The aim of this essay is to plan and suggest an intervention plan for Henry. Henry underwent a temporary loop ileostomy approximately six months ago. The aim of this essay is to discuss the various aspects of peristomal skin care. The evidence for and against various products described for peristomal skin care will be reviewed and discussed. The intervention plan has to focus on reeducating the ostomate about good self-care practice for the peristomal skin.
The peristomal skin is the skin that surrounds the stoma and the skin to which the stoma appliance adheres to. Patients who undergo ileostomy have to contend with the loss of independence and control that affects their physical and mental wellbeing. The overall goal of the intervention described in this essay is to maintain healthy peristomal skin to prevent discomfort around the stoma and to avoid stoma leaking in the ostomate (Burch 2011). The problems very frequently experienced by ostomates are redness and soreness in the peristomal skin. Leakage of stool is also experienced by many patients’. In a study published in 2008, Meisner and Balleby reported that 80% of ostomates can experience soreness in the peristomal skin area. Ratliff et al reported that 40-50% of ileostomates had sore peristomal skin. The damage to the peristomal skin can occur because of proteolytic enzymes present in the loose focal output found with the ileostomy. Additionally the process of emptying of the stoma bag and application of the replacement bag can also result in discomfort to the skin.
The complications associated with leakage or soreness can be prevented by judiciously following a skin care protocol. The stoma appliance has to properly adhere to the peristomal skin. The peristomal skin needs to be free of breaks and intact for proper adhesion. The skin must maintain a slightly acidic pH of 5.5. The peristomal skin should appear exactly like the surrounding abdominal skin and no changes should be observed in the skin pigmentation (Herlufsen et al 2006). The first step in the intervention involves assessment of the peristomal skin regularly to recognize any problems associated with the peristomal skin.
Soreness in the peristomal skin can occur due to a wrong size stoma flange. When the stoma flange is small in size it can rub on the stoma, while a large flange can cause the stool and urine to come in contact with the peristomal skin. These two situations can cause soreness and breaking down of the peristomal skin. (Cronin 2008). The condition can be resolved by measurement of the stoma and use of an appropriate sized stoma opening and flange. Leakage commonly occurs when the patients fail to empty their stoma bags in time. An overfull bag is very likely to leak. As a result, the patient has to re-educated in the appropriate emptying of the bag. If patients consistently have loose stools, they can be prescribed stool thickening agents or recommendation of lowering fiber intake can be made. The content of the small bowel contain proteolytic enzymes and other material that can damage the peristomal skin. Colostomy patients who experience multiple bowel movements per day can benefit from a two-piece stoma appliance. The two piece appliance consists of an adhesive piece called flange and the second piece is the bag. The flange or base plate can be left on while the bag can be emptied as needed. (Cronin 2008)
Many patients experience soreness and pain while replacing the stoma bags. This usually occurs when the bag is not removed gently. It is also known that repeated removal and application to ensure a good seal contributes to skin being sore and stripping. It is also important to not have creasing in the skin following attachment of the appliance. Creasing of the skin can contribute to leakage (Burch 2013). Stripping of the peristomal skin can cause long term damage and prevent healing. A damaged peristomal skin is prone to infections (Cooper, 2010).
Many patients experience discomfort while removing the stoma appliance. The adhesive removers are particularly useful if the ostomate experiences pain while removing the stoma bag (Vlok 2008). The sticky residue of the adhesive can also gather fluff from clothes and be difficult to remove. The traditionally available adhesive removers contained alcohol that could cause the peristomal skin to sting and took a few minutes to work. Furthermore, when the removers are offered as wipes, they can also cause dryness. However, the more recently available skin adhesive removers are alcohol free. Oil-based and silicone based adhesive removers are generally easier to use and do not cause irritation. The silicone based adhesive removers such as Appeel (Clinmed) work by forming a layer between the peristomal skin and the adhesive and do not form a residue after use and are inert to the skin surface (Berry 2007 & Copper 2010). The oil based adhesive removers are also gentler but need to be washed off with soap to ensure application of the replacement bag. This should be done by using a liquid soap applied by using wet cloth and warm water. Care should be taken to avoid excessive stripping and drying of the peristomal skin.
If the problem with soreness and stripping persists, it can cause ulceration of the peristomal skin followed by oozing or skin erosion. A patient who experiences erythematous skin can benefit from using skin protection barrier. These barriers are recommended to be used after the skin has been cleaned and dried prior to application of the appliance bag. If the skin around the stoma is dry; a barrier cream can be sparingly, used (Black 2010). If the skin around the patient’s stoma is wet and broken, he/she could benefit from using protective powder to dry and protect his peristomal skin. Even if the process of cleaning and drying the broken skin is uncomfortable for the patient it has to be carried out. Any excess powder has to be removed as it can prevent proper adhesion of stoma flange to the skin (Williams 2006). Some of the methacrylate and organic polymer based barrier cream contain alcohol or other organic solvents. The silicone and TEWL based protective barrier creams offer better protection, do not sting on application and are more effective than the traditionally used methacrylate based creams (Grove, et al 1993). The moisture level of the peristomal skin has to be neither too dry nor too moist (Burch 2013).
Nurses play a critical role in the various practical aspects of stoma and peristomal care. Leakage of stoma output such as feces can lead to skin irritation and breaking. This condition can be exacerbated by improper or rough handling and removal of adhesive. It is important to practice regular and good peristomal skin care routine. A number of stoma accessories are available that can help with the problems associated with erythematous stoma, sore and red peristomal skin and leaking (Black 2010). If the complications are not treated on time; they can lead to unnecessary hospitalization. Nurses also need to reassure the patients to continue a normal and independent life. Patients should also be educated to recognize the signs of problems and to seek help when needed.
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