Denuded Peristomal Skin

[RachRN11]

Hello all!

I have a patient who has a new end ileostomy. I am the only CWOCN in the hospital and I was gone on vacation when he was in the hospital. So the surgical floor did their best with his ostomy care. However, they were using the wrong pouch which caused leakage and the peristomal skin to become denuded. So, now I'm trying to heal the skin while also trying to stop further leaking - Yikes!

Here's the story -

New end ileostomy (temporary - previous primary anastomosis leaked causing the need for this diverting ileostomy). The stoma only measures 32mm or 1 1/4". It is just slightly oval in shape. Stoma is flush to skin with the opening in the middle. Patient has a fairly flat abdomen with no creases/skin folds/divots. Abdomen is mostly soft (normal-like..if that makes sense). Patient was sent home with a flat one-piece pouching system, had leakage throughout entire weekend and now skin is moderately denuded from about 3-9 o'clock and extends to his groin/thigh area. Upper skin is slightly irritated but I believe that's all from the pouch tape-border and barrier being removed every couple hours. Patient states that he's had to change his pouch 3-4 times a day. The denuded tissue weeps a little which causes it to break the seal on the pouch (at least I think that's the problem).

So this is what I've done so far. Keep in mind that my hospital is on the smaller side so I am limited on products. We are contracted with Hollister for our ostomy supplies so that's what I'll be referring to.

First attempt, I applied stomahesive powder to denuded area

Since patient had a supply of flat pouches, I added an adapt convex barrier ring to it due to stoma being flush to the skin. Skin barrier was flextend.

Patient came back next day and it was leaking and he had to change pouch about 2-3 times.

I then "crusted" the denuded area with stomahesive powder and skin barrier wipe

I placed a hydrocolloid sheet onto denuded area thinking that the pouch would have an easier time adhering to a dry surface (while the "crusting" and hydrocolloid worked on healing the denuded tissue)

I reapplied an adapt convex barrier ring to the flat 1 piece as before.

Again, leakage happened...

So I changed it up a little:

I "crusted" the denuded area and applied the hydrocolloid sheet again.

I switched to the Hollister New Image convex 2-piece pouch (hospital doesn't carry 1 piece convex for some reason) thinking that either the adapt convex barrier ring wasn't applying enough convexity, was applying too much, or was too soft for abdomen.

I also applied an ostomy belt for added support and "window-framed" pouch with paper tape (put tape around border). *Fingers crossed*

Patient empties bag frequently so that isn't the problem (he's doesn't want it to get too full/heavy and pull the pouch off). Patient's stool is pudding-consistency and he isn't having high output. Everywhere I've read says to do the crusting technique but I've also read that sometimes that interferes with the seal. I honestly don't think any pouch will stick to that denuded skin so I have to do something.

I'm not a fan of the ostomy paste because it's hard to get off skin or people use too much so I was trying to stay away from it, but is that something I should try if this last pouch change doesn't work?

This is where I need your help! I've only been doing this for about a year and my hospital only gets maybe 1-2 stoma patients per month so I'm not the most experienced. Since I'm the only CWOCN in the hospital, I don't have anyone to bounce ideas off of or take in with me to see the patient. I'm kind of at a loss now and it's only going to get harder the longer I can't obtain a seal. I don't think a stoma revision will be an option since it's temporary anyway.

Eventually, though, if I can't get it to stop leaking, I may refer him on to another stoma nurse who has more experience or works in a bigger hospital (more supplies available).

Thanks for any input, I greatly appreciate any ideas!

[RachRN11]

Good News!

I wanted to update just in case someone reads this and relates to it in the future.

After my last modification of the pouching system, the pouch stayed on for about 16 hours. That was a significant leap from a previous 3 hour seal so I was ecstatic!

When I went to change the patient's pouch again, the peristomal skin was looking better. It wasn't as bright red and seemed to be starting to dry out (yay!)

So, because of the drastic increase in seal time, I ended up just using the same modified pouching system as before and it lasted 24 hours and counting! No leak yet!

Here's what I did so you don't have to scroll up and search

I "crusted" the denuded area with stoma powder and skin barrier wipe

I cut a hole in a hydrocolloid sheet (looked like a square donut) and applied over stoma and denuded periwound skin

I used Hollister New Image convex 2-piece pouch (I would actually use a 1-piece pouch but my hospital only supplies 2-piece convex for some odd reason)

I also applied an ostomy belt for added support and "window-framed" pouch with paper tape (put tape around border).

Hopefully it will last throughout the weekend!

Ostomy nursing can be so frustating but it's oh-so rewarding when you get it right!

[mrosette]

Don't forget domboro's solution for weeping, denuded, inflamed skin. Helps dry, ad provides comfort. It is frustrating but rewarding as you say...

[Davidaugustyn]

I have a step process I use when I have peri-stomal denuded skin.

I had a horror film patient. Every time I heard a page to the room. I knew I would be dealing with this horrible leaking ostomy.

I've had much practice with probably 50 different supplies on this patient, and can tell you what works.

They cost, but get them:

Medline marathon liquid skin protectant. It's a cyanoacrylate based purple prep that works magic on denuded skin.

Once the skin does better, switch back to whatever you're using.

When you have a bad patient, you have to buy what it takes to provide adequate care. I'm in a facility that uses only hollister too, but it doesn't cut it all the time.

After experience with many bad stomas:

1. I don't crust.

I find that whenever I have a reason to crust (except for rash and nystatin powder) I use the marathon prep instead and it works superior to crusting while holding a better seal.

2. LESS layers!

Don't use hydrocolloids, they just aren't best. Maybe a duoderm brand or another brand works better than what I've used, but the extra layers just make things worse, especially for a patient that applies it. If anything, use eakins discs

3. You don't use paste? You have to learn how to use paste!

Paste is the best thing since sliced bread....when used right.

Make sure you cut your appliance right and place your bead around the appliance opening.

The crucial key is: YOU HAVE TO LET IT SIT OTA FOR 10 MINUTES.

This may be time consuming, but worth it in the end. It works like a O-ring and can seal a denuded area. The slightly dryer paste doesn't get all sticky on the skin either.

4. Experiment on paste until you get it right, and it will be your friend.

[mommy.19, MSN, RN, APRN]

So glad it worked out :) I have had to go back to using a very large wafer, like the convatec 4 in durahesive for patients with peristomal breakdown. This way, there is a much larger surface area to anchor to intact skin. I know you just said you were product limited, and I think you did the best with what you had, for sure. I have done the same thing, cutting the hydrocolloid like a wafer and applying first. I do like hydrocolloids for some things, especially that weeping, denuded skin you described. Sometimes you have to prepare the skin for frequent changes if the peristomal skin is extremely damaged.

Just a note, I hate paste with iliostomies and urostomies, I use eakin cohesive seals. Most paste has alcohol and burns if the skin is broken. Hollister adapt paste, however, is alcohol free I believe. :) And it comes in tiny tubes that last 1-2 uses so you don't have to pull your hair out when someone leaves the cap off and it dries out!

[CWONgal]

Marathon is a great product, agreed...pricey and from what I understand it is not considered a standard ostomy product and may not be covered by insurance.

Lots of folks use paste as though it's a glue and when they plaster it onto that peristomal skin it can be a challenge to get off. I only use paste to fill in crevices and visible gaps and I put it in a syringe first before applying.

Eakin rings need to be warmed and if the peristomal tissue is weeping it can be hard to get the ring to stick. Brava rings get a gummy consistency over time but they really do seem to stick well.

I have had a lot of folks complain about burning with Hollister paste...I THINK it does have alcohol?

[Davidaugustyn]

yeah hollister does have alcohol. I mostly use it for a weeping peristoma. If truly is the key for a a good seal. Ask anyone with a long term difficult stoma. It's just how it's used. Like you said, its not glue. the idea is for the o-ring like seal.

[mommy.19, MSN, RN, APRN]

I apologize, the adapt RINGS are ETOH free, not the paste.

[RachRN11]

Thanks all!

I have heard good things about the eakin rings/discs so I believe you all on that. I just haven't gotten a chance to try them out.

I use paste occassionally, especially when those darn ostomy bridges are in (another nightmare to deal with) but I personally stay away because not many people use it correctly and it drives me nuts trying to clean it off. As it was said earlier, a lot of people use it as glue. I was taught that it is used as a caulking agent and I do try to teach patient's that as well but if the patient doesn't need paste then I just leave it out as fewer steps and less things to handle is easier to remember during pouch changes. All my personal opinion, however, I'm not against paste..just not a huge fan of it. :)

And I was using Duoderm hydrocolloid extra thin sheet so it wasn't a thick layer I added. As soon as the skin was healed, I had the patient discontinue the use of the hydrocolloid sheet and just use a convex pouch.

Anyway, thanks for the input and keep on healing!

[pw2012]

I had a nightmare ileostomy peristomal condition the other day. I also have limited experience with ostomy and was the only one available when asked to assist a nursing home patient. I'll explain my situation and I would be really thankful for any suggestions or tips or tricks in case I run into similiar situations in the future. Revised ileostomy, retracted stoma, deep bumpy denuded crevices at 3 and 9. all peristomal denuded, unable to get any wafer, or appliance to adhere, attempted eakins ring and convexity, applied pieces of warmed eakins to crevices, that did not work, attempted crusting and then paste to crevices as well as crusting to peristomal area, this also did not work, i just could not get anything to adhere. Later it was suggested I could have used maalox to area and dried with hair dryer and then continue with crusting and applying eakins wafer. I would have never have thought to try that. So I am curious what other tips or tricks may be out there.