Peristomal skin is the surface around the stoma to which an ostomy pouching system adheres.1 If the integrity of this area is impaired, it can result in loss of appliance adherence and leakage, contributing to complaints of itching, burning, and pain.1 Up to 80% of individuals with an ostomy experience a peristomal skin complication: a skin inflammation, injury, or damage that occurs within 3 to 4 inches of skin surface surrounding an abdominal stoma or to the skin covered by the adhesive portion of the pouching system.2 All clinicians working with patients with stomas need to be aware of the signs and symptoms of peristomal skin complications and basic strategies to address the most common cause: leakage of stool or other effluent onto the skin. Below is a fictional case study addressing dilemmas of care during a non-ostomy-related hospitalization.
CASE STUDY
A 60-year-old man who is COVID-19 positive with complaints of dyspnea is admitted to a medical floor. The patient received a permanent colostomy 1 year ago secondary to rectal cancer. He completed both preoperative radiation treatment and postoperative chemotherapy and states, "The doc says they got it all!" The ostomy is in the left lower abdomen. He currently has a flat, cut-to-fit, drainable, one-piece pouch and empties soft formed stool once or twice a day. He has gained 15 lb since surgery (body mass index, 32 kg/m2). He notes that the stoma seems to be "harder to see" because of his weight gain, and the appliance has not been "sticking" well, so he changes the pouch daily and reinforces it with "duct tape" found in his kitchen. He reports that the skin under the appliance burns, and he smells stool. Because of insurance issues, he had only two home care visits after surgery, and although the stoma site was marked prior to surgery, he has not seen a certified wound, ostomy, and continence (WOC) nurse since discharge.
Dilemma: What Are Risk Factors?
Peristomal skin complications can be caused by mechanical, chemical, infectious, and/or health factors. They are most frequently identified in persons with an ileostomy, followed by urostomy and colostomy.1,2 Although peristomal skin changes are highest in the first 30 days after surgery,1 they can occur at any time. They occur more often in persons with preexisting skin conditions, abdominal hair, skin creases and folds, age older than 65 years, body mass index greater than 25 kg/m2, diabetes mellitus, abdominal malignancy as the reason for ostomy surgery, lack of stoma site marking and follow-up by a WOC nurse, and frequent appliance/adhesive removal.1-4
Dilemma: How to Assess Peristomal Skin?
Providers should ask: Is skin intact? Are the color and texture similar to adjacent and contralateral abdominal skin? Is the skin free of inflammation? Is the skin itching, burning, or painful? Use of a standardized instrument to assess the skin is important. The Wound, Ostomy, and Continence Nurses (WOCN) Society offers the Peristomal Skin Assessment Guide for Consumers5 and the Peristomal Skin Assessment Guide for Clinicians6 free of charge to assist with peristomal skin assessment and selection of interventions. The World Council of Enterostomal Therapists International Ostomy Guideline7 also includes information for patients with ostomies and their caregivers.8
Dilemma: Should the Appliance Be Removed?
Although there may be hesitancy to remove the appliance, that is the only way the skin and the pouching system can accurately be assessed. Patients may not report skin irritation, and it is important to remember that patients with an ostomy frequently fail to notice a peristomal skin complication in the early stages.1
CASE STUDY, CONTINUED
The appliance is removed once a replacement pouching system is available (Figure 1). The stoma protrudes and measures approximately 1.25 inch in diameter with the opening in the center. The opening in the appliance has been cut much larger than that. The patient shows the nurse the pattern that he has been using to cut the appliance and states, "I don't understand; it's the same pattern they gave me in the hospital." The peristomal skin is erythematous, eroded, and moist with obvious leakage of stool under the wafer. The nurse notes that when the patient sits up, a dip develops around the stoma. The skin under the duct tape is also erythematous with areas of trauma from frequent tape removal. The nurse recognizes moisture-associated skin damage (MASD)2 from constant exposure to stool as well as peristomal medical adhesive-related skin injury (PMARSI)1,6,10 from the duct tape and frequent pouch removals.
Dilemma: How to Prevent MASD and PMARSI?
The WOCN Society documents 19 consensus-based statements and six evidence-based statements to assist clinical decision-making for promoting peristomal health in adults.1 For example, the opening of the barrier should closely fit around the base of the stoma, and when patient weight fluctuates, pouching system effectiveness should be reassessed.1
CASE STUDY, CONTINUED
To improve the seal, the nurse dusts the denuded area with an ostomy powder and adds a barrier ring. The opening to the appliance is correctly sized to keep effluent from pooling on the skin. The nurse educates the patient regarding possible causes of the skin irritation and rationale for barrier ring and powder. A consult is placed for the inpatient WOC nurse to evaluate the patient for a different type of appliance and provide education.
Dilemma: How to Educate?
Peristomal skin health begins prior to surgery with stoma site marking and preoperative education.2 Education is key so the patient knows when to seek assistance. Providers and patients need to know how to use a validated peristomal assessment tool. This is true even for a person with an established ostomy because changes in body weight, treatment strategies and peristomal skin status can result in the need for alternate pouching strategies. Unfortunately, short hospital stays and inconsistent follow-up can result in a lack of necessary education. Every clinician who interacts with a patient with an ostomy should assess the patient's peristomal skin and pouching routines.
CASE STUDY, CONTINUED
The following day, the inpatient WOC nurse assesses the patient's abdominal contours and peristomal skin and agrees with the actions taken by the nurse. She also suggests switching from his current flat pouch to one with convexity and adding an ostomy belt to better accommodate the current abdominal contours. Soon, the patient can demonstrate use of the new pouching system. Emphasis is placed on avoiding use of duct tape because it increases the likelihood of skin injury. A new prescription for supplies is generated, and a follow-up appointment is made with the outpatient WOC nurse for a week after discharge.
SUMMARY
Assessment of peristomal skin health is the responsibility of all clinicians-not only the WOC nurse. Use of an evidence-based, standardized instrument to guide peristomal assessment and selection of appropriate interventions can improve patient outcomes and increase meaningful collaboration among all members of the healthcare team.
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