In the UK, there are some 124 000 people living with a stoma (Boyles and Hunt, 2016), and community nurses will encounter these individuals given that many of them live at home or in the community. The most common issues experienced by people with a stoma are problems with the skin around the stoma (peristomal skin). Community nurses often have to provide skin care for ostomates, and increased knowledge regarding the care of peristomal skin will increase community nurses' confidence in dealing with skin issues, especially those that may result in appliance leakage.
Stomas
There are three main types of output stoma that the community nurse is likely to see. These are the colostomy, ileostomy and urostomy. A colostomy will usually pass formed faeces and flatus between three times a day and three times a week, into a closed appliance. An ileostomy will usually pass porridge-like faeces and flatus into a drainable appliance that is emptied about six times a day and changed every 1–3 days. Finally, a urostomy appliance is drainable with a tap or bung fastening, and it is emptied about six times daily and usually replaced every day or every other day (Black, 2014).
Appliance change
Ideally, patients should be taught how to care for their stoma in hospital before they are discharged into the community, but even when they are, people can become complacent about the various aspects of stoma care over time. The change of a stoma should ideally be integrated into the usual personal care routines, and each person will vary slightly in their change technique. In general, the technique follows a few simple steps (Burch and Black, 2017).
It is important to note that the stoma aperture should ideally be 2–3 mm larger than the stoma but of the same shape as the stoma (Burch and Black, 2017).
Peristomal skin care for community nurses
There are various aspects of peristomal skin that require the attention of community nurses, from the view of preventing both skin damage and infection. The abdominal skin around the stoma is at risk of erosion that can be termed peristomal moisture-associated skin damage (P-MASD) or peristomal medical adhesive-related skin injury (P-MARSI), depending on the cause of the skin damage.
Peristomal moisture-associated skin damage
When the skin has prolonged exposure to with moisture, it can become damaged. Prolonged contact with water, for example, can occur during bathing, where the skin on fingers becomes paler and wrinkles. In more recent years, the term MASD has been used, and this is defined by Colwell et al (2011:541) as ‘inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture’. This includes prolonged contact with the output from a stoma, which can cause erythema or maceration of the peristomal skin. Skin damage can then progress into erosion of the peristomal skin. Skin erosion can also be termed irritant contact dermatitis if it is caused by the output from the stoma (Colwell et al, 2017).
P-MASD can also occur if the stoma appliance is not well secured. This might be for a number of reasons, such as changes in the person's weight, which may result in creases in the skin into which the output from the stoma can leak. Alternatively, the stoma may be flush against the skin, and the output from the stoma might leak under the flange. It is essential to assess and appropriately address the cause of the leakage.
Peristomal medical adhesive-related skin injury
Skin injuries caused by the adhesive used in the stoma appliance are termed P-MARSI, and there are a number of reasons why these might occur. A common one is skin stripping, which occurs when the stoma appliance is removed during an appliance change and the surface of the abdominal wall is removed (LeBlanc et al, 2019). P-MARSI is more likely to occur with stoma appliances that need to be removed and/or changed multiple times each day, if removed roughly, or for people with fragile skin, such as older adults. In some cases, skin loss due to P-MARSI can even cause bleeding.
Nursing assessment
A nursing assessment for stoma-related problems should include a number of aspects, namely, the skin, the stoma and the appliance.
Skin
When assessing the skin, the following aspects should be examined:
Stoma
It is important to assess the stoma from the following aspects:
Appliance and other products
It is important to assess the appliance and any other products that are used. This includes examining the process by which the appliance is changed. Additionally, it is necessary to review the size of the aperture in the stoma appliance.
Treatment of peristomal skin problems
Treatment for issues related to peristomal skin should be tailored to the cause of the problem. There are a number of situations where the community nurse will have to re-educate patients on how to care for their stoma. If skin damage has occurred as a result of excessive wear time, the nurse should educate the patient on their change practice. In general, it is expected that an appliance is changed between once a day and three times a week. This will depend upon the type of stoma, as mentioned previously. If the appliance is left on too long, the output from the stoma will damage the inner edges of the appliance adhesive; thus, nurses should encourage patients to change their appliances more frequently. It should be kept in mind that damage to the stoma appliance is most likely to occur if there is a loose output, as from an ileostomy or urostomy.
Conversely, if the appliance is replaced too often, the skin can break down. In this situation, a patient can be advised to remove the adhesive less frequently. For example, a person who has a colostomy and passes several bowel motions each day might be advised to wear a two-piece colostomy appliance. In this situation, the adhesive section (the flange, baseplate, faceplate or wafer) can be left in situ for several days while the pouch part can be replaced as necessary.
People can forget the importance of thoroughly cleaning and drying the peristomal skin. Faeces or urine can be left on the skin, which can cause damage. Alternatively, if the skin is not dried, adhesion of the new appliance is impaired. For people with fragile skin, such as older adults or young children, it might be useful to use an adhesive remover. This product helps to dissolve the adhesive on the flange and thus reduces any damage to the skin when the appliance is removed.
It is important to ensure that the aperture in the stoma flange is the correct size, as mentioned previously. The wrong-sized aperture can occur when people experience weight change or in the first few months after stoma formation. Ensuring that the stoma appliance aperture is neither too large nor too small reduces the risk of the stoma output touching the skin and causing damage.
If the stoma output is in contact with the skin because of skin creases, it might be useful to fill the creases with filler paste or seals (washers or rings). This will help adhesion of the appliance and reduce the risk of skin damage. Additionally, if the stoma is flush to the skin, there is a higher chance of the output from stoma touching and damaging the skin. In this situation, a convex appliance can be used. However, care must be taken and the patient must be instructed to review the skin at each appliance change for damage from the pressure exerted by the convex appliance on the skin around the stoma. Damage can present as bruising or, if left untreated, it may worsen to skin erosion or ulceration. Patients should be advised to seek nursing review if any anomalies are noted.
Finally, if the output is high, particularly from a faecal output stoma, the reason needs to addressed, for example, there may be an infection that requires antibiotics. Infections are rare, and include folliculitis and fungal infection. Folliculitis is inflammation of the hair follicles, which can be resolved by weekly trimming of the peristomal hair, while fungal infections can be treated with topical powder or small amounts of antifungal creams, such as clotrimazole cream (Stelton et al, 2015). When the output is high, it is potentially corrosive to the skin, and a seal might be considered to protect the skin directly around the stoma.
Community nurses need to feel confident to make changes to assist people with a stoma and peristomal skin problems. Many of these issues can be easily resolved, but if they persist, it is advisable to seek the assistance of the stoma specialist nurse.