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NURS 522 > nurs 522 peristomal skin and complications > Flashcards

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
Q

Stomal Prolapse

A

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)

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26
Q

Stomal Prolapse: Treatment

A 
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
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27
Q

Stomal hernia

A

Defect in ABD fascia allows bulging of intestine
Common @ inguinal ring, umbilicus, esophageal hiatus
2nd + pressure, obesity

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28
Q

Stomal Hernia: s/s, tx

A

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

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29
Q

Fistula: Initial Indications

A

Non-specific: fever and ABD pain
Definitive: GI secretions into wound or unintentional opening
pH of effluent suggests origin of fistula

30
Q

Fistula: Etiologic Factors

A

Anastomotic breakdown
2nd IBD, Cancer, diverticulitis
Complicated by malnutrition, sepsis, hypotension, vasopressors, corticosteroids

31
Q

Spontaneous fistulas

A

25%
2nd intrinsic intestinal disease (radiation, appendicitis), trauma
Resistent to spontaneous closure+ risk w/ pelvic cancer 2nd to radiation

32
Q

Iatrogenic Fistula

A

75%
Anastomotic breakdown
Surgical risk factors: - blood supply, poor suturing, lysis of adhesions

33
Q

Fistula Medical Management

A 
Spontaneous closure: 6-8 weeks
- output
Maintain F/E balance
Control infection
Nutritional support
Definition of fistula tract
Contain effluent
34
Q

Fistula: F/E Balance

A

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
Q

Fistula: Nutritional support

A

Maintain positive Nitrogen balance
TPN and bowel rest
4ft healthy bowel needed for enteral feedings

36
Q

Stomatized Fistula (Pseudostoma)

A

Anterior bowel wall become adherent to ABD wall
Fistula tract undergoes mucosal eversion
Permanent opening = surgery needed to close

37
Q

Fistula Effluent

A

Left transverse/descending: Odorous, semi-formed, - damaging to skin

38
Q

PEG Contraindications

A 
Coagulopathy or thrombocytopenia
Upper tract obstruction
Severe ascites
Hemodynamic instability
SepsisIntra-abdominal perforation
Peritonitis
ABD wall infection
Severe gas troparesis
Total gastrectomy
39
Q

G/J tube hypergranulation

A

2nd to poorly secured tube

40
Q

Nephrostomy Tubes

A

Through flank skin into renal pelvis

Facilitate drainage post obstruction

41
Q

Biliary Tubes

A

Through skin to bile ducts
Keep drainage bag below waist
Weekly dressing change
BID 10mL flush

42
Q

Peristomal candidiasis: risks

A

Corticosteroids
Immunosuppressants
Antibiotics

43
Q

Prevents spontaneous fistula closure

A

Distal bowel obstruction

44
Q

Purpose of skin sealant under fistula pouch

A

Protect from mechanical injury (stripping)

45
Q

Preterm infant surface area to body weight ratio

A

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
Q

Primary intervention for treatment/prevention of pseudoverrucous lesions

A

Resize pouch to fit base of stoma and cover up lesions

47
Q

Silver nitrate and pseudoverrucous lesions

A

Painful

Unnecessary as lesions will resolve w/ removal of urine

48
Q

Complications causing mortality w. fistulas

A

Sepsis
Malnutrition
F/E imbalance

49
Q

Pt w/ isolated episodes of dusky stoma coloration

A

Infant Crying = blood shunted away from bowel

Returns to red after crying stops

50
Q

Primary feature of EC fistula pouching system

A

Sizable surface for cutting

Fistulas in all shapes/sizes

51
Q

Colostomy irrigation w/ hernia

A

Discontinue irrigations if problematic or caustic

52
Q

Pseudoverrucous lesions: contributing factors

A

Due to chronic overexposure to moistureex: oversized pouch

53
Q

Risk factor for stomal stenosis

A

Necrosis

54
Q

Replacement of low-profile G tube

A

Measure length of stoma tract

Too small = necrosis, pain, tenderness

55
Q

Vinegar soaks used for:

A

Encrustations

30-50% vinegar solution when pouch removed

56
Q

Risks for stomal prolapse

A 
Infant (high ABD pressure from crying)
Loop colostomy (limited securing of bowel to skin)
57
Q

Caput Medusae caused by:

A

Portal hypertension in alcoholic or liver disease pt

58
Q

Incarcerated bowel associated with:

A

Parastomal hernia
May contain loop of bowel in herniation = ischemia
s/s ischemia: ABD pain, n/v, change in stoma color

59
Q

Permanent ileostomy w/ ulcer producing fecal material

A

Crohn’s disease = fistula formation

60
Q

Criteria for selecting EC fistula pouch

A

Volume of effluent
Size of fistula
Odor
Need for access

61
Q

Black/flaccid stoma: interventions

A

Rub stoma to note surface bleeding

Prepare to examine stoma w/ glass tube and light

62
Q

Mucocutaneous separation of new stoma

A 
Preoperative corticosteroid use
Poor healing 
Tension
Superficial infection
DM
Malnutrition
Stoma necrosis
Recurrence of disease
63
Q

Encrustations

A

Deposits of urinary crystals of stoma and peristomal skin

64
Q

G tube care

A

Stabilize tube

65
Q

Interventions to prevent G tube clog

A

Liquid meds only

66
Q

G tube balloon

A

Check volume weekly

67
Q

Leakage around Penrose drain

A

Apply ostomy pouch

Drainage is common

68
Q

First radiographic study for origin of EC fistula

A

Fistulagram = injecting dye into fistula and take X-rays

69
Q

Products to use around fistula

A

Skin barrier powder or wafer

70
Q

Endoscopic gastrostomy procedure

A

Use immediately after placement

Surgically placed requires recovery before use

NURS 522 (3 decks)

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