Successful treatment can mean a successful ostomy.
Ostomies and stomas that allow the elimination of urine or fecal material can have a profound effect on the quality of patients' lives. In patients who experience stomal or peristomal complications, these effects can be severe.1, 2 Clinicians play a crucial role in preventing these complications and in improving stoma or ostomy patients' quality of life. One study involving 3,042 stoma patients in Europe found that although patients' scores on quality-of-life measures improved after hospital discharge, those who were satisfied with the care they'd received had higher scores on the Stoma Quality of Life Index than those who weren't satisfied.3
Peristomal skin conditions are a common complication in patients with stomas. Depending on the stoma type, rates of peristomal skin problems of between 30% and 60% have been reported.4-6 The prevention and management of alterations in peristomal skin integrity offer unique challenges for clinicians and patients. An overview of peristomal skin complications can be beneficial to nurses caring for such patients.
Successful rehabilitation in people with ostomies is dependent on a secure, reliable, and odor-proof pouching system, with containment of effluent. The system's security is dependent on healthy peristomal skin and a well-fitted pouch. When either of these two factors is impaired, nursing care involves interventions that address the underlying causes and create an environment for healing. The combination of a leaking pouch and peristomal skin conditions can challenge even the most experienced nurse.
Selection of the pouching system occurs after surgery, and is based on the type of stoma, the patient's lifestyle, and the patient's abdominal contours.7, 8 Postoperatively, mucosal edema diminishes and the contour of the abdomen usually changes. A pouching system that no longer fits properly can leak, exposing the peristomal skin to urine or bowel contents and damaging the epidermis.
The importance of skin integrity. Ideally, peristomal skin will look as healthy as any tissue on the body (such as on the other side of the abdomen); likewise, alterations in peristomal skin integrity, such as infection, can demonstrate classic clinical patterns of skin conditions seen elsewhere on the body.9, 10 The principles of wound care apply to managing peristomal skin conditions, which begins with assessment: lesion size, drainage, the presence of devitalized tissue, the condition of the adjacent skin, and underlying problems associated with the wound.
Options for the care of peristomal skin conditions often involve the use of skin barrier powder and appropriate wound-care products. Nurses should also consider how well the pouching system works for the patient and modification of the pouching system to help heal the skin lesion.
COMMON PERISTOMAL SKIN CONDITIONS
Regardless of stoma type, one skin complication predisposes patients to concurrent (secondary) peristomal skin issues. The challenge is to determine the causative factors (see Table 110-14). The Cleveland Clinic stoma registry data (see The Cleveland Clinic Stoma Registry) and the literature indicate that most peristomal skin conditions fall into the following general etiologic categories: chemical, infectious, mechanical, immunologic, and disease related. The most common conditions are irritant dermatitis, mechanical trauma, and candidiasis.9-11, 15, 16 Other stomal irregularities associated with peristomal skin problems include the stoma being flush with surrounding skin, a parastomal hernia, and improper sizing of the pouch aperture. In addition, problems can arise from improper use or amount of convexity (the use of a barrier ring that's rounded toward the abdomen [convex], in order to provide support to the stoma, preventing it from lying flush with the skin or retracting); convexity is also used "when deep or uneven topography is evident in the peristomal area" or "when stoma shape and size are variable" (or when both occur).17
||Table 1. Common Peristomal Skin Conditions
A HOLISTIC APPROACH TO CARE
A holistic approach, by definition, considers the patient as a whole system. Wound, ostomy, and continence nurses take a holistic view of the patient when determining the best approach to wound management.
The PET model of ostomy care, created by and named for one of us (PET), involves four elements: assessment of the patient's intrinsic environment, assessment of the patient's extrinsic environment, topical wound care, and a complete plan of care based on all of these factors.
Assessment of the intrinsic environment.Intrinsic in this context means originating within the body. Nurses must make a careful accounting of factors within the patient, such as comorbid conditions, that can affect healing. For example, uncontrolled diabetes can lead to peripheral vascular disease, coronary artery disease, and even tissue ischemia. And lower-extremity venous insufficiency interferes with the return of venous blood to the heart, which can lead to pooling of blood in the ankle and calf area of the affected leg.
Skin damage can have many possible causes. Radiation, for example, is a conventional treatment for some types of cancer, but it can also damage skin cells in the adjacent area. That damage can extend deep into the cells' nuclei and reach DNA, changing the cells' physiology and leading to the loss of sebaceous glands, a loss of elasticity with atrophy, and discoloration.9, 15, 18
Bacterial, fungal, and viral organisms can overcome the body's immune system and manifest as skin complications (a fungal rash within skin folds, for instance) or impair the wound-healing process. The important part in this phase of assessment is to recognize when an infection is present and to treat it according to organism type.
Skin and wounds require adequate perfusion and nutrition for normal physiologic maintenance and tissue repair. Wounds complicated by perfusion problems can become devitalized and develop nonviable or necrotic tissue. Patients who have poor nutritional reserves are likely to have delayed healing times. A patient with delayed wound healing must be assessed for adequate perfusion and nutritional stores.
Another intrinsic factor to consider is the medications the patient is taking. Antiinflammatory agents and chemotherapeutic agents in particular can interfere with tissue repair because they have an effect on the wound-healing cascade.10, 11, 13
Finally, nurses must consider the impact of aging and the effects of stress. As part of the normal aging process, the immune system's protective ability starts to diminish. Skin repair is slowed, and there's a greater risk of chronic illness. As the nurse develops a plan of care to manage the wound, optimizing all internal factors will provide the best chance for successful healing.
Assessment of the extrinsic environment.Extrinsic in this context means outside factors that have an effect on the whole. One person may be affected by many extrinsic factors, but these will affect each person differently. The wound, ostomy, and continence nurse needs to consider outside factors that are significant to the patient's situation. Environmental factors are a priority-management issue. For example, what are the environmental considerations if the patient has a pressure ulcer?
* Do the patient's pouching system and accessory products fall within Centers for Medicare and Medicaid Services guidelines for ostomy supplies? If not, why?
* What support surface will offer the optimal pressure redistribution and be covered by the payer?
* What if the patient has no insurance?
* How can we offer the patient safe and effective care while working within organizational policies, predetermined insurance coverage, and the patient's own concerns?
To answer these questions, one must take a careful look at the individual patient and make sure to include the appropriate interdisciplinary team members in the care-planning process.
Functional deficits are also an important consideration. Say the patient has both pressure ulcers and ambulatory problems. Treatment will require more than simply adding a support surface to the bed. Think about how activities of daily living, such as transferring, affect the wound.
* Does the patient require a seating device in addition to a specialized bed?
* How will transfers from one department or facility to another be accomplished?
* What type of repositioning schedule will meet the needs of the patient and be realistic for the caregivers?
Topical wound care. The selection of a specific wound treatment can be daunting if the nurse's assessment is incomplete. Treatment isn't based merely on the depth of tissue injury; rather, it's based on
* a sound understanding of how wounds heal.
* how different categories of wound-care products work.
* a thorough assessment of the wound.
* management of intrinsic and extrinsic factors.
Simply put, the dressing is selected in the context of creating the optimal environment for healing.
Plan of care. The nursing process involves assessment, planning, implementation, documentation, evaluation, and reassessment. Its goal is to alleviate, minimize, or prevent actual or possible problems. And it can be applied in any interaction that involves a nurse and a patient and in a variety of settings, including a hospital, the community, a private home, or a long-term care facility.
The Cleveland Clinic Stoma Registry
The stoma registry was established in 1998 to gather prospective data on patients with ostomies receiving care at the Cleveland Clinic's main campus hospital and ambulatory care clinic. When registered patients return to the hospital or ambulatory care clinic, an ostomy- or surgical-event form is completed. This indicates an interaction with the wound, ostomy, and continence nurse (formerly known as the enterostomal therapy nurse), the surgeon, or both. As of April 2009 the registry had 10,643 enrolled patients, and since 1998, 21,406 ostomy-event forms and 8,768 surgical-event forms had been entered into the registry.
The majority (62%) of patients in the registry had an ileostomy. Of those, more than half were of the temporary loop variety, constructed to provide proximal diversion to protect a distal anastomosis, primarily an ileal pouch–anal anastomosis (IPAA). (Although some centers only use temporary loop ileostomy in patients at high risk for anastomotic leak, other centers use more-specifically defined criteria to determine the appropriateness of a one-step IPAA. Patients who are on immunosuppressive therapy, are diabetic, have aging sphincters, or are morbidly obese have a higher risk of postoperative complications, which may preclude them from receiving a one-step IPAA.19, 20
Two percent of the procedures were loop-end ileostomies; unlike a loop ileostomy, which leads to the distal part of the intestine, a loop-end ileostomy ends up at a blind end. Among procedures in the registry, end descending colostomies constituted 13%; end or loop-end urinary conduits, 9%; and continent ileostomies, loop transverse colostomies, and end sigmoid colostomies approximately 2%. A variety of other stoma types made up the remainder.
Frequency of peristomal skin complications. The most common type of peristomal skin complication listed in the Cleveland Clinic registry, accounting for 26% of ostomy visits, was irritant dermatitis resulting from chemical destruction of the skin from effluent. Other skin complications, appearing at lower rates (4% to 6% of visits), include pseudoverrucous lesions, candidiasis, allergic contact dermatitis, mechanical trauma, and folliculitis. Stoma complications encountered and documented, also infrequently, include peristomal ulcers, parastomal hernias, mucocutaneous separations, and stoma retractions.
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