OST581 Mod III

What are some risk factors for stomal complications? (7)

- Higher BMI - Older - Emergent or planned surgery - Disease process: inflammatory bowel disease, ischemic colitis - Ileostomy (vs colostomy) - Temporary loop procedure

What is involved in allergic contact dermatitis management?

- Patch-testing to determine etiology if the source is unclear - Use antiinflammatory meds

What are the 3 surgical options for a parastomal hernia repair?

1. Primary fascial repair (high recurrence rate) 2. Local repair with mesh. (high potential for erosion of prosthetic material into intestinal stoma) 3. Stomal relocation to opposite side. The hernia is repaired and fascia reapproximated

A fistula between the colon and skin is known as a/an: Select one: a. colocutaneous fistula. b. colovesical fistula. c. rectovaginal fistula. d. internal fistula.

A

This stoma complication is related to healing, tension on sutures, or infection A. mucocutaneous separation B. parastomal hernia C. stomal necrosis D. stomal retraction

A

Which of the following complications is a contributing factor to the high mortality rate associated with the patient who has an enterocutaneous fistula (ECF) or an enteroatmospheric fistula (EAF)? Select one: a. Sepsis b. Dehydration c. Thrombophlebitis d. Pulmonary embolism

A

A patient has a high output enterocutaneous fistula with a pouch seal that has no leakage between changes (every 3-4 days). Removing the pouch skin barrier, you notice a solid patch of raised erythematous skin that matches the size of the skin barrier. The patient is complaining of itching. What is the most likely etiology of this skin condition? Select one: a. Sensitivity or allergy to the skin barrier b. Mechanical irritation during removal of adhesive c. Irritant dermatitis d. Folliculitis

A This description is a classic example of an allergic response: the allergic reaction will conform to the size and shape of the product to which the patient is allergic.

Of the following individuals, who is MOST at risk for developing a stomal prolapse? Select one: a. Infant with a loop transverse colostomy. b. 20-year-old male with a temporary loop ileostomy. c. 65-year-old male with an end sigmoid colostomy and significant ascites. d. 55-year-old female with a transverse double barrel colostomy.

A A loop stoma is always at highest risk of prolapsing because it is usually temporary and has limited suturing to securing the bowel to the structures within the abdominal wall and the skin. Add the increased intra-abdominal pressure of an infant crying and the risk is magnified.

You have a patient with a sigmoid colostomy who developed stomal stenosis 8 weeks postoperatively. What is the key factor that increased your patient's risk for developing this complication? Select one: a. Stoma necrosis. b. Stoma prolapse. c. Significant recent weight loss. d. Performing sit-ups.

A Stomal necrosis is lack of perfusion in the mucosa - this results in cell death and scarring leading to stenosis.

When selecting a pouching system for a patient who has an enterocutaneous fistula (ECF) or an enteroatmospheric fistula, the PRIMARY feature of the system that should guide your selection is: Select one: a. a cut-to-fit surface. b. an opaque pouch film. c. built-in convexity. d. an anti-reflux valve.

A The most important pouch feature for a fistula is a cut-to-fit pouch opening because fistulas come in all shapes and sizes. You will usually need to cut the opening to fit the irregular shape.

Your outpatient presents with pseudoverrucous lesions. His stoma size is 1" and he is wearing a 1 ¼" pre-cut one-piece drainable pouch. He is complaining of burning and itching. What is your PRIORITY in managing this complication? Select one: a. Refit the pouch size opening to 1" to cover the lesions. b. Apply alcohol to dry out the lesions on the peristomal skin. c. Check the pH of the effluent. d. Apply powder and paste to cover the lesions.

A The pouching system is allowing exposure to moisture because it's too large. Refit the opening to cover the lesions.

Ms. Anderson has a diagnosis of varices (caput medusae). You would expect to see protuberant veins in the peristomal field which are caused by: Select one: a. chronic exposure to effluent. b. portal hypertension. c. stoma prolapse. d. parastomal hernia.

A This is a classic question and usually seen on certification exams. Portal hypertension causes varices in the alcoholic or patient with liver disease.

What type of pouching system should be used if a patient has peristomal varices?

A one-piece pouching system is recommended to avoid the plastic rings of the 2-piece system. Soft convexity.

__________________ is a chemical injury of the peristomal skin from sensitivity reaction to ingredients in the product.

Allergic contact dermatitis

What is most frequently the source of stomal complications?

Anatomic circumstances

What topical product is usually used on peristomal candida infections?

Antifungal powder because adhesives will not stick to creams or pastes

How would a specialist manage a stomal prolapse?

Attempt to reduce the prolapse with gentle manual manipulation while the patient is supine, sugar or cold packs

What type of debridement is okay to use in pyoderma gangrenousum lesions?

Autolytic only

Which peristomal skin complication fits this management? Clip the hair in the direction hair grows and less frequently. Remove adhesive parallel to the skin and support the skin during removal. Refit the pouching system if leakage occurs. A. Pyoderma Gangrenosum B. Folliculitis C. Fungal Infection D. Mechanical Injury

B

Spontaneous closure of an enterocutaneous fistula is unlikely to occur when: Select one: a. the patient's albumin level is 3.4. b. a distal bowel obstruction exists. c. the fistula output is less than 100 mL. d. the patient is on antibiotics

B A bowel obstruction distal to the fistula opening will prevent spontaneous closure because the bowel contents will follow the path of least resistance. The effluent cannot evacuate through the bowel because of the obstruction.

Mrs. Owens arrives in your Ostomy Clinic complaining that the pouch leaks within a few hours even though she puts it on exactly how she was instructed. The stoma protrudes 2 cm., her abdomen is soft, and she is slightly overweight. Which of the following steps is essential to assure proper fitting of her ostomy pouch? Select one: a. Use a skin cement to increase the adherence of the pouch. b. Assess her abdominal topography and stoma with her in the sitting position and standing position. c. Trim the skin barrier to be 1/4 inch larger than the stoma and add a convex barrier ring. d. Instruct her to begin using a belt.

B Abdominal assessment of the patient with a stoma requires assessment when the patient is laying, sitting, or standing to identify changes in topography. In this situation, it is likely the patient will require a firm or convexity skin barrier because the abdomen in soft.

Which of the following scenarios would indicate the need for convexity when managing stoma complications? Select one: a. 4" stomal prolapse on a soft abdomen b. Stomal retraction on a soft abdomen c. Mucocutaneous separation on a firm abdomen d. Stomal necrosis on firm abdomen

B The use of a convex pouching system is indicated when the abdominal muscle tone is soft and there is a stomal retraction to augment the level of the stoma above the skin.

How far can ischemia from stomal necrosis extend?

Below the fascia

What is a potential complication of peristomal varices?

Bleeding

Your patient has a laceration to their stoma that is bleeding some. How would you manage this?

Bleeding may be managed with calcium alginate or other hemostatic agents, skin barrier powder, silver nitrate.

Of the following, the most appropriate method for managing a shallow mucocutaneous separation of a newly created ileostomy is to: Select one: a. cut the opening in the skin barrier large enough so the skin barrier does not cover the separation. b. fill the separation defect with dry gauze, cover it with the pouch skin barrier and change the gauze every day. c. fill the separation defect with skin barrier powder and cover with the ostomy pouch skin barrier. d. leave the pouch off, fill the separation defect with a skin barrier powder and use a skin protectant and gauze dressings to contain the stool and protect the peristomal skin

C A shallow (superficial) mucocutaneous separation should be treated like a wound and may be filled with skin barrier powder to fill the defect and absorb exudate. The opening cut in the ostomy skin barrier should match the size of the stoma and cover over the area of separation.

When the ostomy patient is taking corticosteroids and immunosuppressive agents, they are at risk for developing which of the following peristomal skin complications? Select one: a. Pyoderma gangrenosum b. Pseudoverrucous lesions c. Peristomal candidiasis d. Caput medusae

C Corticosteroids and immunosuppressants increase the risk of candidiasis in all patients. However, in the ostomy patient, it is usually peristomal candidiasis because they suppress the immune system.

Vinegar soaks to the stoma are an appropriate intervention to reduce or remove: Select one: a. Peyer's patches on the mucosa. b. urine odor. c. encrustations. d. varices (caput medusa).

C Encrustations are an infrequently seen complication of urinary stomas. They are urinary crystals that accumulate on the stoma and/or peristomal skin. They feel like sandpaper or pebbles and easily rub off. Utilize half strength white vinegar soaks to the stoma 2-3 times per day to dissolve and remove. Also, urine acidification may be useful

An ostomy patient presents to your clinic for a 4-week post-op visit. You notice two firm papules along the mucocutaneous junction that bleed easily. You also note retained sutures in the region. What is the most likely condition and treatment option for these lesions? Select one: a. Mucosal transplantation; apply skin barrier powder b. Suspect malignancy; refer for biopsy c. Granuloma; treat with silver nitrate d. Pseudoverrucous lesions; resize the ostomy barrier opening

C Granulomas may occur due to an immune response to retain suture or excessive friction or rubbing from the ostomy barrier edge. They are described as soft to firm papules that bleed easily and are either at the mucocutaneous junction or on the stoma. Treatment involves removing the irritant i.e., retained suture and use silver nitrate stick to debride the lesion and manage any excessive moisture with stoma powder.

You have a 4-year-old child that needs his low-profile gastrostomy tube replaced. What step would be MOST important when performing this procedure? Select one: a. Have parents give pain medication prior to procedure. b. Cleanse the skin with soap & water. c. Measure the length of the stoma tract with a measuring device. d. Use sterile gloves.

C Manufactures will provide a stoma-measuring device to be sure the correct size tube is used as the child grows and gains weight. If the small profile tube is too small it could cause pressure necrosis, pain, tenderness.

Which of the following patients is at risk for fistula formation after a surgical procedure? A patient who has: Select one: a. experienced intraoperative hypothermia for more than 2 hours. b. had preoperative hyponatremia. c. undergone radiation therapy in the surgical area 20 years ago. d. a preoperative serum prealbumin level of 18.0.

C The combination of blood flow damaged by radiation and the interruption of blood flow by surgical procedures places the patient at a high risk for breakdown of anastomoses and consequently fistula formation.

An incarcerated bowel is an emergent complication associated with: Select one: a. mucocutaneous separation. b. stoma stenosis. c. parastomal hernia. d. peristomal pyoderma gangrenosum.

C This is a classic question frequently seen on certification exams. A peristomal hernia may contain a loop of bowel in the herniation. If the mesentery of this segment of bowel is compromised, ischemia to the bowel segment can develop. When the patient has a peristomal hernia, it is important to teach them the s/s of ischemic bowel (abd. pain, n/v and/or change in stoma color) so they can contact their physician immediately or go to the ER.

A patient with a stomal prolapse notices the stoma mucosa color becomes purple, almost black. What should they do?

Call the surgeon immediately.

Patient teaching for pseudoverrucous lesions

Change pouch more frequently to avoid pooling or leaking of effluent. Instruct in product use and rationale

Which peristomal skin complication fits this management? Refit the pouching ssytem and reevaluate when weight changes of abdominal contour changes occur - especially when using firm and supportive skin barriers, convexity, or belts. A. Pyoderma Gangrenosum B. Folliculitis C. Fungal Infection D. Mechanical Injury

D

You have applied a liquid skin barrier film under the adhesive surface of a fistula pouch. You indicate to the nursing staff that the rationale for this intervention is to PRIMARILY protect the skin from: Select one: a. chemical injury. b. allergy to adhesives. c. contact with skin barrier pastes. d. mechanical injury.

D

Mr. Smith has had a sigmoid colostomy that he irrigates every day with regular results. Lately, he has noticed a bulging around the stoma and consistently poor returns of the irrigation fluid and feces. What complication is Mr. Smith likely experiencing? Select one: a. Stoma prolapse. b. Pseudoverrucous lesions. c. Stoma necrosis. d. Parastomal hernia.

D These are classic signs of parastomal hernia and the patient who irrigates the colostomy should stop irrigating and schedule a visit with the WOC Nurse.

A 28-year-old female has a permanent ileostomy, and you notice ulceration at 9 o'clock in the peristomal area 7 mm. from the base of the stoma. The ulcer is producing fecal material. Without knowing her history, what is this describing? Select one: a. Candidiasis due to steroids. b. Familial adenomatous polyposis. c. Peristonal pyoderma gangrenosum. d. Enterocutaneous fistula (ECF).

D This is a classic description of a fistula to the skin from the bowel. When you think about enterocutaneous fistulas, think about Crohn's disease. It's the most common cause.

What causes stomal necrosis?

Death of mucosal tissue secondary to tension on or inadequate blood flow from the mesentery

What 4 things does the specialist assess with stomal prolapse?

Degree of prolapse (length, width) Viability of stoma (colo) Output characteristics Stomal/peristomal pain

How does the specialist assess stomal stenosis?

Digital exam with lubricated finger.

If the mucocutaneous separation is deep, how is it managed?

Fill with antimicrobial dressing and systemic antibiotics. Deep separations put the patient at risk for infection

Management options for a pressure injury in the peristomal area

Flexible pouch system (soft convexity?), avoid snug binders/belts. Ulcer treatment: Skin barrier powder and liquid skin barrier to form a crust. If a deeper or draining ulcer, use alginate or hydrofiber and cover with a transparent film or hydrocolloid.

What are some conservative management techniques for a parastomal hernia?

Flexible pouching systems, soft convexity if needed. Hernia support belt or garment. Fecal stoma patients should maintain soft stools.

How should someone go about pouch changes if they have peristomal varices?

Gentle removal in the direction of hair growth. Use adhesive solvents. Skin barrier film products may assist to decrease the trauma of removal of the pouching system.

__________ is considered to be an immunologic response to a foreign material (sutures) or rubbing of the pouching system

Granuloma

______________ are erythematous, soft to firm papules usually seen at the mucocutaneous junction or on the stoma. They bleed easily and may be tender.

Granuloma

What time length is considered late for stomal complications?

Greater than 30 days post op

__________________ is a type of PMASD. It's chemical injury of the peristomal skin from ileal output.

Irritant contact dermatitis

What causes folliculitis?

It is an infection secondary to trauma (adhesive removal, shaving)

What are some ostomy-nurse related issues that could lead to stomal complications?

Lack of preop education, involvement of a wound, ostomy and continence nurse

What time length is considered early for stomal complications?

Less than 30 days after surgery

What type of stoma (end/loop) does stomal prolapse usually occur in?

Loop

What are 3 examples of PMASD?

Maceration Irritant contact dermatitis Pseudoverrucous lesions

What is an example of a stoma complication resulting in infection?

Mucocutaneous separation

What are the 3 early stomal complications?

Mucocutaneous separation, stomal necrosis, stomal retraction

_______ is often confused with hypergranulation.

Mucosal transplantation

_________ appears as several bright red erythematous moist papules on the skin and looks like mucosal tissue

Mucosal transplantation

What are some examples of long term stoma complications?

Musculature changes or intraabdominal pressure changes (parastomal hernia or prolapse)

Is the patient with a parastomal hernia allowed to continue colostomy irrigations?

Only if the hernia is small

What is an example of a stoma complcation with iatrogenic etiology?

Ostomy care equipment related injury, such as stoma laceration

An example of iatrogenic stomal complications is

Ostomy care equipment related injury; stoma laceration

_________________ is a defect in abdominal fascia that allows the intestine to bulge into the parastomal area.

Parastomal hernia

What causes peristomal varices?

Portal hypertension caused by liver cirrhosis and primary sclerosing cholangitis leading to dilated, tortuous superficial veins in peristomal skin.

Assessment and management of granulomas

Probe each granuloma gently to look for foreign material. Silver nitrate may be applied twice a week PRN. Apply skin barrier powder to absorb moisture. Liquid barrier applied over the powder. If no progress, refer for biopsy

___________ is a benign condition of exuberant overgrowth of papules around the stoma due to chronic exposure to moisture such as urine or stool.

Pseudoverrucous lesions

_________________Is the result of an inflammatory skin response. Lesions may be white, gray, brown, bumpy, dark red, wart-like

Pseudoverrucous lesions

____________________ is also known as chronic papillomatous dermatitis, peristomal epitheliomas hyperplasia, and pseudoverrucous papules or nodules.

Pseudoverrucous lesions

____________ symptoms can involve a thickening and elevation of the skin circumferentially around the stoma in exposed areas of skin. May be painful and bleed easily.

Psuedoverrucous lesions

What peristomal skin complications is this describing? A rare condition (neutrophilic dermatosis) that causes painful ulcers possibly due to a disorder of the immune system. Associated with autoimmune disorders (Rheumatoid arthritis, IBD, hematologic disorders). Minor injuries may induce lesions.

Pyoderma gangrenousum

Management for mucosal transplantation

Refit pouching system Document and watch lesions over time Skin barrier powder if excessive moisture with liquid skin barrier Silver nitrate PRN

How would you manage pseudoverrucous lesions around a urostomy?

Refit the pouching system so all the skin is covered by the skin barrier. Consider use of an acidic skin barrier and pouch has anti-reflux feature, empty frequently, use nighttime drainage.

How would you pouch a stomal prolapse?

Resize the pouch to makesure there is plenty of room for the prolapsed stoma. It msut be flexible and a lubricant may be used on the inside of the pouch to minimize stomal trauma. If the prolapse is long, it may be adivsable to avoid a two piece pouching system.

What is involved in a comprehensive review prior to an assessment?

Review the patient's general health history, allergies, medications. Current treatments for health care problems

What are some treatment options for pseudoverrucous lesions aside from pouch-refitting?

Skin barrier powder to absorb excess moisture, silver nitrate cautery

What is an example of a stoma complication resulting from vascular issues?

Stoma necrosis. Long term could be trauma

What should be documented in a focused stoma/peristoma assessment?

Stoma, type of effluent, peristomal skin status (dermatitis or wounds?) Abdomen tone/contours in different positions Clock face reference points

What type of stomal complication would this be used for? It may be useful to select a moldable skin barrier technology around the stoma, cutting radial slits in the solid skin barrier to accommodate __________, and the use of barrier rings may prove effective.

Stomal prolapse

________ can occur with increased intra-abdominal pressure, obesity, the stomal opening in the abdominal wall is too large, or the stoma was created outside the rectus muscle.

Stomal prolapse

If surgery is indicated for a parastomal hernia, what is the preferred procedure/method?

Stomal relocation to the opposite side of the abdomen

This stomal complication is usually caused by tension from a short mesentery, thick abdominal wall, increased BMI, adhesions or scar formation. Can also result from other stomal complications such as necrosis or mucocutaneous separation

Stomal retraction

This stomal complication is usually the result of other complications: mucocutaneous separation, stoma necrosis, or retraction of the stoma, or recurrence of a disease such as Crohn's. The structure of the stomal opening or fascia level tissue impairs effluent drainage.

Stomal stenosis

What stomal complication is this? The fecal stoma may function with pain upon evacuation, small ribbon-like stool, or constipation followed by large explosive evacuations, loud with excessive gas. Urinary stomas may function with a projectile urine stream. patient may report frequent UTIs and/or flank pain

Stomal stenosis

What are the 4 late stomal complications?

Stomal stenosis, stomal prolapse, stomal trauma, parastomal hernia

Stomal necrosis is usually (superficial/deep)

Superficial

Why should a two piece pouching system be avoided with a long stomal prolapse?

The stoma may be injured by being pinched by the plastic flange, or the stoma may protrude over the flange and be injured.

Management of pyoderma gangrenosum lesions in the peristomal area

Topical/oral/injectable steroids may be used to decrease inflammation. Remove all sources of pressure and friction (avoid firm convexity, extended wear barriers, use adhesive removers). Topical wound care using absorptive products (alginates, hydrofibers, foams) secured with thin hydrocolloid to provide dry surface for pouch adherence.

How does a specialist assess and document stomal necrosis?

Use a pen light and a clear, lubricated lab tube (lab collection vial) to inspect for depth of the ischemia

What are the 5 common etiologies of stomal complications?

Vascular issues, Infection, Surgical technique, Long-term changes, Iatrogenic

How is pyoderma gangrenosum diagnosed?

Via exclusion Refer for biopsy from dermatology and systemic management.

How does the WOC specialist assess a parastomal hernia?

Visual inspection, patient may report erratic colostomy irrigation results

Is surgery indicated for parastomal hernia? When?

When obstruction, incarceration with/without strangulation, stenosis, intractable dermatitis, pouching management problems, large hernia, cosmesis, and pain are present

Does stomal necrosis require surgical intervention? When?

When stomal stenosis or severe mucocutaneous separation or deeper ischemia

Is surgery indicated in stomal retraction? When?

When the stoma is not manageable, with a sustained predictable pouching wear time

T/F Routine digital exams are recommended for stomal senosis

false

What kind of ostomy most commonly experiences stomal prolapse?

ileostomies (distal)

___________ is a complication caused by suturing techniques during surgery. The stoma is sutured to the abdomen rather than the dermis.

mucosal transplantation

How is stoma stenosis managed?

severe - surgery for fecal stomas - low-residue diet, stool softeners, or high fluid intake

Caput medusae are also known as _____

varices

Name the peristomal skin complication: Peristomal skin may appear to have a blueish discoloration or raspberry-looking skin in the submucosal area. Spontaneous bleeding of the stoma or mucocutaneous junction may occur. Or bleeding may occur when the pouch is changed or when a pouching system with a firm or pressure support is used.

varices