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Debra Netsch DNP,APRN,FNP-BC,CWOCN-AP,CFCNWEB WOC Nurse Education Programs: Co-Director & Faculty

Ridgeview Medical Center, Wound & Hyperbaric Clinic: NP & CWOCN-APJWOCN: Clinical Challenges Section Editor

No financial or off label use disclosures.

1. Describe skin problems for an ostomate and interventions for management

2. Discuss stomal and peristomal complications management techniques

3. Identify techniques when dealing with a fistula

4. Review different crusting procedure

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Pouching difficulties causes◦ Stoma complications◦ Peristomal complications◦ Topography

Top 5 ◦ peristomal skin irritation (76%)◦ pouch leakage (62%) ◦ odor (59%)◦ reduction in previously enjoyed activities (54%)

depression/anxiety (53%)(Richbourg , Thorpe , Rapp. JWOCN 2007: Jan-Feb;34(1):70-9)

20% who experienced difficulties after surgery did not seek help.

(Richbourg , Thorpe , Rapp. JWOCN 2007: Jan-Feb;34(1):70-9)

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Most common first couple of weeks postoperative Complications may occur 5 to 10 years later Approximately 20% of patients will require surgical

intervention

Early : ◦ Necrosis◦ Mucocutaneous Junction Separation

Late:◦ Parastomal Hernia◦ Prolapse◦ Stenosis◦ Retraction

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Construction of ideal stoma

In Ostomies and Continent Diversions: Nursing Management, Hampton, B and Bryant, R eds.,1992, Mosby

Preoperative stoma site marking can prevent the majority of stoma complications

Good surgical technique Normal BMI Optimize co-morbid disease

processes

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defined as a healthy stoma becoming black or dark purple resulting in mucosal death

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incidence 12% to 22% fecal stomas usually within the first 24 hours may skip areas most frequent occurrence in end stoma least frequent occurrence in loop stomas avoid confusion with melanosis coli

skeletonization of bowel excessive mesentery tension higher adipose (BMI) end sigmoid colostomy higher risk especially if created for

diagnosis of cancer

Delayed necrosis:◦ colitis: radiation, ischemic, pseudomembranous

surgical technique obese patients lose weight if

feasible optimize oxygenation & blood

supply

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may occur at different depths (above or extend below fascia)

Folkedahl

evaluation of extent of necrosis observation if above fascia level superficial debridement

Folkedahl

Folkedahl

Folkedahl

Pouching system properly sized to accommodate

odor control teach the patient what to expect

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emergent surgery if extends below fascia level

Folkedahl

stenosis and/or retraction of stoma mucocutaneous junction separation perforation and peritonitis serositis

FolkedahlFolkedahl

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defect created by interruption of suture approximation of stoma mucosa to skin

early complication induration and/or erythema may be early indicators may be limited area or circumferential fistula formation may occur

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excessive tension on mucocutaneous suture line systemic factors that delay wound healing surgical defect is created too large stoma necrosis involving mucocutaneous junction

decreased tension on sutures improve preoperative nutritional status correction of factors interfering with wound healing preoperative weight loss if feasible

fill separation with absorptive material correction of systemic factors interfering with wound healing

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Silicone foams Skin barriers

Stoma stenosis at skin level Stoma retraction

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narrowing of stoma lumen at fascia or skin level

4% of all stoma types may interfere with output stool ribbon formation large amounts of residual urine in conduit with projectile

urine

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infection improper sizing of fascia or skin as stoma

constructed scar formation (necrosis, mucocutaneous

junction separation)

recurrent forceful dilatations of stoma prior irradiation alkaline urine if urostomy excessive weight gain

inadequate amount of bowel mobilization disease processes pseudoverrucous lesions

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weight loss prior to surgery proper fitting of pouching system treatment of disease processes avoid excessive weight gain

implement measures to keep stools soft low residue diet gentle dilatation (controversial) local surgical correction with fasciotomy

and stoma refashioned surgical revision/reconstruction

Erythemic area which may be intact, weepy or with shallow ulcerations

Causation: ◦ Exposure to effluent◦ Exposure to allergan

Management:◦ Correct pouching system◦ Remove allergan◦ Absorb moisture until healed

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Epidermis of the peristomal skin is thickened with discoloration being silvery gray, brown, or red. Wartlike papules or nodules are present.

Causation: Exposure to effluent

Management: ◦ Correct pouching system◦ Silver nitrate◦ Surgical debridement

At risk:◦ Poor abdominal musculature◦ Too large fascial opening◦ Edematous bowel ◦ Heavy lifting

Treatment:◦ Surgical repair

Management:◦ Hernia belt

Hernia belts

◦ Keep hernia reduced when standing.

◦ Some with prolapse belt others without

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An ulceration which occurs with the use of rigid barrier with a firm abdomen.

Causative Factors:Too rigid of convexity

Treatment: More flexible convexityAbsorptive wound dressing with secondary dressing for pouching.

Violaceous borders with painful ulcerations. Frequently with increased bacterial load.

Causative Factors:◦ Inflammatory Bowel Disease◦ Cancers (Multiple myeloma)◦ Unknown

Treatment:◦ Systemic steroids◦ Topical steroids◦ Treat disease process◦ Antimicrobial, atraumatic dressings

A peristomal or stomal ulcer beginning with an inflammatory appearance which rarely may lead to a fistula, when Crohn’s is present.

Causative Factors: ◦ Crohn’s disease

Treatment: Treat Crohn’ disease Atraumatic pouching system

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Creases

Folds

Morbid Obesity

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One complication can lead to another complication Preoperative marking can reduce complications Decrease or have a normal BMI to prevent complications Selection of a surgeon with good surgical technique will

reduce complications