Lessons 23-25: Peristomal Skin Complications Flashcards
(26 cards)
Principles of Protection
- protect against mechanical trauma
- protect against irritants
- protect against allergens/irritants
- protect against impact of occlusion
Protection against mechanical trauma
- Gentle pouch removal + cleansing
- Push+pull technique
- Silicone-based adhesive remover
- Atraumatic hair removal re: folliculitis
Protection Against Irritants
- Enzymatic drainage = small bowel, pancreatic, and gastric
- Size opening in wafer accurately
- Use of filler protects
- Change leaking pouch promptly
Protection Against Allergen
- allow adhesives to dry fully before application
- watch for s/s of sensitivity/allergy
Protection Against Impact of Occlusion
Reduction in levels of skin lipid
- Dry skin
- Itching
- Peristomal breakdown
- Reacts poorly to management
Liquid Skin Barriers
- 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
Solid Hydrocolloid Barriers
- 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
Adhesive Products
- Used to improve pouch seal
- Spray or stick applicator
- Paint-on is latex based
- Watch for allergies
Primary Goals for WOCN
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
Differential Assessment - Key Questions
- 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?
Differential Assessment - Key Observations
- 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
Differential Assessment - Location + Distribution of Damage
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
Differential Assessment - Manifestations
Itching = yeast rash or allergic dermatitis
Burning pain = irritant dermatitis
Tenderness = skin loss
Constant severe pain = pyoderma gangrenosum
PMASD - Maceration
- 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
PMASD - Pseudoverrucous Lesions
- 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
PMASD - Irritant Contact Dermatitis
- 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
PMASD - Yeast Dermatitis
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
PMASD - Allergic Contact Dermatitis
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
PMARSI - Folliculitis
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
PMARSI - Mechanical Damage
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
Peristomal Pressure Injuries
- 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
Bacterial Infection
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
Peristomal Pyoderma Gangrenosum
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
Caput Medusae
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
