9/14/2018 1 Welcome to the WCET® Webinar on Peristomal Complications by Janice Colwell RN, MS, CWOCN, FAAN Denise Hibbert, RGN, MSc, BSc, STN, ONC, FSSCRS WCET Education Committee Chairperson Webinar Moderator Thank you to: WCET® Education Committee Jen Wood, WCET® Central Office Administrator In Celebration of World Ostomy Day WCET® thank Hollister® Journal Sustaining Partner for Sponsorship of this Webinar on “Current State of the Art and Science of Peristomal Complications” by Janice Colwell RN, MS, CWOCN, FAAN
26
Embed
WCET® thank Hollister® colwell wcet webinar... · 2018-10-05 · 9/14/2018 1 Welcome to the WCET®Webinar on PeristomalComplications by Janice Colwell RN, MS, CWOCN, FAAN Denise
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
9/14/2018
1
Welcome to the WCET® Webinar on Peristomal Complications by Janice Colwell RN, MS, CWOCN, FAAN
or damage that occurs within 3-4 inches of the skin surface surrounding the stoma or
– Skin inflammation in the area covered by the pouching system
• Pouching system– Skin barrier
– Adhesive tape
– Skin barrier rings, paste, powder
– Skin barrier strips
– Other items used to secure the seal
• Ex: liquid skin barrier, adhesive sprays
8
9/14/2018
5
Types of Peristomal Skin
• Moisture Associated Skin Damage1
– Inflammation and denudation of the skin adjacent to a stoma associated with exposure to effluent such as urine or stool
• Medical Adhesive Related Injury2
– Erythema and/or other manifestation of cutaneous abnormality (including, but not limited to, vesicle, bulla, erosion, or tear) persists 30 minutes or more after removal of the adhesive
1Gray M, et al, 2013, JWOCN 2McNichol L, et al, 2013, JWOCN
Types of Peristomal Skin Complications
• Pressure1
– Medical device injury or from pressure such as clothing or activity
– Prolonged wear time (allowing erosion of the skin barrier)
Photographs by J. Colwell
not for reprint
9/14/2018
12
Definition:
– Erythema and/or other manifestation of cutaneous abnormality (including, but not limited to, vesicle, bulla, erosion, or tear) persists 30 minutes or more after removal of the adhesive
– Defined area of skin damage beneath adhesive
– Other terms: skin stripping, skin tears
Medical Adhesive Related Skin Injury (MARSI)
Photographs by J. Colwell not for reprint
Medical Adhesive Related Skin Injury (MARSI)
• Treatment Address Etiology:
– Adhesive releaser
– Adhesive remover
– Gentle removal
• Topical Treatment
– Thin hydrocolloid
Thin Hydrocolloid
Adhesive remover
Push Pull Removal
Photographs by J. Colwell
not for reprint
9/14/2018
13
PMASD: Topical Treatment
• Topical Treatment
– Skin barrier powder1
– Liquid skin barrier
– Thin hydrocolloid sheet
1Salavadalena, WOCN Core Curriculum, 2016
Photographs by J. Colwell
not for reprint
Peristomal Skin Complication
• History:
– 60 yr. old female
– Ulcerative colitis/Ileostomy for 20 years
– Kidney failure: transplant
– Lung failure: transplant
– Non healing peristomal issues
– Differential Dx
• Extended wear time
• Poor skin barrier fit
• Moisture associated skin damage
Photographs by J. Colwell
not for reprint
9/14/2018
14
Peristomal Skin Complication• Interventions
– Decreased wear time
– Increase fit around stoma
• Skin barrier rings/paste
• Extended wear barrier
– Considered: silver nitrate
– Topical: triamcinolone spray and crème
• Significant findings
– Pain in some areas
– Areas increasing in size
– All topical and therapies unsuccessful
• Biopsy of area
– Adenocarcinoma
Photographs by J. Colwell
not for reprint
• Bladder cancer
• Ileal conduit
• Hard firm painful peristomal area
• CT: metastatic disease
• Inflammatory bowel disease
• Using reusable equipment
• Presented with inability to maintain pouch seal
Peristomal Skin Complication: Cancer
Photographs by J. Colwell not for reprint
9/14/2018
15
PSC: Allergic Contact Dermatitis
• Identify offending agent
• Substitute product
• Topical: anti inflammatory
– Triaminicolone spray
• Oral antihistamine
Photographs by J. Colwell
not for reprint
PSCs: Pressure Ulcers/Injuries
• Morbidly obese patient with bladder cancer
• End loop with support bridge
• High marking
• Tension on the rod
• Left in for one month
• Result: pressure ulcer from support bridge
Photographs by J. Colwell not for reprint
9/14/2018
16
PSCs: Pressure Ulcers/Injuries
Photographs by J. Colwell
not for reprint
PSCs: Pressure Ulcers/Injuries
• Treatment: Address Etiology
– Fit of skin barrier
– Avoid convexity
• Consider light or soft if necessary
– No belt
• Topical Therapy
– Dressing choice
• Foam
• Thin hydrocolloid
Photographs by J. Colwell
not for reprint
9/14/2018
17
Historical Perspective• Evolution of Skin Barriers
– Karaya
– Hydrocolloids
– Standard wear barrier: sheet
Pouching Systems: Skin Barrier Options
• Stoma opening
– Cut to fit
– Precut
– Moldable
Precut
Moldable
9/14/2018
18
Pouching Systems: Skin Barrier Options
• Skin barrier shape
– Flat
– Convex
• Light
• Soft
• Deep
Hoeflok, et al JWOCN 2013
Pouching Systems: Skin Barrier Options
• Outer footprint
– Oval
– Round
– Square
Photographs by J. Colwell
not for reprint
9/14/2018
19
Pouching Systems: Skin Barrier Options
• Skin Barrier Material– Hydrocolloid
• Regular wear
• Extended wear
• Combination
• Skin Barrier Material– Infused
• Honey
• Ceramides
• Aloe vera
The basic principle of ostomy care: a consistent seal that provides
security and maintains the peristomal skin
Tool Box
9/14/2018
20
Peristomal Complications: Varices
• Etiology
– Portal hypertension
• Management
– Avoid pressure
– Careful removal
– Bleeding control
Photographs by J. Colwell
not for reprint
Peristomal Complication
• 32 year old female
• Crohn’s dx, status post proctocolectomy
• On no maintenance Crohn’s Disease medications
• Present with warm painful area next to stoma
• Differential Diagnosis:
• Pyoderma
• Abscess
• Other?
Photographs by J. Colwell
not for reprint
9/14/2018
21
Peristomal Complication• Progressive pain, warmth
• Presentation with beige drainage
• Placed on antibiotics
• Ten days later developed stool from the area
• Final diagnosis: Crohn’s flare with fistula
Photographs by J. Colwell
not for reprint
Peristomal Complication
Peristomal Fistula
Photographs by J. Colwell
not for reprint
9/14/2018
22
Peristomal Abscess
Photographs by J. Colwell
not for reprint
Peristomal Skin Complication
• 98 year old male
• Rectal cancer/APR
• Colostomy
• Caregiver noted blisters
• Son sent image
Photographs by J. Colwell
not for reprint
9/14/2018
23
Peristomal Skin Complication:
• Treatment:
– Antiviral
– Burrow’s Solution soaks
– Adhesive releaser
Herpes
Photographs by J. Colwell
not for reprint
Peristomal Skin ComplicationsSnap Shot
• Cottam et al, 20071
– 3097=n– 34% developed problems
within 3 weeks after surgery
– Risk factors• Stoma height• BMI• Emergent surgery