Altered peristomal skin and tissue integrity: risk factors and prevention
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Take a careful history and assess | Level of Evidence Not Assessed |
| Address Patient-centered Concerns | ||
|---|---|---|
| 2 | Develop and implement a comprehensive perioperative education program for ostomates and incorporate frequent reinforcement. | Level of Evidence Not Assessed |
| 3 | Implement a postoperative follow-up schedule that incorporates assessment of the stoma, peristomal skin, the pouching system, and patient self-care. | Level of Evidence Not Assessed |
| Provide Local Care | ||
|---|---|---|
| 4 | Address problems with skin complications by reviewing appropriate self-care techniques, product and appliance selection and treating the complication. | Level of Evidence Not Assessed |
| Provide Organizational Support | ||
|---|---|---|
| 5 | Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information. | Level of Evidence Not Assessed |
Background
Protection of peristomal skin and maintenance of skin integrity plays a central role in ensuring a predictable pouch wear time with an intact seal. Compromised skin integrity may result in a worsening cycle of pouch leakage and skin erosion. Care of peristomal skin involves creating a dry surface, smoothing irregular contours and treating infection, while maintaining an adhesive seal.Most ostomates require treatment for peristomal skin complications at some point. The following are risk factors for skin complications:
• A poorly sited or constructed stoma
• The presence of stoma complications, such as retraction, hernia or prolapse
• The presence of wound complications in or near the peristomal area
• Recurrent disease
• Obesity.
Skin complications may also occur due to lack of patient access to care by specialized ostomy nurses.
Prevention of peristomal skin complications begins preoperatively, with selection of an appropriate site by a qualified stoma nurse, according to specific guidelines. The right site allows a secure pouch seal, simplifies self-care, and reduces the risk of stoma and skin complications. Surgical technique is also important, as an upward-pointing lumen and a minimum 2.5-cm protrusion of the stoma both reduce the risk of erosion of the barrier adhesive by effluent. Postoperatively, patient knowledge and use of meticulous skin care can keep the peristomal skin clean, dry and protected from injury from trauma and effluent. Maintenance of the integrity of peristomal skin relies on the following:
• The ostomate must know that peristomal skin should be normal in appearance and recognize changes. However, many patients believe that it is normal for the skin to be irritated. The most common peristomal skin complication is irritant contact dermatitis.
• The pouching system must be properly sized and contoured so that the skin at the base of the stoma is covered. Due to changes in the stoma and the abdomen over time, regular assessment of fit is necessary. Several pouch refittings may be necessary over the first few postoperative months, and additional refittings may be required over the patient’s lifetime.
• An appropriate pouch change schedule (usually every 4–7 days) must be established to prevent leakage. If leakage does occur, a clean system should be applied.
• Atraumatic adhesives, skin sealants for sensitive skin, and gentle cleansing can all protect peristomal skin from mechanical trauma. Using water or a pH-balanced cleanser and avoiding unnecessary use of skin care products reduces the risk of irritant contact dermatitis.
• Maintaining dry peristomal skin is critical both to obtaining a good seal and to reducing the risk of candidiasis. After showering with the pouch on, the patient may use a hair dryer (cool setting) or allow the skin barrier and pouching system to air dry. On the day of a pouch change, if the pouch is removed before showering, the patient should pat the skin dry.
• The ostomate should be able to manage leakage using skin barrier powder, more frequent pouch changes and use of skin barriers to fill irregular surfaces. If these strategies do not correct the problem, a specialized ostomy nurse should be consulted.
References
| Essential Publications |
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