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|Newsletters: Peristomal Skin Care|
Peristomal Skin Care
Paula Erwin-Toth, MSN, RN, CETN, Cleveland Clinic Foundation, Cleveland, Ohio
As with most situations, an ounce of prevention is worth a pound of cure when it comes to peristomal skin care. A stoma is a surgically created opening in the body for the purpose of access (as in a feeding gastrostomy or jejunostomy) or diversion (as in an ileostomy, colostomy or urostomy). If the skin is exposed to urine, stool or digestive enzymes you can experience some distressing and often painful symptoms around the stoma.
Caring for the skin around your stoma is not difficult as long as you keep in mind some basic principles. The skin around your stoma is exposed to potential trauma every day. The products that you use to remove adhesive as well as cleanse and protect your skin can help your skin stay healthy or conversely, contribute to skin breakdown. Below are some recommendations for skin care at the stoma site that people with all types of ostomies should review. If the skin at your stoma site is irritated, be sure to discuss the matter with an Enterostomal Therapy (ET) nurse or another clinician familiar with ostomy management.
First, remember that the removal of any skin barrier or adhesive is very important. Do not aggressively pull or tear the adhesive away from your skin. Instead try using warm water or a commercially available skin adhesive solvent to prevent stripping of your skin. Next, cleanse your skin with a pH balanced soap or commercial cleanser. Avoid solutions that are high in alkaline or contain alcohol. These agents raise your normally slightly acidic skin pH and can contribute to drying, breakdown and infection.
If you have difficulty removing adhesives, you may benefit from a skin sealant. This type of product puts a plasticized coating over the skin. It should be allowed to completely dry before you apply the skin barrier or adhesive. Mild peristomal skin irritation caused from trauma or leakage can be treated with a light dusting of skin barrier powder. But don’t forget the importance of correcting the cause.
In addition, if you are removing hair as you remove the adhesive, try trimming or shaving the hair at the stoma site. Be sure to use an electric or single use disposable razor. Always shave along the line of the hair shafts, not against. Shaving against the hair shaft can strip the skin and cause a painful condition known as folliculitis.
Next, inspect the skin barrier or adhesive that you just removed. Do you see any signs of undermining or tunneling on the skin barrier? This appears as a melting or staining of the skin barrier underneath the seal. When urine, stool or gastric juices come in contact with your skin and remain trapped there, your skin can breakdown. This “hidden leakage” means your equipment needs to be changed more frequently or revised.
Take a Closer Look
Examine your skin for any unusual coloring, lesions or other signs of irritation. The chart should help you and your clinician figure out the source of trouble and a solution. For example, are there any open, reddened areas? Are they localized or spread out? Do they hurt? Are they draining?
Look at your stoma. How is the color? In general, ileostomies, colostomies and urostomies should be a beefy red hue. Are there any cuts or areas that are bleeding? Does your stoma protrude more or less than it usually does? Has the pattern of functioning remained the same?
If you wear a pouch, you should measure your stoma before applying your pouching system. The stoma should be measured at the base from mucosa to mucosa. The opening in the skin barrier should be 1/8” larger than the stoma size. Too large an opening will result in skin damage from the effluent. Too small an opening can injure the stoma.
If you are leaking around a feeding gastrostomy or jejunostomy catheter, do not put in a larger diameter catheter without checking with your doctor. A larger catheter often enlarges the tract and makes your problems worse. Be sure your feeding tube is anchored securely with a “T” bar or a drain tube attachment device. Peristalsis in the intestine can cause your catheter to be pulled inside your body. This not only can cause leakage, but can be painful as well. You may want to protect the skin around a gastrostomy or jejunostomy with a skin barrier wafer or moisture barrier salve. If you have little or no drainage, a single layer of gauze may suffice.
Next consider the big picture. How are you feeling in general? Are you having any disease-related problems such as nausea, abdominal pain, fever or flank pain? In addition to indicating an internal problem, symptoms like these may be contributing to peristomal skin irritation. Be sure to call your physician.
Finally, you need to pay attention to how you apply your pouch, skin protection or catheter anchoring system. Be certain you have adequate lighting and take the time to carefully center the system. Most people find standing to be the best position. If you wear bifocals, it may be easier for you to look in a mirror to apply the system because of the tendency to place the center too high.
In the case of a feeding tube, be sure it is anchored properly. Too little tension can cause it to migrate; too much tension may dislodge it. In the case of a pouch, smooth out the adhesive from the center outward. Allow your hand to rest over the pouch for a few minutes to enhance the adhesion. Be sure the closure clip or spout is secure.
For children or confused adult patients, be sure the pouch or feeding tube is protected by clothing to prevent accidental dislodgment. For all patients, the addition of a pouch/tube cover or ostomy brief can have the dual affect of boosting your spirits and wicking perspiration away from your skin.
If you are having problems with skin care around your stoma, seek the assistance of an E.T. nurse or someone well versed in ostomy management. Occasionally, despite your best efforts, peristomal skin problems will occur. Early intervention treatment can save you time, aggravation and expense.