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Picture 1: Peristomal Contact Dermatitis

Discuss about the Stoma and Peristomal Complications and Assessment Details.

Creation of intestinal or urological stomas is an integral part of the surgical interventions for several complications such as gastro-intestinal tract disease (Salvadalena, 2013). Numerous people undergo surgical interventions every year resulting in intestinal or urological stoma. The modern healthcare system uses several means such as ostomy equipments or pouches, providing the patient access to wound ostomy continence (WOC) expert nurses and advanced wound care system (Baykara et al., 2014). However, as these means decreased the hospital stay of patients, they are unable to manage their wounds using ostomy basics, leading to high morbidity and affecting the patient, physically, psychologically and economic prospect (Kwiatt & Kawata, 2013). These peristomal skin complications are divided into five categories such as mechanical, infection related, noxious chemicals and irritants, skin allergies and disease related to the skin (Jonkers et al., 2012). This assignment will be identifying five pictures related to the stoma and peristomal infection and will discuss their etiology, pathophysiology, stoma and peristomal assessment, the way these conditions affect the patient and the pouching system and finally recommendations to solve the problem. The assessment will be presented in a tabular format.

Picture 1: Peristomal contact dermatitis

Etiology

· The primary reason for this condition is exposure to urinary or fecal drainage.

· This condition is also known as contact irritant dermatitis and exposure to chemicals may lead to such condition around the stoma (Haugen & Ratliff, 2013).

· It can also occur due to enzymatic drainage. Furthermore, exposure of the stoma to adhesives, solvents and soaps as well as leakage from the stoma pouch mat also lead to such infection (Meisner et al., 2012).

Pathophysiology

· Presence of erythema with swollen skin around the stoma, Presence of pruritus, vesicles and papules, redness, dark and discolored skin around the stoma

· Furthermore, the stoma was observed as oozing and a well defined circular layer of erythema, edema and burned out skin was observed (Grey et al., 2013).

Stomal assessment

· Moist and oval shaped, red (healthy) stoma was observed. Protrusion was around 1-2 cm from the skin surface and located near the lower right quadrant of skin fold surface of abdomen.

· Yellowish circular patch was observed and from the end stoma tip a yellowish exudates was oozing which had paste like consistency.

· It had shiny, textured and bloody appearance having oval shaped bud, around which red swollen allergic condition was observed

Peristomal assessment

· The peristomal area is spread around the wound in 2-3cm radius.

· No hair was observed on the skin, however the skin folding were present.

· The adjacent area of the peristomal skin appears red and yellowish, yellow streaking on red erythema skin. Intact skin integrity, moist texture, and normal turgor was observed.

· Further, away from stoma the skin has a red rash in a circular pattern all the way around the stoma where the wafer would sit.  

Patients condition

· The patient develops irritation, itching, burning sensation, discomfort and due to the exudates from the stoma bud, infection spread to other body parts as well.

· This will increase the inflammation and erythema to spread. Papules in the stomal area may lead to spread the infection by releasing effluents (Grey et al., 2013).

· Further, the pain may also increase, as once the sensitivity presents, it is usually permanent.

· This is because; the ostomy care products used on the skin could potentially cause a reaction that leads to allergic condition as well as pain sensation in the stoma area (Martins et al., 2012).

· This might affect the patient psychologically and usage of these costly product can affect the patient economically as well. 

Pouching system condition

· The pouching system has to suffer as cleansing becomes a challenge due to chemical and urine related infection.

· Hence, the proper pouch that can fit the area properly should be instead of leaky pouch, which lead to spread the exudates from one area to another leading to inflammation and allergic condition (Grey et al., 2013).

How to deal with the problem

· Correct size opening pouch system can be used, using an ostomy belt or a convex skin barrier instead of a flat one, using crusting method so that dryness can be maintained

· convex barrier or flat barrier ring for stoma management. Using warm water for cleansing and application of stoma power for weeping can help in the treatment (Haugen & Ratliff, 2013).

· Usage of soaps, solvents and other chemical products should be prohibited.

· As well as, usage of medicinal solvents should also be prohibited as it can lead spreading if the infection in other regions as well. This is because swollen bruise can lead to loss of skin (Meisner et al., 2012).

Picture 2: Candidiasis and folliculitis

Etiology

· The primary reason is fungal infection due to overgrowth of Candida albicans, which is the normal flora of the mouth, gut and vagina.

· red rash, pustules and satellite lesions, may have a collar/edge with a scaled appearance (Rippon et al., 2017)

· Traumatic hair removal due to pouch removal can be the reason for the elevated skin surface and related infection

· Thus, inflammation leads to erythema and edema around the stoma infection.

· Shaving the peristomal skin around the stoma prior to application of pouch can also lead to the formation of follicular and Candidiasis related stoma infection. Further, occlusion of the hair follicles and in the process ripped skin barriers can lead to stoma related infection (Huq, Rahman & Hossain, 2014).

Pathophysiology

· Leaking pouch system with red and swollen radius around the infection

· Papules, pustules and pruritus is observed

· Satellite lesion with raised pustules was observed due to folliculitis.

· collar/edge with a scaled appearance was also observed in the lesion

· overgrown bud with red appearance observed (Huq, Rahman & Hossain, 2014)

Stomal assessment

· Dry and round reddish stoma was observed, having protrusion more than 4 cm from the skin level.

· The infection is located in the lower right quadrant of the abdomen, 4 to 5 inches elevated swollen and reddish allergic area was present around the stoma.

· Loop stoma was observed having dark red color, the appearance of the bud was shiny, dry and bloody having a circular appearance

Peristomal assessment

· The peristomal skin around the stoma was reddish and the traumatic hair follicle removal due to pouch removal lead to red and swollen skin periphery near the stoma.

· Scars and crusty skin integrity, with firm turgor was assessed

· Round or rotund abdomen.  Further, away from stoma the skin has a red rash in a circular pattern all the way around the stoma where the wafer would sit.

Patients condition

The patient is at higher risk of developing abcess, increased itching, discomfort leads to spread the infection to other adjacent regions.

Financial and psychological impact might also impact the patient condition

Physically as well, the position of scar was such that the patient would not be able to move freely.

Pouching system condition

· The pouching system leads to leaking; affecting the stoma, further occlusion of hair follicle can also be seen.

· Therefore, lift of, and secondary accessory might be seen in this scenario.

· The pouch becomes loose, leading to spread the infection from the stoma to another portions of the body (Beitz & Colwell, 2016).

How to deal with the problem

· Removal of all the hair before application of pouch should be done, adhesive remover should be used, antimicrobial soap and power should be used, proper elimination of moisture should be done, further a pouch cover should be used to protect it from moisture (Huq, Rahman & Hossain, 2014)

· If the patient has history of fungal infection, then prophylactic treatment should be used, the caretaker and patient should be taught the skills to protect stoma infection in condition of Candidiasis and folliculitis (Rippon et al., 2017).

· The pouch should be changed in short term duration and in that process, usage3 of antifungal treatment powder should be applied in the inflammated area.  These antifungal powders (Nystatin and Mycostatin) should be used to dust the area, massage on the reddish skin around the stoma, let sit for several minutes. Further, excess powder after massage of the skin should be removed prior to application of pouch (Lyon, 2016).

Picture 9 : Allergic contact dermatitis

Etiology

· The primary cause for allergic contact dermatitis is usage of any product, which is allergic to the patient, as this condition is not related to leakage from pouch.

· Further, not proper cleansing of the peristomal skin may also lead to allergic conditions (Kaur et al., 2012).

· Usage of film barriers or additional tape may also involve in the cause of such infectious condition.

· Furthermore, an appliance having a bad fitting, letting moisture or vapor infect the area may also lead to such allergic condition.

· Whereas, frequently changing apparatus, ripping off the appliances, irregular borders and abrasive cleansing of the area also leads to allergic condition in case of stoma related infections (Watson et al., 2013).

Pathophysiology

· This stoma infection is present with erythema or redness due to increased blood flow around the peristomal skin. The primary stoma site appears as “bulls eye” target, swelling around that target is observed and the “bulls eye target” appears darker and oozing.

· Furthermore, the patient feels itching, burning or stinging around the infection site (González-Rodríguez et al., 2013).

· Partial or full thick allergic reaction may be seen near the stomal area. Regular or irregular swollen border around the stoma bud is the characteristic of allergic contact dermatitis.

· This infection is itchy and painful and might lead to spread due to exudates release (Kaur et al., 2012)

Stomal assessment

· Round, red, moist mucosa was observed

· flush or low profile stoma

· end stoma, intact muco-cutaneous junction

· Lumen was observed in the4 center of stoma

· Likely an ileostomy as it is on the right lower quadrant

Peristomal assessment

· Redness in the skin is observed, due to allergy, patching, or usage of tapes and bandage.

· However, the skin color is healthy.

· The skin integrity is intact.

· No hair was observed on the body.

· The skin texture is crusty, normal skin turgor (palpation test)

· Away from stoma, the skin has a red rash in a circular pattern all the way around the stoma where the wafer would sit.

· Lower right hand aspect of the skin shows mechanical stripping and denuded skin.  

Patients condition

· This allergic contact dermatitis increases the pain around the stoma site, itching and irritations leads to discomfort.

· It can affect the activities of daily life of the patient

· Further discomfort can affect the mental state and to treat that financial strength would be required. Hence, all the aspect might suffer due to this wound. 

Pouching system condition

· The pouching system is also affected as papules and vesicles create complication in the ostomy management (Watson et al., 2013).

· The place of stoma was such that it may affect the integrity oif pouching as lift up might occur, and pouch management was crucial.

· Specific secondary accessories might also be required to keep the pouch on the place.

How to deal with the problem

· The allergen product should be removed, as removal of offending product will remove the allergic condition.

· The fragranced stoma bag deodorizer should be checked, the stoma appliances such as soaps, wipes adhesive removers should be checked for allergic dermatitis.

· The caretaker of the patient should use non-oily steroid cream and powder (Gardiner, 2013).

· To protect the stoma, an interface such as a Coloplast barrier sheet can be used if any proper pouching system is not available that can properly fit in the stomal region (González-Rodríguez et al., 2013). 

Picture 5: healthy stoma with contact dermatitis around the lesion

Etiology

· It is a healthy stoma, which is in the primary stage of development

· The stoma developed contact dermatitis because of the presence of infected substances around the patient

· The ulcer may spread due to open surface and microbial infection as well as due to the release of exudates from the stoma (Wu & Shen, 2013). 

Pathophysiology

· Shallow and deep ulcer having cavity witnessed, having a reddish and ragged edge surrounded by swollen and reddish skin is observed

· Further, the allergic condition may be due to irritants or pouch related allergens used in the process.

· The ragged edges of the swollen skin around the stoma are whitish or yellowish in color and the skin is hard and broken textured which may lead to blackish blemish 

Stomal assessment

· Moist and round cavity was observed, which is bud shaped and shiny red.

· The cavity was 2-3cm deep, located in the smoother section of the belly. Possible the left lower section of the body.

· The periphery of the cavity was swollen and reddish allergic condition was observed.

· Red mucus was observed, which determines healthy stoma. Further, shiny, smooth and textured cavity was observed

· Lumen was present in the center of the stoma and it was in developing stage with intact muco-cutaneous junction.

Peristomal assessment

· The surrounding of stoma was light reddish and further only edema was observed,

· The peripheral skin was normal in color and therefore denoted healthy peri-stoma however had broken structure with whitish skin rashes.

· Redness was observed due to the allergy spread by the released exudates from the stomal cavity, which made the skin around the cavity inflammated and leading to symptoms of erythema and edema around the stoma where the wafer would sit.  

Patients condition

· Itching and pain can be the discomfort and further healing of the lesion leads to formation of cribriform scars, which appears as small hole.

· Further, the patient suffers from high risk of microbial infection that can occur from the normal microbial flora of skin in that area

· However, less financial and much more psychological trauma can be faced by the patient 

Pouching system condition

· The pouch may be affected due to swollen cavity in the stoma infection site

· However due to the smoth surface, it will not dislocate of lift up.

· With the increasing size of stoma, the pouch wear time and need of addition of secondary accessories can be increased,

· Therefore, special cavity convex pouches should be used for the protection of the stoma 

How to deal with the problem

· Usage of topical steroid agents may be beneficial as using this application of systematic steroidal agent leads to healing of the wound (Wu & Shen, 2013)

· Further Pain management and Time management is also beneficial in the faster healing of the wounds.

· Cleansing and hygiene should be maintained properly as this stomal condition may lead to severe condition.

· Hence, the care taker and the patient as well should take care of cleansing using medicinal solvents and warm water should be done so that further infection can be prevented (Fahmy et al., 2012). 

Picture 11: Pyoderma Gangrenosum with allergic reaction

Etiology

· The primary etiology is the presence of inflammatory bowel disease. Further, due to the usage of allergic substances in the pouch management, allergic condition arises.

· It is often associated with autoimmune diseases such as ulcerative colitis, Crohn's disease and rheumatoid arthritis (Ahmad et al., 2017).

· There is also a possibility that due to not frequent changes of the pouch of this stomal region, infection spreads through the exudates.

· People with blood disorders (hematologic malignancies) are at increased risk of pyoderma gangrenosum

Pathophysiology

· Irregular budded stoma, with reddish brown color, and cavities around the stoma was observed. This occurs mainly because of the variety of immune mediators such as IL-8, IL-1β, IL-6, interferon (IFN)-γ, G-CSF, TNF, which is elevated in the patients affected with Pyoderma Gangrenosum.

· Further, the circular periphery had reddish swollen skin represented erythema and edema (Randall et al., 2012). 

Stomal assessment

· Swollen, reddish, irregular stoma was observed, having irregular swollen network of skin around and over it forming the border. The stoma was protruded by 2-3cm from the skin level of that area.

· Reddish moist mucosa was observed in the center.

· The stoma was present on a smooth surface. Healthy reddish stoma, with shiny and textured layer was observed. Further, around the stoma small holes having yellow patches were observed.

· Possibly, it is the right upper quadrant of the body.

Peristomal assessment

· No hair was observed on the abdomen, intact skin was present near to stoma

· However, the closer skin had several perforations in it.

· Further, away from stoma the skin has a red rash and it was spread unevenly.

· It was a plane surface for the wafer to sit on.

· Lower right hand aspect of the skin shows mechanical stripping and denuded skin

Patients condition

The physical impacts may include, restlessness, pain, itching discomfort furthermore, infection may spread to other regions due to the smudged exudates.

Psychologically having around on upper left quadrant can impact the patient as it would stay always in their mind and they will not be able to move freely. However, financially it is not that costly to avail treatment of this system.

Pouching system condition

· The pouch will be unable to stay at proper place due to the position of the wound. Further, leakage of effluent from stoma may also displace the pouch. This made moisture and microbial load to infect the stoma.

· Further, due to irregular shape of the stoma and protruded and barrel shaped non-cellular lumen of the stoma, it is difficult to properly cover this stoma with pouch, hence, the brand will be changed and special bandage or custom pouches made for the specific stoma will be used to protect this lesion (Randall et al., 2012).

· This will affect the general bandage time, as it will frequently lift off the place. Hence, to make it stay on the place secondary accessories will be used. 

How to deal with the problem

· Cleansing of the opening with warm water and solvents to prevent the exudates from spreading, stomal relocation and surgical reconstruction might also be used as a disease prevention intervention (Kwiatt & Kawata, 2013).

· Od puch changes will be used for wound management

· Properly fitting appliances will also be used as secondary accessories to protect the infection from moisture (Grey et al., 2013).

· Using convex shaped pouch can be helpful in this condition, as the convex shaped pouch has and outward curve, that puts enough pressure around the stomal area and this pressure will help the stoma to protrude into the pouch.

· Topical steroidal agent and systemic steroidal therapy will be used for this purpose. 

There are several implications of stoma and peristomal issues both for the patient and the caregiver assessing their development. These complications may range from small ulcers and edema/erythema to deep cavity and thick skin ulcers. Further there are also examples of contact dermatitis due to allergy or irritant, fistula relates stoma complication, peristomal skin complications and the treatment. Management and prevention is different from one another. Therefore, the role of assesso9r is very crucial, as they have to assess accurately the type of stomal and peristomal infection and chose appropriate intervention for the treatment. Prevention and treatment both are important as prevention helps to avoid the complication to occur in present and in future and if it is combined with proper treatment, it will help to fasten the healing process. However, adding the patient and their family in the prevention process increases the degree of it as educating the patient will help him or her to stay aware of the conditions that can lead to infection. Hence, such assessments, treatments and education should be provided to the patient through properly trained ostomy nurses, so that the patient can be influenced to maintain stomal pouches, and use the products that are prescribed by the physician for the proper healing of the stoma and peristomal infection

Picture 2: Candidiasis and Folliculitis

References

Ahmad, Z., Sharma, A., Saxena, P., Choudhary, A., & Ahmed, M. (2017). A clinical study of intestinal stomas: its indications and complications. International Journal of Research in Medical Sciences, 1(4), 536-540.

Baykara, Z. G., Demir, S. G., Karadag, A., Harputlu, D., Kahraman, A., Karadag, S., ... & Cihan, R. (2014). A multicenter, retrospective study to evaluate the effect of preoperative stoma site marking on stomal and peristomal complications. Ostomy/wound management, 60(5), 16-26.

Beitz, J. M., & Colwell, J. C. (2016). Management Approaches to Stomal and Peristomal Complications: A Narrative Descriptive Study. Journal of Wound Ostomy & Continence Nursing, 43(3), 263-268.

Fahmy, M., Ramamoorthy, S., Hata, T., & Sandborn, W. J. (2012). Ustekinumab for peristomal pyoderma gangrenosum. The American journal of gastroenterology, 107(5), 794.

Gardiner, A. (2013). Addressing common stoma complications. Nursing & Residential Care, 15(3), 128-133.

González-Rodríguez, A. J., Gutiérrez-Paredes, E. M., Fernández, Á. R., & Jordá-Cuevas, E. (2013). Allergic contact dermatitis to benzocaine: the importance of concomitant positive patch test results. Actas Dermo-Sifiliográficas (English Edition), 104(2), 156-158.

Gray, M., Colwell, J. C., Doughty, D., Goldberg, M., Hoeflok, J., Manson, A., ... & Rao, S. (2013). Peristomal moisture–associated skin damage in adults with fecal ostomies: a comprehensive review and consensus. Journal of Wound Ostomy & Continence Nursing, 40(4), 389-399.

Haugen, V., & Ratliff, C. R. (2013). Tools for assessing peristomal skin complications. Journal of Wound Ostomy & Continence Nursing, 40(2), 131-134.

Huq, M. A. U., Rahman, A. M., & Hossain, T. (2014). Use of Betel Leaves in Pediatric Stoma Care. Journal of Paediatric Surgeons of Bangladesh, 1(2), 148-152.

Jonkers, H. F., Draaisma, W. A., Roskott, A. M., Van Overbeeke, A. J., Broeders, I. A. M. J., & Consten, E. C. J. (2012). Early complications after stoma formation: a prospective cohort study in 100 patients with 1-year follow-up. International journal of colorectal disease, 27(8), 1095-1099.

Kaur, S., Zilmer, K., Leping, V., & Zilmer, M. (2012). Comparative study of systemic inflammatory responses in psoriasis vulgaris and mild to moderate allergic contact dermatitis. Dermatology, 225(1), 54-61.

Kwiatt, M., & Kawata, M. (2013). Avoidance and management of stomal complications. Clinics in colon and rectal surgery, 26(2), 112.

Lyon, C. (2016). Cutaneous Complications of Stomas and Fistulae. Rook's Textbook of Dermatology, Ninth Edition.

Meisner, S., Lehur, P. A., Moran, B., Martins, L., & Jemec, G. B. E. (2012). Peristomal skin complications are common, expensive, and difficult to manage: a population based cost modeling study. PLoS One, 7(5), e37813.

Randall, J., Lord, B., Fulham, J., & Soin, B. (2012). Parastomal hernias as the predominant stoma complication after laparoscopic colorectal surgery. Surgical Laparoscopy Endoscopy & Percutaneous Techniques, 22(5), 420-423.

Rippon, M., Perrin, A., Darwood, R., & Ousey, K. (2017). The potential benefits of using aloe vera in stoma patient skin care. British Journal of Nursing, 26(5), S12-S19.

Salvadalena, G. D. (2013). The incidence of stoma and peristomal complications during the first 3 months after ostomy creation. Journal of Wound Ostomy & Continence Nursing, 40(4), 400-406.

Teagle, A., & Hargest, R. (2014). Management of pyoderma gangrenosum. Journal of the Royal Society of Medicine, 107(6), 228-236.

Watson, A. J., Nicol, L., Donaldson, S., Fraser, C., & Silversides, A. (2013). Complications of stomas: their aetiology and management. British journal of community nursing, 18(3), 111-116.

Wu, X. R., & Shen, B. (2013). Diagnosis and management of parastomal pyoderma gangrenosum. Gastroenterology report, 1(1), 1.

Wu, X. R., Mukewar, S., Kiran, R. P., Remzi, F. H., Hammel, J., & Shen, B. (2013). Risk factors for peristomal pyoderma gangrenosum complicating inflammatory bowel disease. Journal of Crohn's and Colitis, 7(5), e171-e177.

Zuo, K. J., Fung, E., Tredget, E. E., & Lin, A. N. (2015). A systematic review of post-surgical pyoderma gangrenosum: identification of risk factors and proposed management strategy. Journal of Plastic, Reconstructive & Aesthetic Surgery, 68(3), 295-303.

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