A practical guide for Stoma problems Developed by the Ostomy Forum
Dedicated to Stoma Care A practical guide for Stoma and Peristomal skin problems A practical guide for Stoma
Developed by: Frances McKenzie, Amanda Smith, Doreen Woolley, Beverley Colton, Bart Tappe and Global Clinical Marketing, Dansac A/S.
The practical guide is based on the Observation Index developed by the Ostomy Forum group (a specialized group of ET nurses from Sweden, Norway, The Netherlands, Poland, Japan, UK and Denmark) and is Normal Stoma made to help you manage common stoma and peristomal skin problems you might come across in your nursing practice. Stoma is a Greek word that means opening or mouth. It is a surgically created opening that can be temporary or permanent and allows for the Sharing best practice by use of this educational tool will lead to early excretion of faecal waste (colostomy, ileostomy) or urine (urostomy). detection and appropriate intervention to secure a high standard of stoma care. A stoma is a surgically made opening of the bowel: • The bowel is brought out through the abdominal wall This tool should be used in consultation with your Stoma Care Specialist. • It is matured and sutured subcutaneously • Faeces and urine will pass and be collected in a specially designed Disclaimer: ostomy pouch. We recognize that nurses in other practices will have different ways of treating the identified problems. The scope of this guide is to give first In the following pages you will find examples of different stoma problems step, easy to use, practical advice that is recognized and accepted and concrete suggestions for intervention and management of the stoma. internationally.
Convex products should only be used under the supervision of an experienced Stoma Care Specialist.
A practical guide for Stoma A practical guide for Stoma
Stoma Status Definition/Presentation Proposed intervention and management
Flush Mucosa level with the skin Most flush stomas do not cause problems.
• If causing leakage it may require soft or shallow convexity. Contact your Stoma Care Specialist for appropriate advice. • If causing pancaking the aim is to keep the pouch away from the stoma surface to prevent a vacuum. One or more of the following may be effective; trap air in the pouch, cover the filter with the filter covers supplied in the box, add lubricating gel in the pouch, change the consistency of the output by fluid and dietary intake, consider bulking agents.
Retracted Mucosa below skin level, partial or • Partial retraction: use of paste or seals to fill/level out the point of circumferential retraction and thereby reduce the risk of leakage, soft or shallow convexity, appropriate use of a belt. • Circumferential retraction: Use of paste or seals, consider a convex product with appropriate use of a belt. Contact your Stoma Care Specialist for assessment and advice on possible use of dilator (to reduce the risk of stoma stenosis).
Prolapsed Notable increased length of stoma • This is not necessarily a medical emergency unless there is a change in stoma colour, the stoma is non-functioning, the patient has severe pain at the stoma site or is vomiting. The patient should be reviewed by the Stoma Care Specialist or medical practitioner. • To accomodate the oedomatous stoma the hole of the appliance should be cut larger, this will cause the peristomal skin to be exposed. The use of seals/washers will protect the exposed skin. Cover the stoma with a swab while placing the pouch; this will stop the flange getting wet. • Many patients are able to manage their prolapsed stoma by using a flexible adhesive appliance. Depending on the length of the prolapse a large capacity appliance may be required.
Stoma Stoma A practical guide for Stoma A practical guide for Stoma
Stoma Status Definition/Presentation Proposed intervention and management
Hernia Bowel entering parastomal space • Check the stoma size regularly as the hernia will usually cause the stoma to change shape. This should be assessed in both a sitting and standing position. • Large / oval shaped adhesive flanges may give more security. “Picture framing” of the flange with retention strips/tape may prolong wear time. However, if the seal is broken and the pouch is leaking it must be changed! • After assessment the Stoma Care Specialist may refer the patient for surgical review. • Use of support garments or abdominal belts are only effective if the hernia is reducible. Belts or garments should be fitted by an appropriately trained specialist.
Stenosis Tightening of stomal orifice • This is not necessarily a medical emergency unless the stoma is non-functioning, the patient is in pain or vomiting. • Pouch management does not need to be changed. However ensure the aperture is sufficient to allow faeces to enter the pouch. • The stoma may require dilation. Refer the patient to a medical practitioner or Stoma Care Specialist for assessment. • Surgical correction may be required.
Granulomas Raised nodules/lumps on the stoma • The granulomas may be painful, bleed easily and cause the pouch to leak. They may be due to friction from the appliance, belts, clothing or patient behaviour. • Treat the stoma very gently. Excessive bleeding may be stopped by using a cold compress. • Use a soft and flexible appliance to reduce friction. • Contact your Stoma Care Specialist who will initiate treatment according to local protocol.
Stoma Stoma A practical guide for Stoma A practical guide for Stoma
Stoma Status Definition/Presentation Proposed intervention and management
Separation Mucocutaneous separation, partial No treatment is required for superficial separation. If there is a deep or circumferential cavity, filler paste/seals or alginates may be used.
Reassure the patient that this will heal in time. Stoma care practice differs when treating this condition. Common forms of management are:
1. Cut the adhesive to the edge of the separation. Change the appliance according to local protocol.
2. Cut the adhesive to the stoma size so the adhesive seals as a lid over the separation. Change the appliance according to local protocol.
3. Use non-alcohol based paste/seals or alginates in the separation. Cut the adhesive to the stoma size and seal as a lid over the separation. Change the appliance according to local protocol.
Convex products should only be used under the supervision of an experienced Stoma Care Specialist and according to local protocol.
Recessed Stoma in a skin fold or a crease • Use filler paste and /or seals in the creases to level the area. • Flatten out the skin folds when applying the paste/seals and the appliance. • Consider using a convex product under Stoma Care Specialist advice.
Stoma Stoma A practical guide for Stoma A practical guide for Stoma
Stoma Status Definition/Presentation Proposed intervention and management
Necrosis Lack of blood supply causing par- • Reassure the patient. tial or complete tissue death • Close observation of colour and temperature of the stoma. • Report changes immediately. • The stoma may be examined via an endoscope to identify the depth of the necrosis and check the viability of the bowel. • Apply a clear pouch for easier assessment. • May require surgical intervention.
Laceration Mucosa that is jagged/torn or • Observe and identify the cause, it might be accidental or non ulcerated due to trauma accidental (inappropriate use of belts, convex appliances, self harm etc). • Remove the cause, re-educate the patient and refer to other agencies as necessary (Stoma Care Specialist, Clinical Psychologist etc). • Surgical intervention is unlikely unless the stoma is completely cut through.
Oedema Gross swelling of the stoma • Post operative oedema is normal after surgery. It will slowly reduce within 10 days. Unexplained gross oedema needs further investigation. • Review the stoma size daily and adjust the aperture of the pouch to avoid exposure of the peristomal skin. • If the stoma is very oedematous the use of a cold compress may help reduce the swelling before applying the pouch. • After cutting the aperture to the correct size, the adhesive can be cut with radial slits (feathering/frilling) to enable easier application of the pouch.
Entero-cutaneous An abnormal tract between the • Make sure the adhesive of the appliance does not cover the fistula. fistula bowel and the skin surface • Consider seal or paste to protect the peristomal skin. • Use of convex appliances may be indicated under supervision of the Stoma Care Specialist.
10 Stoma Stoma 11 A practical guide for Stoma All rights reserved. All pictures in this booklet are copyright of Dansac A/S. The pictures of flush, prolapsed, stenosis, granulomas, separation, recessed, necrosis, oedema, Notes infection, Pyoderma Gangrenosum, psoriasis, Chronic papillomatous dermatitis, ulcerated, erythema, normal stoma and normal skin are copyright of Medical Illustrations, Salford Royal NHS Foundation Trust. The pictures of retracted, fistula, folliculitis and granulomas on skin are copyright of Dr. Calum Lyon.
Dansac wish to thank Medical Illustrations and Dr. Lyon for allowing the use of their materials in this booklet. No pictures in this booklet may be distributed or reproduced in any other materials.
Your Local Stoma Care Specialist
Name:
Phone:
A practical guide for Peristomal Skin 12 Stoma Stoma 13 A practical guide for Stoma & Peristomal Skin A practical guide for Stoma & Peristomal Skin
Dansac Accessories Dansac Convexity products
Flat wafers All Dansac Skin Barriers are made Soft Convex The Dansac Soft Convex wafer is of hydrocolloid and skin-friendliness flexible and moldable and provides is a top priority for Dansac. The a moderate pressure around the smooth EMA carrier allows the skin stoma. Made for patients with to breathe, eases cleaning and a flush stoma, a partly retracted prevents tugging from clothes. stoma, a stoma in a pliable skin fold or peristomal ulceration.
X3 Wafers The X3 wafer is a 3 mm thick Convex* The Dansac Convex wafers are hydrocolloid providing enhanced standard convex wafers with 6 mm skin protection, extra security and convexity. It is firm and provides comfort. extra pressure around the stoma. For difficult cases: e.g. severe obesity, a stoma in a deep crease or a severely retracted stoma.
Soft Paste Dansac Soft Paste is ideal for GX-tra Seals Dansac GX-tra Seals are designed levelling skin folds and scars to to reduce the risk of leakage. GX- make the appliance fit securely tra Seals are an ideal solution if the around stomas or fistulae. Dansac skin around the stoma is uneven or Soft Paste helps protect the skin, creased - they can easily be formed increase security and extend to fit individual needs. weartime.
*Notice that Convex products should only be applied after consulting a Stoma Care Specialist.
14 Dansac Accessories Dansac Convexity products 15 A practical guide for Peristomal Skin References:
Notes Lyon C. and Smith A.: Abdominal stomas and their skin disorders. An atlas of diagnosis and management. Martin Dunitz, London 2001. (2nd edition 2009)
Ogden S., Mukasa Y., Lyon C.C. & Coulson I.H.: Nicorandil-induced ulcers: is nicorandil also associated with gastrointestinal fistula formation? British Journal of Dermatology 2007, March 156 (3): p. 608-9.
A practical guide for Stoma Skin 12
11 0 1 Skin Skin
protocol.
If very severe, oral antibiotic treatment/skin washes as per local local per as washes treatment/skin antibiotic oral severe, very If •
patient on shaving technique using single use razor and water. water. and razor use single using technique shaving on patient
the Re-educate removal. hair peristomal for technique patient Assess • follicles hair Infected Folliculitis
products.
care stoma with conjunction in treatments topical non-oily Apply •
appear on any part of the body the of part any on appear excema Refer to the Stoma Care Specialist for further advice. advice. further for Specialist Care Stoma the to Refer •
Common skin disorders that that disorders skin Common Psoriasis/ Take a microbiology swab to culture the area. the culture to swab microbiology a Take •
Depending on the severity there are various treatment options. options. treatment various are there severity the on Depending •
strands may be present present be may strands Take a microbiology swab to culture the ulcer. the culture to swab microbiology a Take •
which ooze exudate, skin bridges/ skin exudate, ooze which Gangrenosum assessment. assessment.
Purple edged, very painful ulcers ulcers painful very edged, Purple Pyoderma Refer to the Stoma Care Specialist/Dermatologist for further further for Specialist/Dermatologist Care Stoma the to Refer •
supervision of the Stoma Care Specialist. Care Stoma the of supervision
After positive results, appropriate treatment to be used under the the under used be to treatment appropriate results, positive After •
Re–educate if necessary. necessary. if Re–educate
Assess patient self care and pouch changing technique. technique. changing pouch and care self patient Assess •
Take a skin scraping and/or a microbiological swab for culture. for swab microbiological a and/or scraping skin a Take •
Infection can be bacterial or fungal or bacterial be can Infection Infection Skin can appear dry and flaky or raised, red and moist. and red raised, or flaky and dry appear can Skin •
Proposed intervention and management and intervention Proposed Definition/Presentation Status Peristomal skin Peristomal A practical guide for Peristomal Skin Peristomal for guide practical A
18 Skin Peristomal for guide practical 19 A
9 8 Skin Skin
juice/tablets are contraindicated if your patient is on Warfarin). on is patient your if contraindicated are juice/tablets
Cranberry (NB: urine. acidify to help also may /tablets juice Cranberry •
help to acidify urine. acidify to help
may day per tablets C Vitamin gram 1 than more no of intake, Oral •
pouch change till the problem is resolved. is problem the till change pouch
every at solution water and Vinegar weak a with lumps the Wash •
Consider seal or paste to protect skin from urine. from skin protect to paste or seal Consider •
changing technique. changing
Provide the patient with written information on correct pouch pouch correct on information written with patient the Provide •
Re-educate the patient on good peristomal hygiene. hygiene. peristomal good on patient the Re-educate •
Review within 4 weeks. 4 within Review
Consider using a pre cut convex product with a belt until resolved. resolved. until belt a with product convex cut pre a using Consider
stoma. the fit to template new a cut and size stoma the Measure •
Assess patient self care, pouch application and removal. removal. and application pouch care, self patient Assess •
into contact with the skin the with contact into (CPD) dermatitis
exposed to urine over a prolonged period of time, can be painful. be can time, of period prolonged a over urine to exposed coming urine alkaline by caused papillomatous
Only urostomates are affected, this is due to peristomal skin being being skin peristomal to due is this affected, are urostomates Only skin on lumps raised Greyish, Chronic
* Requires doctors prescription doctors Requires *
practicioner for surgical removal. surgical for practicioner
Large areas of over-granulation may require referral to medical medical to referral require may over-granulation of areas Large •
of a Stoma Care Specialist. Care Stoma a of
All of the above as prescribed and must be used under the supervision supervision the under used be must and prescribed as above the of All
- Convex products Convex -
- Liquid nitrate* Liquid -
- Steroid cream* Steroid -
- Silver nitrate* Silver -
Management options may include: may options Management •
When cleaning the area treat the skin very gently and pat dry. pat and gently very skin the treat area the cleaning When •
this. into
granulomas the include not Do . appliance to fit the stoma only stoma the fit to
appliance to leak. leak. to appliance the of template the maintain to important is It skin on
The granulomas may be painful, bleed easily and cause the the cause and easily bleed painful, be may granulomas The • Nodules/over-granulation tissue tissue Nodules/over-granulation Granulomas
Proposed intervention and management and intervention Proposed Definition/Presentation Status Peristomal skin Peristomal A practical guide for Peristomal Skin Peristomal for guide practical A
20 Skin Peristomal for guide practical 21 A
7 6 Skin Skin
the Stoma Care Specialist). If persistent refer to Dermatologist. to refer persistent If Specialist). Care Stoma the
resolved or for a maximum of 4 weeks (under supervision of of supervision (under weeks 4 of maximum a for or resolved
until treatment steroid topical local apply present, is infection no If •
the irritant. the
of use discontinue so, If adhesives. powder, washing lotions,
wipes, soaps, example: for used products and technique care stoma
their to changes/additions any been have there whether Check •
further assessment. further
for Specialist Care Stoma to refer and skin the culture and Swab •
Review as for Erythema. for as Review •
and Smith). Smith). and
diagnosis can only be confirmed after positive patch testing (ref. Lyon Lyon (ref. testing patch positive after confirmed be only can diagnosis
sore, itchy and red and itchy sore,
leakage onto the peristomal skin. Allergic reactions are very rare and and rare very are reactions Allergic skin. peristomal the onto leakage
Irritant causing skin to be inflamed, inflamed, be to skin causing Irritant Irritated
The most common cause for the skin to be irritated is faecal or urine urine or faecal is irritated be to skin the for cause common most The
Trauma /self harm or infection. or harm /self Trauma •
Pyoderma Gangrenosum (see other). (see Gangrenosum Pyoderma •
Check medication e.g. Nicorandil induced ulcer (ref. Ogden et al.). et Ogden (ref. ulcer induced Nicorandil e.g. medication Check •
advice.
Specialist Care Stoma with appliance stoma of type change belt, the
removing Consider belt. and/or convexity by caused ulcer Pressure •
Differential diagnoses may be: be: may diagnoses Differential
conjunction with topical treatments following local protocols. local following treatments topical with conjunction
subcutaneous skin layer skin subcutaneous
Skin protecting wafers and/or seal to fit the area; can be used in in used be can area; the fit to seal and/or wafers protecting Skin •
Skin defect reaching into into reaching defect Skin Ulcerated
Review as for Erythema. for as Review •
Proposed intervention and management and intervention Proposed Definition/Presentation Status Peristomal skin Peristomal A practical guide for Peristomal Skin Peristomal for guide practical A
22 Skin Peristomal for guide practical 23 A
5 4 Skin Skin
Apply topical treatments as per local stoma care protocols. protocols. care stoma local per as treatments topical Apply • skin
Review as for Erythema and Macerated. and Erythema for as Review • bleeding and moist Excoriated; Eroded
Alcohol based paste should not be used on broken skin. broken on used be not should paste based Alcohol •
Consider the use of seals or change of product. of change or seals of use the Consider •
the problem is resolved. resolved. is problem the
when use discontinue and only areas moist on powder protective Use •
Review frequency of appliance change. appliance of frequency Review •
Review as for Erythema. for as Review • skin moist Excoriated; Macerated
Consider seal or paste to protect the peristomal skin. peristomal the protect to paste or seal Consider •
problem resolves, to avoid residue build up. build residue avoid to resolves, problem
practices may advise usage. They should be discontinued when when discontinued be should They usage. advise may practices
local however required, normally not are accessories protecting Skin •
motility drugs/bulking agents if necessary. if agents drugs/bulking motility
anti add type; stoma to appropriate is consistency output Check •
changing technique. changing
Provide the patient with written information on correct pouch pouch correct on information written with patient the Provide •
appliance. appliance.
Educate the patient to support the skin whilst removing the the removing whilst skin the support to patient the Educate •
Educate the patient to measure their stoma regularly. regularly. stoma their measure to patient the Educate
Measure the stoma size and alter the cutting template to fit the stoma. stoma. the fit to template cutting the alter and size stoma the Measure •
Assess patient self care, pouch application and removal. removal. and application pouch care, self patient Assess •
Good stoma care practice is to: is practice care stoma Good
large, excessive changing of the appliance or poor changing technique. changing poor or appliance the of changing excessive large,
an ostomy pouch. Common causes of erythema are: appliance cut too too cut appliance are: erythema of causes Common pouch. ostomy an
Transient erythema or “blushing” of the skin is normal when removing removing when normal is skin the of “blushing” or erythema Transient skin intact Red Erythema
Proposed intervention and management and intervention Proposed Definition/Presentation Status Peristomal skin Peristomal A practical guide for Peristomal Skin Peristomal for guide practical A
24 Skin Peristomal for guide practical 25 A
Greater Glasgow and Clyde NHS Trust NHS Clyde and Glasgow Greater
Frances McKenzie - Glasgow Royal Infirmary, Infirmary, Royal Glasgow - McKenzie Frances suggestions for intervention and management. and intervention for suggestions
Doreen Woolley - Manchester NHS Primary Trust Primary NHS Manchester - Woolley Doreen conditions and we will provide suggestions for treatment and specific specific and treatment for suggestions provide will we and conditions
Bart Tappe - Royal United Hospital Bath Hospital United Royal - Tappe Bart In the following pages you will find examples of different peristomal skin skin peristomal different of examples find will you pages following the In
Amanda Smith - Salford Royal Foundation NHS Trust NHS Foundation Royal Salford - Smith Amanda
Beverley Colton - United Hospitals Bristol Foundation Trust Foundation Bristol Hospitals United - Colton Beverley changing technique. changing
Provide the patient with written information on correct pouch pouch correct on information written with patient the Provide •
a success Dansac would like to thank the following people: following the thank to like would Dansac success a appliance. appliance.
For outstanding contribution towards making this project this making towards contribution outstanding For Educate the patient to support the skin whilst removing the the removing whilst skin the support to patient the Educate •
Educate the patient to measure their stoma regularly. regularly. stoma their measure to patient the Educate
Measure the stoma size and alter the cutting template to fit the stoma. stoma. the fit to template cutting the alter and size stoma the Measure •
Assess patient self care, pouch application and removal. removal. and application pouch care, self patient Assess •
Good stoma care practice is to: is practice care stoma Good
review stoma care practice. care stoma review
First line management of any peristomal skin problem is always to to always is problem skin peristomal any of management line First
the skin barrier/pouching system is adhered. adhered. is system barrier/pouching skin the
peristomal skin is vital in stoma care as it provides the surface on which which on surface the provides it as care stoma in vital is skin peristomal Peristomal skin is the skin immediately surrounding the stoma. Intact Intact stoma. the surrounding immediately skin the is skin Peristomal
E24-82-300
Skin Peristomal Normal 03/09 ©2009 Dansac A/S A/S Dansac ©2009
Lindegaard & Co & Lindegaard A practical guide for Peristomal Skin Peristomal for guide practical A
26 27
Dedicated to Stoma Care Stoma to Dedicated
Developed by the Ostomy Forum Ostomy the by Developed
Peristomal Skin problems Skin Peristomal A practical guide for for guide practical A
28