CPD
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Stomas multiple choice questionnaire
CONTINUING PROFESSIONAL DEVELOPMENT
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Abby Morrow-Barnes’s practice profile on temperature monitoring
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Guidelines on how to write a practice profile
Care of patients with peristomal skin complications NS743 Burch J (2014) Care of patients with peristomal skin complications. Nursing Standard. 28, 37, 51-57. Date of submission: September 15 2013; date of acceptance: March 6 2014.
Abstract Stoma formation is common and may be necessary in the management of certain diseases and as a result of surgery to the gastrointestinal tract or urinary tract. Because stomas provide an alternative route for the excretion of faeces and urine, they can have a significant effect on the individual’s physical, psychological and social functioning. Stomas require careful management and patients need to be taught how to self-care for the stoma and how to recognise common complications. This article focuses on the signs, symptoms and management of peristomal skin complications.
Author Jennie Burch Enhanced recovery nurse, St Mark’s Hospital, Harrow, Middlesex. Correspondence to: [email protected]
Keywords Peristomal skin complications, skin care, stoma, stoma accessories
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
Aims and intended learning outcomes This article aims to increase the reader’s knowledge of stoma formation and the importance of effective management of patients with peristomal skin complications. After reading this article and completing the time out activities you should be able to:
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Describe the anatomy and physiology of the gastrointestinal (GI) tract and urinary system. Provide an overview of the different types of stomas and their indications. Identify the appropriate stoma appliance for each type of stoma. Discuss the causes of peristomal skin complications and appropriate management. Outline when and why stoma accessories can be used.
Introduction Stomas are formed from the GI tract or urinary system and provide an alternative passage for the excretion of urine or faeces. There are many reasons necessitating stoma formation, including bowel or bladder cancer, ulcerative colitis, Crohn’s disease and diverticular disease. The three main types of stoma are a colostomy, ileostomy and urostomy. These require different nursing management to prevent problems such as peristomal skin complications and improve patient outcomes and quality of life. Complete time out activity 1
Gastrointestinal tract and urinary system The GI tract or alimentary canal is the passage from the mouth to the anus. The GI tract is involved in the digestion of food, absorption of nutrients to provide energy for the cells in the body and elimination of waste products. The GI tract consists of several sections. The mouth contains the teeth and saliva, which break down food and fluid, allowing it to be swallowed and to travel down the oesophagus to the stomach. In the stomach, enzymes are involved in may 14 :: vol 28 no 37 :: 2014 51
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CPD skin care further digestion. Churning of the food also helps to break it down further before it passes to the small bowel, which consists of the duodenum, jejunum and ileum. Here, products of digestion, including nutrients and fluid, are absorbed into the bloodstream. Waste products travel along the colon, which is composed of the caecum, ascending colon, transverse colon, descending colon and sigmoid colon. Sodium and more fluids are reabsorbed, and loose faeces become formed faeces. Flatus, or gas, is also produced in the colon. Faeces and flatus are excreted via the anus (Tortora and Derrickson 2007). The urinary or renal system consists of two kidneys, two ureters, the bladder and the urethra. The urinary system is involved in the formation and excretion of urine. Urine is formed and then stored in the bladder until it is excreted through the urethra. Complete time out activity 2
Stoma formation
1 Using an appropriate anatomy and physiology textbook, study the GI tract and urinary system. Think about how particular diseases or surgery involving these areas may necessitate formation of a stoma. 2 Describe the different types of stoma and indications for their use. How might nursing management differ for each type of stoma?
In general, stoma formation involves making an incision in the abdominal wall and bringing the bowel (colon or ileum, depending on whether it a colostomy or ileostomy) through this hole and stitching it onto the abdominal wall using dissolvable sutures. These sutures usually dissolve within eight weeks of stoma formation (Burch 2008). A colostomy is minimally raised above the abdominal wall by around 5mm. The ileostomy and urostomy are formed to have a small 25mm spout to ensure that faeces and flatus or urine is kept away from the skin surrounding the stoma (Buckle 2013). An end or loop stoma can also be formed. A loop stoma is usually temporary and an end stoma is often permanent, but this is not always the case. An end stoma tends to be slightly more circular and a loop stoma may be egg-shaped. When a loop stoma is formed, there are two openings on the abdominal wall, but often the lower loop, which does not pass faeces, is small. The lower or distal loop may pass some mucus that travels up, rather than down, the defunctioned segment of bowel.
Type of stoma A stoma is formed during a surgical procedure to divert the passage of faeces and flatus or urine outside of the body for collection in a stoma appliance (Recalla et al 2013). The stoma is formed from a part of the bowel and appears red or pink in colour and wet and warm to touch. The stomal output leaves the
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body from the stoma and is then collected and contained in a stoma appliance. There are three main types of stoma: the colostomy, ileostomy and urostomy. Stomas may be formed for several reasons, as identified in Box 1. Surgical operations that may result in stoma formation are shown in Box 2.
Colostomy
A colostomy is formed from the colon or large bowel and may be required as a result of bowel cancer or diverticular disease (Cronin 2012). The descending or sigmoid colon is the most common section of the colon used to form a colostomy. It is also possible to form a colostomy from the transverse colon. Faeces passed from a colostomy are generally soft and formed, although the consistency of faeces can vary from individual to individual, and according to diet. Flatus is also passed from a colostomy. The stomal output is collected and contained in a closed colostomy appliance. The stoma will enable the passage of flatus multiple times per day and will pass faeces usually between three times weekly and three times daily, most commonly once or twice daily. Therefore, the appliance needs to be changed once or twice each day (Voergaard et al 2007). Transverse colostomies involve the passage of loose stool and usually require a drainable appliance to collect and contain the faeces. The faeces may need to be drained several times per
BOX 1 Reasons for stoma formation Cancer, for example involving the colon, rectum or bladder. Inflammatory bowel disease, including ulcerative colitis or Crohn’s disease. Congenital malformations, such as imperforate anus. Diverticular disease.
BOX 2 Surgical operations that may result in stoma formation Total colectomy and temporary end ileostomy. Cystectomy and permanent end urostomy. Abdominoperineal resection of the rectum and permanent end colostomy. Low anterior resection and temporary loop ileostomy. Panproctocolectomy and permanent end ileostomy. Hartmann’s procedure and temporary end colostomy.
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day and the appliance replaced on a daily basis or every few days (Burch 2008).
Ileostomy
An ileostomy is formed from the small bowel usually near the end that joins the colon (terminal ileum) and may be necessary in the treatment of inflammatory bowel disease (Burch 2008). Faeces passed from the ileostomy are generally loose, with a porridge-like consistency. There is also a small amount of flatus passed. The stomal output will vary depending on the food and fluid consumed. The ileostomy output is collected in a drainable bag. Most people with an ileostomy will empty the appliance about four to six times daily (Black 2012) and may change the appliance daily or every few days.
Urostomy
A urostomy, also known as an ileal conduit, is formed from a small segment of the ileum, which may be necessary in the treatment of patients with bladder cancer (Black 2012). Infrequently, a small segment of the colon is used for the conduit and in this case may be referred to as colonic conduit. The output from the urostomy will contain urine and a small amount of mucus. Urine is passed continually and collected in a drainable appliance that is emptied using a tap or bung about four to six times daily (Burch 2008). The urostomy appliance is usually changed on a daily basis or every alternate day. Complete time out activity 3
Care of patients with a stoma A person due to have a stoma will be seen by a stoma specialist nurse before surgery. Issues that will be discussed include (Cronin 2012): What a stoma is. What a stoma looks like. What is normal, for example in terms of the stomal output. How activities of daily living and lifestyle might be affected. Basic care of the stoma. Siting or marking of the position of the stoma. The patient also needs to be shown how to care for the stoma (Bryan and Dukes 2010). This will include information about changing the appliance and what is considered ‘normal’ skin, namely the absence of any changes such as redness or soreness. Although changing the appliance is relatively simple, care needs to be taken to prevent problems, such as leakage of the stomal output causing sore skin.
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The patient should be advised to gather all the equipment needed before changing the appliance. If the stoma appliance is drainable, it is important to empty the appliance to prevent spillage. The old appliance should be gently removed to prevent damaging the skin. The edges of the flange, the adhesive part of the stoma bag, should be stuck together and it should be placed into a fragranced rubbish bag. These bags may be available from the stoma supplier, or bought in a pharmacy. The skin around the stoma needs to be gently but thoroughly cleaned and carefully dried to remove all traces of faeces or urine to prevent skin irritation. The stoma does not need to be cleaned because it is designed to come into contact with faeces. The aperture in the stoma flange should be cut 2-3mm larger than the size of the stoma and should be the same shape to prevent leakage of the stomal output on to the surrounding skin (Rust 2007). Once the stoma size has settled after being formed, which takes about eight weeks because stomas are initially oedematous, the hole in the flange can be pre-cut if desired. The plastic backing has to be removed from the flange and the aperture placed around the stoma. The adhesive needs to be carefully but firmly pressed into place and held in position for about 30-60 seconds. The waste is then sealed in the fragranced rubbish bag and disposed of in the rubbish bin. Once the patient is discharged from hospital, he or she should be able to undertake basic care of the stoma. Some hospitals have structured follow up with the stoma care nurse and others will offer access to stoma clinics if needed.
Stoma appliances A stoma appliance is necessary to collect and contain the stomal output. Colostomy and ileostomy appliances have a flatus filter, which allows the gas to leave the appliance but contains the odour. The filter means that the appliance will not balloon out as it fills with flatus. To prevent the backflow of urine and reduce the risk of a urinary tract infection, there is a non-return valve in the urostomy appliance (Kirkwood 2006). Many patients will also use a night bag with the urostomy appliance to allow greater volumes of urine to be collected, enabling them to sleep without having to empty the bag frequently. The stoma appliance is formed of two parts: the adhesive part and the collection part. The adhesive part has a variety of different names including the flange, face plate and base plate. The collection part is formed from plastic and
3 Describe the hospital care that a patient undergoing stoma formation should receive. What advice would you give to a patient to prepare him or her for stoma formation?
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CPD skin care
4 Reflect on the different stoma accessories that can be used to help a patient with peristomal skin problems. How do these work? Discuss the advice you would give to a patient presenting with sore peristomal skin.
will generally have a soft, fabric-like cover to aid patient comfort. The appliance is also available in clear plastic, which is particularly useful for a newly formed stoma, permitting the stoma and stomal output to be seen in the early post-operative period. The flange is generally flat and thus is ideally placed on a flat area of the abdominal wall. If the abdominal wall is not flat it may not be possible to secure the appliance, potentially resulting in leakage of the stomal output. This, in turn, may result in peristomal skin complications such as sore skin. This may be resolved with the use of a stoma adhesive paste or a seal, which is a more flexible version of the flange formed into a small circular shape. Stomas can be used with either a one-piece or two-piece appliance. In a one-piece appliance, the flange and bag section are joined. In a two-piece appliance, these two parts are separate and the patient needs to attach them (Bradshaw and Collins 2008). There are advantages with both one and two-piece appliances. Some patients will prefer to have a simple change and thus might choose a one-piece appliance. Others prefer to reduce the number of times that the flange is removed from the skin and, therefore, will choose a two-piece appliance. This can prevent skin trauma such as skin stripping for people with a colostomy who need to change their appliance frequently. Toilet disposable colostomy appliances are also available. Generally, patients need to be advised not to throw appliances or cleaning cloths into the toilet to prevent blockage. Small fragranced bags allow the stomal equipment to be disposed of safely in the rubbish bin. Appliances also come in a variety of sizes to suit the needs of individual patients. Furthermore, small caps that can be used after colostomy irrigation, or during sporting or sexual activities are available. These are used to cover the stoma for short periods, collecting and containing any stomal output. With several manufacturers producing stoma appliances, patients are able to select the most suitable option to meet their individual needs. Complete time out activity 4
Stoma accessories Stoma accessories may be used in combination with the stoma appliance. Stoma accessories may be necessary for several reasons, such as to protect the skin or to assist adhesion of the appliance. However, this article will focus on
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stoma accessories that can be used to prevent peristomal skin problems (Box 3).
Skin care Williams et al (2010) reported that three quarters of people with a stoma will experience sore skin. The most common cause for sore peristomal skin is the stomal output coming into contact with the surrounding skin (Mitchell et al 2007). This may be caused by the aperture of the stoma flange being too large (Recalla et al 2013). Frequent removal of the flange can also cause skin stripping, and patients may have allergic reactions that result in sore skin, in rare cases. When a complication is reported, it is essential to undertake a full assessment of the patient and stoma. A stoma assessment tool such as that described by Buckle (2013) and Haugen and Ratliff (2013) can be used. Assessment includes a diagram or photograph of the extent of the skin problem to establish a baseline, enable review and monitor the success of any changes in treatment. A description of the skin should include what the skin looks like and may include terms such as erythema, broken skin, oozing, erosion, ulcer or bleeding. The affected area and the dimensions of sore skin should be described. The assessment will also need to document how long the patient has been experiencing the problem, whether anything has changed or preceded the problem, and whether any treatments have already been tried and their efficacy. The assessment can assist in planning alternative treatments, which may involve the use of a stoma accessory (Black 2013). Leaking stoma appliances can lead to
BOX 3 Examples of stoma accessories Adhesive removers to help remove the appliance. Adhesive paste to help secure the appliance to the abdominal wall. Seals or washers to help secure the appliance to the abdominal wall. Convex flanges to prevent the appliance leaking in cases of a flush or retracted stoma. Stoma belt to secure the stoma flange to the abdominal wall. Hernia support belt to support a hernia around the stoma. Protective cream to moisturise and protect the skin. Protective film to act as a skin barrier. Protective paste – a greasy protective paste to protect the skin. Powder to protect and dry wet skin.
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sore skin, patient frustration and anxiety, and increased costs to the health service.
Allergies and sensitivities
Allergies in stoma patients are rare (Lawson 2003), but can occur soon after contact with the allergen or several years later. Allergies or sensitivity to the stoma appliance may occur, and treatment should involve removal of the current stoma appliance and replacement with an alternative. It is advisable to perform a patch test to establish the best appliance for the patient. This is performed by the stoma specialist nurse when the patient presents with the allergy. A small patch of the stoma flange is adhered to abdominal skin for several days to observe for any adverse effects.
Bleeding
When the stoma is cleaned, a small amount of bleeding may occur. Bleeding that occurs through the lumen of the bowel – blood passed with the stoma content – can be a serious cause for concern and may be a symptom of bowel cancer. Bleeding of this nature requires further investigation. Bleeding may also result from trauma, such as a car accident. A short period of direct pressure will usually stop the bleed. Bleeding may occur as a result of varices or caput medusae, which present as distended and engorged veins near the stoma. These can bleed profusely and require urgent treatment to stop the bleeding and may require a blood transfusion.
Dermatitis
The most common cause of sore skin results from faeces or urine coming into contact with the skin, and may result in irritant contact dermatitis. This can occur if the aperture in the appliance is too large and is not resized after post-operative oedema has subsided. Ratliff et al (2005) reported that two months after stoma formation, about 10% of patients had irritant contact dermatitis. This was usually resolved by remeasuring the size of the aperture in the stoma appliance and ensuring that it was 2-3mm larger than the stoma size to protect the surrounding skin. If the skin is sore because of frequent appliance changes, termed skin stripping, a two-piece appliance might be required because it allows the flange to be left in situ for several days, but the bag can be replaced as necessary (Trainor et al 2003). Alternatively, the use of a barrier film will help protect the skin (Rudoni 2011). Richbourg et al (2007) reported that a leaking appliance was the cause of sore skin in 62% of patients with a stoma. If the leak is caused
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by a crease in the peristomal skin, then stoma adhesive paste can be applied to the crease to level the skin under the stoma flange. If there is a skin dip, a seal can help to level the dip. If the skin is wet, using stoma powder (Boyles 2010) or a cool hairdryer (Burch 2008) will help to dry it.
Hernia
It is possible for patients to develop a parastomal hernia. Thompson and Trainor (2007) reported that 58% of patients had a parastomal hernia within six months of stoma formation. A parastomal hernia can be seen as a bulge around the stoma, which may be small or large. Treatment can include a hernia support belt or a surgical repair. A support belt is available on prescription, but is ideally fitted by the stoma specialist nurse to ensure that it is appropriate for the patient. A parastomal hernia may stretch the size of the stoma and the parastomal skin. This can lead to a large stoma size, which may require a larger stoma flange or the use of flange extenders. These are adhesive strips or curves designed to provide increased adhesion and security to the stoma flange. The parastomal skin may be stretched, making it thin and fragile. In this situation, a skin protective film can be useful. Thompson and Trainor (2005) undertook research on reducing the incidence of parastomal herniation and recommended that patients wear a hernia support belt from three months after the operation for at least one year, and perform abdominal exercises. Parastomal herniation may also be reduced if this treatment regimen is maintained for several years (Thompson and Trainor 2007).
Infection
In the UK, infection of the skin surrounding the stoma is uncommon. It is more common in hot countries and in people who are immunocompromised (Williams 2007). Lyon et al (2000) reported that UK infection rates are about 6% for people with a stoma and are more commonly seen in people who are immunocompromised, such as those undergoing chemotherapy (Williams 2007). Candida can be treated with antifungal powder (Burch 2008). The hair follicles can also become inflamed (folliculitis). To prevent folliculitis, the hairs should be trimmed or shaved weekly (Burch 2008). A urinary tract infection can occur in patients with a urostomy because the urinary tract is shortened. Drinking a glass of cranberry juice, in addition to an adequate intake of oral may 14 :: vol 28 no 37 :: 2014 55
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CPD skin care fluids daily, may help to prevent urinary tract infection (Burch 2013). Antibiotics may also be necessary. To diagnose urinary tract infection it is important to take a urine specimen correctly. This means taking the urine specimen from the stoma itself and not from the urostomy appliance, to reduce the risk of a contaminated sample. This is achieved by gently intubating the urostomy with a urinary catheter.
Mucocutaneous separation
Mucocutaneous separation occurs when the skin of the abdominal wall and the stoma separate. This can be superficial or involve total breakdown of the abdominal wall from the stoma and is often the result of an infection, tension or necrosis (Burch 2008). Mucocutaneous separation occurs within a few weeks of surgery and can result in a stenosed or retracted stoma. Treatment may not be necessary if the separation is superficial; protective paste or protective powder can be applied if the separation is deeper (Boyd-Carson et al 2004). For deep wounds, an alginate dressing may be necessary, and a seal or stoma belt may add security (Burch 2008).
Overgranulation
Granulomas, or overgranulation, have a red cauliflower-like appearance and can bleed easily. Overgranulation occurs on the edge of the stoma where the stoma and skin join, in about 10% of people with a colostomy and 2% of people with an ileostomy (Persson et al 2005). Overgranulation can be attributed to rubbing of the flange and aggravation of the area by faeces. Treatment should be determined on an individual basis by the stoma specialist nurse but can include the use of silver nitrate two or three times weekly for a few weeks (Wondergem 2007). Care must be taken to ensure that the growths are not cancerous. Overgranulation can recur and in severe cases surgery may be necessary.
Prolapsed stoma
Persson et al (2005) reported that 2% of people with an ileostomy will have a prolapse, but it is more common with a transverse colostomy because the transverse colon is not totally fixed within the abdomen. A prolapsed stoma occurs when the stoma itself lengthens and it can be 10cm or more in length. It may be caused by inadequate fixation to the abdominal wall during stoma formation, or increased abdominal pressure (Chandler et al 2013). The prolapsed stoma can be manually manipulated back into the body or surgically 56 may 14 :: vol 28 no 37 :: 2014
repaired. Manipulation is usually performed by hospital staff, for example the stoma specialist nurse or the surgical team. This may involve the use of a cold compress to reduce oedema (Colwell and Beitz 2007). However, the patient can be taught how to reduce the prolapse by lying down to apply the new stoma bag and then using a stoma shield to keep the prolapsed bowel inside. The aperture in the flange can also be ‘feathered’ by cutting small incisions into the flange to allow for some movement if prolapse occurs frequently.
Retracted stoma
A retracted stoma occurs when the colostomy moves below the level of the skin or an ileostomy or urostomy is flush with the skin. Stomal retraction occurs in about 2% of patients with a stoma (Persson et al 2005). This may be caused by weight gain or occur as a result of post-operative necrosis. Necrosis can lead to the death of the top surface of the stoma, resulting in the stoma being below the level of the abdominal surface. Treatment can include a seal or a convex flange (Black 2009). A stoma belt may be used in conjunction with the convex flange. A convex appliance can be soft or firm, but it should be used with caution because pressure on the peristomal skin can result in bruising or, infrequently, ulceration (Buckle 2013).
Closures
A stoma can be temporary and may be reversed or closed at a later stage. This may be a minimum of six weeks after the initial surgery, but more commonly occurs after three months or more – particularly if the patient requires chemotherapy, because chemotherapy is given as part of the treatment for cancer before the stoma is reversed. The most common form of temporary stoma is a loop stoma. To reverse the stoma, it has to be separated from the abdominal skin; the bowel is then re-joined, or anastomosed, and replaced into the abdominal cavity before the skin opening is closed. Bowel function may take several days to return and is often not the same as it was before surgery, particularly if the rectum was removed. Changes in bowel function may occur following anterior resection and may be referred to as anterior resection syndrome. Alteration of bowel function can include frequency and urgency (Taylor and Bradshaw 2013). Frequency may make it necessary for the patient to go to the toilet several times; urgency means the patient has to rush to the toilet. There may be some faecal incontinence, or it may be difficult to distinguish between the passage of flatus and stool.
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It is essential to ensure that the peri-anal skin remains intact. Because of the increased number of bowel motions passed in the initial period after the stoma is reversed, the skin can quickly become broken (Burch 2008). A barrier cream of any type is useful. For people with a small bowel pouch, also termed an ileopouch anal anastomosis or ileoanal pouch, the risk of sore peri-anal skin is increased because the faecal output is similar to the ileostomy output because there is no colon to thicken and thus reduce the corrosive potential of the faeces. Changes to diet may be necessary to improve bowel function and to reduce frequency. A diet low in fibre may be helpful, for example substituting white bread for brown bread and reducing the intake of fruit and vegetables
to thicken the faecal output (Burch 2008). Medications such as loperamide might be necessary to thicken the faeces (Burch 2008).
Conclusion Stomas must be managed appropriately to prevent peristomal skin complications. Assessment of the stoma and surrounding skin is essential to identify any problems and to ensure treatment is appropriate. Any leakage needs to be resolved. A secure stoma appliance is required to prevent leakage and consequent skin problems. Stoma specialist nurses are ideally placed to provide support and advice for patients with stomas NS Complete time out activity 5
5 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 62.
References Black P (2009) Managing physical postoperative stoma complications. British Journal of Nursing. 18, 17, S4-S10. Black P (2012) Choosing the correct stoma appliance. Gastrointestinal Nursing. 10, 7, 18-25. Black P (2013) The role of accessory products in patients with a stoma. British Journal of Nursing. 22, 5, S24. Boyd-Carson W, Thompson MJ, Trainor B, Boyd K (2004) Mucocutaneous separation. Nursing Standard. 18, 17, 41-43. Boyles A (2010) Stoma and peristomal complications: predisposing factors and management. Gastrointestinal Nursing. 8, 7, 26-36. Bradshaw E, Collins B (2008) Managing a colostomy or ileostomy in community nursing practice. British Journal of Community Nursing. 13, 11, 514-518. Bryan S, Dukes S (2010) The enhanced recovery programme for stoma patients: an audit. British Journal of Nursing. 19, 13, 831-834. Buckle N (2013) The dilemma of choice: introduction to a stoma assessment tool. Gastrointestinal Nursing. 11, 4, 26-32. Burch J (2008) Stoma Care. Wiley-Blackwell, Chichester. Burch J (2013) Stoma complications: an overview. British
Journal of Community Nursing. 18, 8, 375-378. Chandler P, Cox H, Lowther C (2013) Management of a prolapsed stoma. Gastrointestinal Nursing. 11, 5, 12-14. Colwell JC, Beitz J (2007) Survey of wound, ostomy and continence (WOC) nurse clinicians on stomal and peristomal complications. Journal of Wound, Ostomy, and Continence Nursing. 34, 1, 57-69. Cronin E (2012) What the patient needs to know before stoma siting: an overview. British Journal of Nursing. 21, 22, 1304-1308. Haugen V, Ratliff CR (2013) Tools for assessing peristomal skin complications. Journal of Wound, Ostomy, and Continence Nursing. 40, 2, 131-134. Kirkwood L (2006) Postoperative stoma care and the selection of appliances. Journal of Community Nursing. 20, 3, 12-18. Lawson A (2003) Complications of stomas. In Elcoat C (Ed) Stoma Care Nursing. Hollister, London, 157-163. Lyon CC, Smith AJ, Griffiths CE, Beck MH (2000) The spectrum of skin disorders in abdominal stoma patients. British Journal of Dermatology. 143, 6, 1248-1260. Mitchell KA, Rawl SM, Schmidt CM et al (2007) Demographic, clinical, and quality of life variables related to embarrassment in veterans living
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with an intestinal stoma. Journal of Wound, Ostomy, and Continence Nursing. 34, 5, 524-532. Persson E, Gustavsson B, Hellström AL, Lappas G, Hultén L (2005) Ostomy patients’ perceptions of quality of care. Journal of Advanced Nursing. 49, 1, 51-58. Ratliff CR, Scarano KA, Donovan AM, Colwell JC (2005) Descriptive study of peristomal complications. Journal of Wound, Ostomy, and Continence Nursing. 32, 1, 33-37. Recalla S, English K, Nazarali R, Mayo S, Miller D, Gray M (2013) Ostomy care and management: a systematic review. Journal of Wound, Ostomy, and Continence Nursing. 40, 5, 489-500.
Thompson MJ, Trainor B (2005) Incidence of parastomal hernia before and after a prevention programme. Gastrointestinal Nursing. 3, 2, 23-27. Thompson MJ, Trainor B (2007) Prevention of parastomal hernia: a comparison of results 3 years on. Gastrointestinal Nursing. 5, 3, 22-28. Tortora GJ, Derrickson B (2007) Introduction to the Human Body and Essentials of Anatomy and Physiology. Seventh edition. Wiley, New York NY. Trainor B, Thompson MJ, Boyd-Carson W, Boyd K (2003) Changing an appliance. Nursing Standard. 18, 13, 41-42.
Richbourg L, Thorpe JM, Rapp CG (2007) Difficulties experienced by the ostomate after hospital discharge. Journal of Wound, Ostomy, and Continence Nursing. 34, 1, 70-79. Rudoni C (2011) Peristomal skin irritation and the use of a silicone-based barrier film. British Journal of Nursing. 20, 16, S12-S18. Rust J (2007) Care of patients with stomas: the pouch change procedure. Nursing Standard. 22, 6, 43-47. Taylor C, Bradshaw E (2013) Tied to the toilet: lived experiences of altered bowel function (anterior resection syndrome) after temporary stoma reversal. Journal of Wound, Ostomy, and Continence Nursing. 40, 4, 415-421.
Voergaard LL, Vendelbo G, Carlsen B et al (2007) Ostomy bag management: comparative study of a new one-piece closed bag. British Journal of Nursing. 16, 2, 95-101. Williams J (2007) A guide to maintaining healthy peristomal skin. Gastrointestinal Nursing. 5, 7, 18-23. Williams J, Gwilliam B, Sutherland N et al (2010) Evaluating skin care problems in people with stomas. British Journal of Nursing. 19, 17, S6-S15. Wondergem F (2007) Stoma care – a guide to daily living. Journal of Community Nursing. 21, 4, 18-22.
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Page 58
Stomas multiple choice questionnaire
CONTINUING PROFESSIONAL DEVELOPMENT
Page 61
Abby Morrow-Barnes’s practice profile on temperature monitoring
Page 62
Guidelines on how to write a practice profile
Care of patients with peristomal skin complications NS743 Burch J (2014) Care of patients with peristomal skin complications. Nursing Standard. 28, 37, 51-57. Date of submission: September 15 2013; date of acceptance: March 6 2014.
Abstract Stoma formation is common and may be necessary in the management of certain diseases and as a result of surgery to the gastrointestinal tract or urinary tract. Because stomas provide an alternative route for the excretion of faeces and urine, they can have a significant effect on the individual’s physical, psychological and social functioning. Stomas require careful management and patients need to be taught how to self-care for the stoma and how to recognise common complications. This article focuses on the signs, symptoms and management of peristomal skin complications.
Author Jennie Burch Enhanced recovery nurse, St Mark’s Hospital, Harrow, Middlesex. Correspondence to: [email protected]
Keywords Peristomal skin complications, skin care, stoma, stoma accessories
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Aims and intended learning outcomes This article aims to increase the reader’s knowledge of stoma formation and the importance of effective management of patients with peristomal skin complications. After reading this article and completing the time out activities you should be able to:
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Describe the anatomy and physiology of the gastrointestinal (GI) tract and urinary system. Provide an overview of the different types of stomas and their indications. Identify the appropriate stoma appliance for each type of stoma. Discuss the causes of peristomal skin complications and appropriate management. Outline when and why stoma accessories can be used.
Introduction Stomas are formed from the GI tract or urinary system and provide an alternative passage for the excretion of urine or faeces. There are many reasons necessitating stoma formation, including bowel or bladder cancer, ulcerative colitis, Crohn’s disease and diverticular disease. The three main types of stoma are a colostomy, ileostomy and urostomy. These require different nursing management to prevent problems such as peristomal skin complications and improve patient outcomes and quality of life. Complete time out activity 1
Gastrointestinal tract and urinary system The GI tract or alimentary canal is the passage from the mouth to the anus. The GI tract is involved in the digestion of food, absorption of nutrients to provide energy for the cells in the body and elimination of waste products. The GI tract consists of several sections. The mouth contains the teeth and saliva, which break down food and fluid, allowing it to be swallowed and to travel down the oesophagus to the stomach. In the stomach, enzymes are involved in may 14 :: vol 28 no 37 :: 2014 51
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CPD skin care further digestion. Churning of the food also helps to break it down further before it passes to the small bowel, which consists of the duodenum, jejunum and ileum. Here, products of digestion, including nutrients and fluid, are absorbed into the bloodstream. Waste products travel along the colon, which is composed of the caecum, ascending colon, transverse colon, descending colon and sigmoid colon. Sodium and more fluids are reabsorbed, and loose faeces become formed faeces. Flatus, or gas, is also produced in the colon. Faeces and flatus are excreted via the anus (Tortora and Derrickson 2007). The urinary or renal system consists of two kidneys, two ureters, the bladder and the urethra. The urinary system is involved in the formation and excretion of urine. Urine is formed and then stored in the bladder until it is excreted through the urethra. Complete time out activity 2
Stoma formation
1 Using an appropriate anatomy and physiology textbook, study the GI tract and urinary system. Think about how particular diseases or surgery involving these areas may necessitate formation of a stoma. 2 Describe the different types of stoma and indications for their use. How might nursing management differ for each type of stoma?
In general, stoma formation involves making an incision in the abdominal wall and bringing the bowel (colon or ileum, depending on whether it a colostomy or ileostomy) through this hole and stitching it onto the abdominal wall using dissolvable sutures. These sutures usually dissolve within eight weeks of stoma formation (Burch 2008). A colostomy is minimally raised above the abdominal wall by around 5mm. The ileostomy and urostomy are formed to have a small 25mm spout to ensure that faeces and flatus or urine is kept away from the skin surrounding the stoma (Buckle 2013). An end or loop stoma can also be formed. A loop stoma is usually temporary and an end stoma is often permanent, but this is not always the case. An end stoma tends to be slightly more circular and a loop stoma may be egg-shaped. When a loop stoma is formed, there are two openings on the abdominal wall, but often the lower loop, which does not pass faeces, is small. The lower or distal loop may pass some mucus that travels up, rather than down, the defunctioned segment of bowel.
Type of stoma A stoma is formed during a surgical procedure to divert the passage of faeces and flatus or urine outside of the body for collection in a stoma appliance (Recalla et al 2013). The stoma is formed from a part of the bowel and appears red or pink in colour and wet and warm to touch. The stomal output leaves the
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body from the stoma and is then collected and contained in a stoma appliance. There are three main types of stoma: the colostomy, ileostomy and urostomy. Stomas may be formed for several reasons, as identified in Box 1. Surgical operations that may result in stoma formation are shown in Box 2.
Colostomy
A colostomy is formed from the colon or large bowel and may be required as a result of bowel cancer or diverticular disease (Cronin 2012). The descending or sigmoid colon is the most common section of the colon used to form a colostomy. It is also possible to form a colostomy from the transverse colon. Faeces passed from a colostomy are generally soft and formed, although the consistency of faeces can vary from individual to individual, and according to diet. Flatus is also passed from a colostomy. The stomal output is collected and contained in a closed colostomy appliance. The stoma will enable the passage of flatus multiple times per day and will pass faeces usually between three times weekly and three times daily, most commonly once or twice daily. Therefore, the appliance needs to be changed once or twice each day (Voergaard et al 2007). Transverse colostomies involve the passage of loose stool and usually require a drainable appliance to collect and contain the faeces. The faeces may need to be drained several times per
BOX 1 Reasons for stoma formation Cancer, for example involving the colon, rectum or bladder. Inflammatory bowel disease, including ulcerative colitis or Crohn’s disease. Congenital malformations, such as imperforate anus. Diverticular disease.
BOX 2 Surgical operations that may result in stoma formation Total colectomy and temporary end ileostomy. Cystectomy and permanent end urostomy. Abdominoperineal resection of the rectum and permanent end colostomy. Low anterior resection and temporary loop ileostomy. Panproctocolectomy and permanent end ileostomy. Hartmann’s procedure and temporary end colostomy.
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day and the appliance replaced on a daily basis or every few days (Burch 2008).
Ileostomy
An ileostomy is formed from the small bowel usually near the end that joins the colon (terminal ileum) and may be necessary in the treatment of inflammatory bowel disease (Burch 2008). Faeces passed from the ileostomy are generally loose, with a porridge-like consistency. There is also a small amount of flatus passed. The stomal output will vary depending on the food and fluid consumed. The ileostomy output is collected in a drainable bag. Most people with an ileostomy will empty the appliance about four to six times daily (Black 2012) and may change the appliance daily or every few days.
Urostomy
A urostomy, also known as an ileal conduit, is formed from a small segment of the ileum, which may be necessary in the treatment of patients with bladder cancer (Black 2012). Infrequently, a small segment of the colon is used for the conduit and in this case may be referred to as colonic conduit. The output from the urostomy will contain urine and a small amount of mucus. Urine is passed continually and collected in a drainable appliance that is emptied using a tap or bung about four to six times daily (Burch 2008). The urostomy appliance is usually changed on a daily basis or every alternate day. Complete time out activity 3
Care of patients with a stoma A person due to have a stoma will be seen by a stoma specialist nurse before surgery. Issues that will be discussed include (Cronin 2012): What a stoma is. What a stoma looks like. What is normal, for example in terms of the stomal output. How activities of daily living and lifestyle might be affected. Basic care of the stoma. Siting or marking of the position of the stoma. The patient also needs to be shown how to care for the stoma (Bryan and Dukes 2010). This will include information about changing the appliance and what is considered ‘normal’ skin, namely the absence of any changes such as redness or soreness. Although changing the appliance is relatively simple, care needs to be taken to prevent problems, such as leakage of the stomal output causing sore skin.
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The patient should be advised to gather all the equipment needed before changing the appliance. If the stoma appliance is drainable, it is important to empty the appliance to prevent spillage. The old appliance should be gently removed to prevent damaging the skin. The edges of the flange, the adhesive part of the stoma bag, should be stuck together and it should be placed into a fragranced rubbish bag. These bags may be available from the stoma supplier, or bought in a pharmacy. The skin around the stoma needs to be gently but thoroughly cleaned and carefully dried to remove all traces of faeces or urine to prevent skin irritation. The stoma does not need to be cleaned because it is designed to come into contact with faeces. The aperture in the stoma flange should be cut 2-3mm larger than the size of the stoma and should be the same shape to prevent leakage of the stomal output on to the surrounding skin (Rust 2007). Once the stoma size has settled after being formed, which takes about eight weeks because stomas are initially oedematous, the hole in the flange can be pre-cut if desired. The plastic backing has to be removed from the flange and the aperture placed around the stoma. The adhesive needs to be carefully but firmly pressed into place and held in position for about 30-60 seconds. The waste is then sealed in the fragranced rubbish bag and disposed of in the rubbish bin. Once the patient is discharged from hospital, he or she should be able to undertake basic care of the stoma. Some hospitals have structured follow up with the stoma care nurse and others will offer access to stoma clinics if needed.
Stoma appliances A stoma appliance is necessary to collect and contain the stomal output. Colostomy and ileostomy appliances have a flatus filter, which allows the gas to leave the appliance but contains the odour. The filter means that the appliance will not balloon out as it fills with flatus. To prevent the backflow of urine and reduce the risk of a urinary tract infection, there is a non-return valve in the urostomy appliance (Kirkwood 2006). Many patients will also use a night bag with the urostomy appliance to allow greater volumes of urine to be collected, enabling them to sleep without having to empty the bag frequently. The stoma appliance is formed of two parts: the adhesive part and the collection part. The adhesive part has a variety of different names including the flange, face plate and base plate. The collection part is formed from plastic and
3 Describe the hospital care that a patient undergoing stoma formation should receive. What advice would you give to a patient to prepare him or her for stoma formation?
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CPD skin care
4 Reflect on the different stoma accessories that can be used to help a patient with peristomal skin problems. How do these work? Discuss the advice you would give to a patient presenting with sore peristomal skin.
will generally have a soft, fabric-like cover to aid patient comfort. The appliance is also available in clear plastic, which is particularly useful for a newly formed stoma, permitting the stoma and stomal output to be seen in the early post-operative period. The flange is generally flat and thus is ideally placed on a flat area of the abdominal wall. If the abdominal wall is not flat it may not be possible to secure the appliance, potentially resulting in leakage of the stomal output. This, in turn, may result in peristomal skin complications such as sore skin. This may be resolved with the use of a stoma adhesive paste or a seal, which is a more flexible version of the flange formed into a small circular shape. Stomas can be used with either a one-piece or two-piece appliance. In a one-piece appliance, the flange and bag section are joined. In a two-piece appliance, these two parts are separate and the patient needs to attach them (Bradshaw and Collins 2008). There are advantages with both one and two-piece appliances. Some patients will prefer to have a simple change and thus might choose a one-piece appliance. Others prefer to reduce the number of times that the flange is removed from the skin and, therefore, will choose a two-piece appliance. This can prevent skin trauma such as skin stripping for people with a colostomy who need to change their appliance frequently. Toilet disposable colostomy appliances are also available. Generally, patients need to be advised not to throw appliances or cleaning cloths into the toilet to prevent blockage. Small fragranced bags allow the stomal equipment to be disposed of safely in the rubbish bin. Appliances also come in a variety of sizes to suit the needs of individual patients. Furthermore, small caps that can be used after colostomy irrigation, or during sporting or sexual activities are available. These are used to cover the stoma for short periods, collecting and containing any stomal output. With several manufacturers producing stoma appliances, patients are able to select the most suitable option to meet their individual needs. Complete time out activity 4
Stoma accessories Stoma accessories may be used in combination with the stoma appliance. Stoma accessories may be necessary for several reasons, such as to protect the skin or to assist adhesion of the appliance. However, this article will focus on
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stoma accessories that can be used to prevent peristomal skin problems (Box 3).
Skin care Williams et al (2010) reported that three quarters of people with a stoma will experience sore skin. The most common cause for sore peristomal skin is the stomal output coming into contact with the surrounding skin (Mitchell et al 2007). This may be caused by the aperture of the stoma flange being too large (Recalla et al 2013). Frequent removal of the flange can also cause skin stripping, and patients may have allergic reactions that result in sore skin, in rare cases. When a complication is reported, it is essential to undertake a full assessment of the patient and stoma. A stoma assessment tool such as that described by Buckle (2013) and Haugen and Ratliff (2013) can be used. Assessment includes a diagram or photograph of the extent of the skin problem to establish a baseline, enable review and monitor the success of any changes in treatment. A description of the skin should include what the skin looks like and may include terms such as erythema, broken skin, oozing, erosion, ulcer or bleeding. The affected area and the dimensions of sore skin should be described. The assessment will also need to document how long the patient has been experiencing the problem, whether anything has changed or preceded the problem, and whether any treatments have already been tried and their efficacy. The assessment can assist in planning alternative treatments, which may involve the use of a stoma accessory (Black 2013). Leaking stoma appliances can lead to
BOX 3 Examples of stoma accessories Adhesive removers to help remove the appliance. Adhesive paste to help secure the appliance to the abdominal wall. Seals or washers to help secure the appliance to the abdominal wall. Convex flanges to prevent the appliance leaking in cases of a flush or retracted stoma. Stoma belt to secure the stoma flange to the abdominal wall. Hernia support belt to support a hernia around the stoma. Protective cream to moisturise and protect the skin. Protective film to act as a skin barrier. Protective paste – a greasy protective paste to protect the skin. Powder to protect and dry wet skin.
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sore skin, patient frustration and anxiety, and increased costs to the health service.
Allergies and sensitivities
Allergies in stoma patients are rare (Lawson 2003), but can occur soon after contact with the allergen or several years later. Allergies or sensitivity to the stoma appliance may occur, and treatment should involve removal of the current stoma appliance and replacement with an alternative. It is advisable to perform a patch test to establish the best appliance for the patient. This is performed by the stoma specialist nurse when the patient presents with the allergy. A small patch of the stoma flange is adhered to abdominal skin for several days to observe for any adverse effects.
Bleeding
When the stoma is cleaned, a small amount of bleeding may occur. Bleeding that occurs through the lumen of the bowel – blood passed with the stoma content – can be a serious cause for concern and may be a symptom of bowel cancer. Bleeding of this nature requires further investigation. Bleeding may also result from trauma, such as a car accident. A short period of direct pressure will usually stop the bleed. Bleeding may occur as a result of varices or caput medusae, which present as distended and engorged veins near the stoma. These can bleed profusely and require urgent treatment to stop the bleeding and may require a blood transfusion.
Dermatitis
The most common cause of sore skin results from faeces or urine coming into contact with the skin, and may result in irritant contact dermatitis. This can occur if the aperture in the appliance is too large and is not resized after post-operative oedema has subsided. Ratliff et al (2005) reported that two months after stoma formation, about 10% of patients had irritant contact dermatitis. This was usually resolved by remeasuring the size of the aperture in the stoma appliance and ensuring that it was 2-3mm larger than the stoma size to protect the surrounding skin. If the skin is sore because of frequent appliance changes, termed skin stripping, a two-piece appliance might be required because it allows the flange to be left in situ for several days, but the bag can be replaced as necessary (Trainor et al 2003). Alternatively, the use of a barrier film will help protect the skin (Rudoni 2011). Richbourg et al (2007) reported that a leaking appliance was the cause of sore skin in 62% of patients with a stoma. If the leak is caused
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by a crease in the peristomal skin, then stoma adhesive paste can be applied to the crease to level the skin under the stoma flange. If there is a skin dip, a seal can help to level the dip. If the skin is wet, using stoma powder (Boyles 2010) or a cool hairdryer (Burch 2008) will help to dry it.
Hernia
It is possible for patients to develop a parastomal hernia. Thompson and Trainor (2007) reported that 58% of patients had a parastomal hernia within six months of stoma formation. A parastomal hernia can be seen as a bulge around the stoma, which may be small or large. Treatment can include a hernia support belt or a surgical repair. A support belt is available on prescription, but is ideally fitted by the stoma specialist nurse to ensure that it is appropriate for the patient. A parastomal hernia may stretch the size of the stoma and the parastomal skin. This can lead to a large stoma size, which may require a larger stoma flange or the use of flange extenders. These are adhesive strips or curves designed to provide increased adhesion and security to the stoma flange. The parastomal skin may be stretched, making it thin and fragile. In this situation, a skin protective film can be useful. Thompson and Trainor (2005) undertook research on reducing the incidence of parastomal herniation and recommended that patients wear a hernia support belt from three months after the operation for at least one year, and perform abdominal exercises. Parastomal herniation may also be reduced if this treatment regimen is maintained for several years (Thompson and Trainor 2007).
Infection
In the UK, infection of the skin surrounding the stoma is uncommon. It is more common in hot countries and in people who are immunocompromised (Williams 2007). Lyon et al (2000) reported that UK infection rates are about 6% for people with a stoma and are more commonly seen in people who are immunocompromised, such as those undergoing chemotherapy (Williams 2007). Candida can be treated with antifungal powder (Burch 2008). The hair follicles can also become inflamed (folliculitis). To prevent folliculitis, the hairs should be trimmed or shaved weekly (Burch 2008). A urinary tract infection can occur in patients with a urostomy because the urinary tract is shortened. Drinking a glass of cranberry juice, in addition to an adequate intake of oral may 14 :: vol 28 no 37 :: 2014 55
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CPD skin care fluids daily, may help to prevent urinary tract infection (Burch 2013). Antibiotics may also be necessary. To diagnose urinary tract infection it is important to take a urine specimen correctly. This means taking the urine specimen from the stoma itself and not from the urostomy appliance, to reduce the risk of a contaminated sample. This is achieved by gently intubating the urostomy with a urinary catheter.
Mucocutaneous separation
Mucocutaneous separation occurs when the skin of the abdominal wall and the stoma separate. This can be superficial or involve total breakdown of the abdominal wall from the stoma and is often the result of an infection, tension or necrosis (Burch 2008). Mucocutaneous separation occurs within a few weeks of surgery and can result in a stenosed or retracted stoma. Treatment may not be necessary if the separation is superficial; protective paste or protective powder can be applied if the separation is deeper (Boyd-Carson et al 2004). For deep wounds, an alginate dressing may be necessary, and a seal or stoma belt may add security (Burch 2008).
Overgranulation
Granulomas, or overgranulation, have a red cauliflower-like appearance and can bleed easily. Overgranulation occurs on the edge of the stoma where the stoma and skin join, in about 10% of people with a colostomy and 2% of people with an ileostomy (Persson et al 2005). Overgranulation can be attributed to rubbing of the flange and aggravation of the area by faeces. Treatment should be determined on an individual basis by the stoma specialist nurse but can include the use of silver nitrate two or three times weekly for a few weeks (Wondergem 2007). Care must be taken to ensure that the growths are not cancerous. Overgranulation can recur and in severe cases surgery may be necessary.
Prolapsed stoma
Persson et al (2005) reported that 2% of people with an ileostomy will have a prolapse, but it is more common with a transverse colostomy because the transverse colon is not totally fixed within the abdomen. A prolapsed stoma occurs when the stoma itself lengthens and it can be 10cm or more in length. It may be caused by inadequate fixation to the abdominal wall during stoma formation, or increased abdominal pressure (Chandler et al 2013). The prolapsed stoma can be manually manipulated back into the body or surgically 56 may 14 :: vol 28 no 37 :: 2014
repaired. Manipulation is usually performed by hospital staff, for example the stoma specialist nurse or the surgical team. This may involve the use of a cold compress to reduce oedema (Colwell and Beitz 2007). However, the patient can be taught how to reduce the prolapse by lying down to apply the new stoma bag and then using a stoma shield to keep the prolapsed bowel inside. The aperture in the flange can also be ‘feathered’ by cutting small incisions into the flange to allow for some movement if prolapse occurs frequently.
Retracted stoma
A retracted stoma occurs when the colostomy moves below the level of the skin or an ileostomy or urostomy is flush with the skin. Stomal retraction occurs in about 2% of patients with a stoma (Persson et al 2005). This may be caused by weight gain or occur as a result of post-operative necrosis. Necrosis can lead to the death of the top surface of the stoma, resulting in the stoma being below the level of the abdominal surface. Treatment can include a seal or a convex flange (Black 2009). A stoma belt may be used in conjunction with the convex flange. A convex appliance can be soft or firm, but it should be used with caution because pressure on the peristomal skin can result in bruising or, infrequently, ulceration (Buckle 2013).
Closures
A stoma can be temporary and may be reversed or closed at a later stage. This may be a minimum of six weeks after the initial surgery, but more commonly occurs after three months or more – particularly if the patient requires chemotherapy, because chemotherapy is given as part of the treatment for cancer before the stoma is reversed. The most common form of temporary stoma is a loop stoma. To reverse the stoma, it has to be separated from the abdominal skin; the bowel is then re-joined, or anastomosed, and replaced into the abdominal cavity before the skin opening is closed. Bowel function may take several days to return and is often not the same as it was before surgery, particularly if the rectum was removed. Changes in bowel function may occur following anterior resection and may be referred to as anterior resection syndrome. Alteration of bowel function can include frequency and urgency (Taylor and Bradshaw 2013). Frequency may make it necessary for the patient to go to the toilet several times; urgency means the patient has to rush to the toilet. There may be some faecal incontinence, or it may be difficult to distinguish between the passage of flatus and stool.
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It is essential to ensure that the peri-anal skin remains intact. Because of the increased number of bowel motions passed in the initial period after the stoma is reversed, the skin can quickly become broken (Burch 2008). A barrier cream of any type is useful. For people with a small bowel pouch, also termed an ileopouch anal anastomosis or ileoanal pouch, the risk of sore peri-anal skin is increased because the faecal output is similar to the ileostomy output because there is no colon to thicken and thus reduce the corrosive potential of the faeces. Changes to diet may be necessary to improve bowel function and to reduce frequency. A diet low in fibre may be helpful, for example substituting white bread for brown bread and reducing the intake of fruit and vegetables
to thicken the faecal output (Burch 2008). Medications such as loperamide might be necessary to thicken the faeces (Burch 2008).
Conclusion Stomas must be managed appropriately to prevent peristomal skin complications. Assessment of the stoma and surrounding skin is essential to identify any problems and to ensure treatment is appropriate. Any leakage needs to be resolved. A secure stoma appliance is required to prevent leakage and consequent skin problems. Stoma specialist nurses are ideally placed to provide support and advice for patients with stomas NS Complete time out activity 5
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with an intestinal stoma. Journal of Wound, Ostomy, and Continence Nursing. 34, 5, 524-532. Persson E, Gustavsson B, Hellström AL, Lappas G, Hultén L (2005) Ostomy patients’ perceptions of quality of care. Journal of Advanced Nursing. 49, 1, 51-58. Ratliff CR, Scarano KA, Donovan AM, Colwell JC (2005) Descriptive study of peristomal complications. Journal of Wound, Ostomy, and Continence Nursing. 32, 1, 33-37. Recalla S, English K, Nazarali R, Mayo S, Miller D, Gray M (2013) Ostomy care and management: a systematic review. Journal of Wound, Ostomy, and Continence Nursing. 40, 5, 489-500.
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