So yea...this wound isn't getting any better...

[ceebeeRN]

I originally posted in the wound/ostomy section to no avail...go figure! since I work in a post acute unit in a SNF, I figured I'd try my luck here.

I am the treatment nurse on my unit on a pretty consistent basis and we recenty admitted a patient with both an ileostomy and a colostomy. The colostomy site and the skin around it is fine but its the product from th ileostomy site that leaks through the skin barrier and his skin is now as raw,red, and angry looking looking as this bird-->.

The site is so irritated:arghh:, that one MD saw it and suggested maybe we send him back to the hospital or at least follow up with the doctor who did the surgery to see what can be done about resolving the irritation.

we've tried multiple pouches and multiple skin barriers, including the presized 1 pieces and the 2 peices that need to be measured and cut to size. Nothing seems to be sticking...literally or figuratively! hence the leaking and further irritation. the rawer his skin gets, the less the skin barriers are adhering. the drainage from the stoma just breaks the seal of the skin barrier and the acidic drainage gets everywhere. To relieve a bit of the discomfort, the MD ordered mylanta to be applied to the irritation skin but it seeems like the mylanta further weakens the seal and once again, it doesn't really solve issue or provide a great amount of relief. I feel so bad for my patient!!

any suggestions for what we should do to help?

[kiszi, RN]

That can be such a difficult issue! My suggestion is a thin hydrocolloid with a hole cut for the stoma applied first, then a one piece pouch applied to the hydrocolloid instead of the skin. A bit of strip paste around the pouch opening may help as well.

I had a rough case like this once where all else failed and we applied a liberal amt of calmoseptine or some such to the areas of breakdown and used dry dressings for a couple of days with frequent changes. Helped a bit.

[chrisrn24]

^ I like those ideas!

What about using skin prep to toughen the skin and then dust with nystatin? It makes the skin kinda sticky and tough. That worked well for one of our patients.

Also maybe try not using a bag for a while? We would cover the stoma with abds and then cover with another dressing. Needs to be changed frequently but it might let the stoma site heal.

[ceebeeRN]

I will try this tomorrow...I know we have hydrocolloid and we should have calmoseptine. If not, I'll put in an order for it. Thanks for the advice. For my patient's sake, I hope it works!

[ceebeeRN]

I've seen another nurse use the skin prep + nystatin powder method on a patient, however, that patient's site was no where as irritated as my resident's is. I actually tried using the skin prep once and he let out a scream so loud, I practically fell backwards, so I Know not to do that again. Oops! lol

We have been leaving the site open to air from time to time, with just a towel against it to absorb the drainage, but the DNS was not so happy about that. I, however, do think my patient would benefit from having the pouch off for a bit and the application of some type of dressing.

[kiszi, RN]

See if you can order some no sting skin prep, it's a lifesaver!

[systoly]

can you get an ostomy nurse to have a look

[ceebeeRN]

just when i was about to try your hydrocollloid suggestion, i went back to work only to find that the resident out to the hospital because of how aggravated the area became. now that he;s back we're really trying to nip this issue in the bud, so what I did is used Duoderm instead of hydrocolloid (we are out of that at the moment). do you think that duoderm is a suitable temporary subsitute for the hydrocolloid?

I've only used it a couple times and it seems to have helped to a degree. the leaking is minimized but since we are using the one piece pouches we have to be very diligent about changing the bags and keeping the area as dry as possible. Even with the lessened leaking, I can already see his skin getting a bit red but its not nearly as bad as before. Hopefully the added barrier of the hydrocolloid or duoderm keeps the leaking at a minimum. it would be wishful thinking to think it would stop it all together! =/

[ceebeeRN]

we may need an ostomy nurse consult after all. we have a wound doctor but honestly, he's not that effective when it comes to ostomies lol

[SHGR, MSN, RN, CNS]

...the resident out to the hospital because of how aggravated the area became. now that he;s back we're really trying to nip this issue in the bud...

What was the hospital staff doing for this patient? Could you find out and do the same thing?

[misstrinad]

Regular skin prep can only go on intact skin or it does hurt. Use it for the edges of intact skin. Any chance they having an allergic reaction to the ostomy products that are exasperating the skin breakdown? I would definitely get a consult from an ostomy nurse