mL flush
42
Peristomal candidiasis: risks
Corticosteroids Immunosuppressants Antibiotics
43
Prevents spontaneous fistula closure
Distal bowel obstruction
44
Purpose of skin sealant under fistula pouch
Protect from mechanical injury (stripping)
45
Preterm infant surface area to body weight ratio
Avoid use of skin solvents More surface area to absorb chemicals in sealants, barrier paste, adhesives Skin barrier wafers have 0 solvents or chemicals
46
Primary intervention for treatment/prevention of pseudoverrucous lesions
Resize pouch to fit base of stoma and cover up lesions
47
Silver nitrate and pseudoverrucous lesions
Painful | Unnecessary as lesions will resolve w/ removal of urine
48
Complications causing mortality w. fistulas
Sepsis Malnutrition F/E imbalance
49
Pt w/ isolated episodes of dusky stoma coloration
Infant Crying = blood shunted away from bowel | Returns to red after crying stops
50
Primary feature of EC fistula pouching system
Sizable surface for cutting | Fistulas in all shapes/sizes
51
Colostomy irrigation w/ hernia
Discontinue irrigations if problematic or caustic
52
Pseudoverrucous lesions: contributing factors
Due to chronic overexposure to moistureex: oversized pouch
53
Risk factor for stomal stenosis
Necrosis
54
Replacement of low-profile G tube
Measure length of stoma tract | Too small = necrosis, pain, tenderness
55
Vinegar soaks used for:
Encrustations | 30-50% vinegar solution when pouch removed
56
Risks for stomal prolapse
``` Infant (high ABD pressure from crying) Loop colostomy (limited securing of bowel to skin) ```
57
Caput Medusae caused by:
Portal hypertension in alcoholic or liver disease pt
58
Incarcerated bowel associated with:
Parastomal hernia May contain loop of bowel in herniation = ischemia s/s ischemia: ABD pain, n/v, change in stoma color
59
Permanent ileostomy w/ ulcer producing fecal material
Crohn's disease = fistula formation
60
Criteria for selecting EC fistula pouch
Volume of effluent Size of fistula Odor Need for access
61
Black/flaccid stoma: interventions
Rub stoma to note surface bleeding | Prepare to examine stoma w/ glass tube and light
62
Mucocutaneous separation of new stoma
``` Preoperative corticosteroid use Poor healing Tension Superficial infection DM Malnutrition Stoma necrosis Recurrence of disease ```
63
Encrustations
Deposits of urinary crystals of stoma and peristomal skin
64
G tube care
Stabilize tube
65
Interventions to prevent G tube clog
Liquid meds only
66
G tube balloon
Check volume weekly
67
Leakage around Penrose drain
Apply ostomy pouch | Drainage is common
68
First radiographic study for origin of EC fistula
Fistulagram = injecting dye into fistula and take X-rays
69
Products to use around fistula
Skin barrier powder or wafer
70
Endoscopic gastrostomy procedure
Use immediately after placement | Surgically placed requires recovery before use

NURS 522 (3 decks)

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