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9/10/2018
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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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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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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