A Descriptive Study to Explore the Effect of Peristomal Skin Complications on Quality of Life of Adults With a Permanent Ostomy

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Ostomy Wound Management 2017;63(5):10–23
Diane Maydick-Youngberg, EdD, RN, APRN, ACNS-BC, CWOCN

Abstract

Approximately 1 million people are living with an ostomy, and 100 000 to 130 000 new ostomies are created each year. The exact incidence and prevalence of complications are unknown but have been reported to be as high as 70% and to affect quality of life (QoL). Using convenience sampling methods, a descriptive study was conducted to explore QoL scores and peristomal complications reported by adults with a permanent ostomy attending the 2009 United Ostomy Associations of America conference.

Attendees who had a permanent ileostomy, colostomy, or urostomy; were at least 18 years of age; and able to read and speak English were invited to participate. Participants completed a paper/pen survey containing questions about demographics (age, gender, marital status), ostomy (time since and reason for surgery, ostomy type), and peristomal complication variables (number and type, who provided help, and satisfaction with treatment rated on a Likert-type scale from 0 [not satisfied] to 100 [completely satisfied]). QoL data were collected using the City of Hope-Quality of Life-Ostomy Questionnaire (COH-QOL-OQ), which consists of 2 sections — Lifestyle Impact and Quality of Life Impact — and measures 4 QoL domains on a scale of 1 (lower) to 10 (higher) QoL. Descriptive statistics (means, standard deviation, frequencies, percentages) were used to describe the demographic, ostomy, and peristomal complication variables. Univariate analyses of covariance were used to investigate the relationships among QoL scores and peristomal complications, and the number of different complications was correlated with the QoL total score using hierarchical multiple regression analysis. Of the 230 eligible participants invited, 140 (the majority women [83, 59.3%], with an ileostomy [86, 61.4%], and a diagnosis of ulcerative colitis [55, 39.3%]) met inclusion criteria and completed the survey. The majority of participants were married both before (97, 69.3%) and after (88, 62.9%) surgery; the mean QoL score was 7.56 (SD 1.59). The mean number of complications was 0.83 (SD 1.03); approximately one third of participants experienced allergic contact dermatitis (43, 32.3%), and persons with irritant contact dermatitis reported significantly lower QoL total scores (mean 6.64 [SD 1.64], P = .02) than those without this complication (mean 7.77 [1.56]). Of those with complications, most saw an ostomy nurse (33, 47.8%), but many did not see anyone for help with their complications (24, 16.3%). Persons who sought help were generally satisfied with the help received (mean satisfaction score 77.94 ± 24.71). In this study, allergic contact dermatitis was the most common peristomal complication reported. Irritant contact dermatitis negatively affected QoL, and almost half of the participants sought the help of an ostomy care nurse. The results of this study suggest patients may benefit from more education about peristomal complications and the reporting of appliance-related contact dermatitis. Studies examining the presence of peristomal skin complications and their  influence on QoL, as well as availability of and access to follow-up care with qualified ostomy nurses, are needed.

 

Although the exact number of individuals living with a permanent ostomy is difficult to ascertain, estimates range from 650 000 to 1 million; 100 000 to 130 000 new ostomies are created annually in the United States.1-3 Quality-of-life (QoL) studies demonstrated surgery to create a stoma (ostomy) impacts QoL,2,4-18 and in this population many experience either stomal or peristomal complications.8,17-31 

Although the exact incidence and prevalence of stomal and peristomal complications are unknown, a variety of studies have reported the rate of both early (<30 days) and late (>30 days) peristomal skin complications can range as high as 70%.8,18,20,24-26,29,32 Historically, the way stomal and peristomal complications have been reported in the literature is inconsistent but most studies conclude peristomal skin complications create ostomy self-management issues that affect individuals emotionally, psychologically, and financially.6,8,10-15,18,27,33 

An ostomy requires intact skin to facilitate adherence of a well-fitted pouch to contain odor and effluent. Peristomal complications such as skin rashes, irritation, and skin breakdown interfere with pouch adherence28 that may present additional hurdles, both immediately and long after surgery, that negatively affect patient adjustment.33 In a cross-sectional correlational study by Mitchell et al2 pouch leakage, odor, and skin irritation were shown to lead to embarrassment, social isolation, lost work days, and diminished productivity; other studies identified avoidable costs related to patient care visits and equipment.2,6,14,21,22,27

Literature Review

Park et al24 performed a retrospective analysis of all gastrointestinal stomas (N = 1616) performed at their hospital over a period of almost 20 years that examined early and late complications. Early complications were defined as occurring within 1 month of surgery and included skin irritation, poor location, partial necrosis, retraction, parastomal separation, parastomal abscess, bleeding, complete necrosis, evisceration, stenosis, pseudoepithelial hyperplasia, protruding sigmoid, and allergy. Late complications occurred 1 month or more after surgery and included skin irritation, prolapse, stenosis, parastomal hernia, pseudoepithelial hyperplasia, retraction, allergy, and perforation. The authors presented evidence that 553 individuals (34%) had 807 complications. Of these, 448 had 600 early complications, 105 had 207 late complications, and 30 experienced both early and late complications. Of the late complications, 93% occurred within the first 6 months.

By ostomy type, the highest percentage of complications in Park et al’s study24 occurred with ileostomy (49%), followed by ascending colostomy (35%), sigmoid colostomy (34%), descending colostomy (31%), and transverse colostomy (22%). Loop ileostomy had the highest overall rate of complications, and end colostomy had the lowest rate. Although “skin irritation” was not clearly defined, this was the most common early complication and was attributed or secondary to stoma neglect, leakage, improper fit, or frequent changing of the pouching system. Less frequent late complications were predominantly related to skin irritation, prolapse, and stenosis.24 

Ratliff et al26 assessed a cohort of individuals with a new ostomy during a postoperative visit for the presence of peristomal complications including mechanical injury, chemical damage (irritant dermatitis, pseudoverrucous lesions, hyperplasia), infection (Candida, bacterial, folliculitis), and allergic response. Over the course of 1 year, 220 individuals with an ostomy were seen 2 months after surgery by the wound ostomy continence (WOC) nurse during a routine examination. The frequency of peristomal complications was 13%; complications included chemical (irritant) damage (n = 24), mechanical damage (n = 7), and Candida infection (n = 3). The WOC nurses who examined each patient reported the complications were related to stomas that were flush or retracted, peristomal hernias in which the opening of the pouch was cut too large, or due to an injury caused by the pouch itself. Citing a wide variation regarding how peristomal complications are reported in the literature, the authors emphasized the importance of using universal definitions for peristomal complications for reporting and tracking.

Herlufsen et al20 reported the frequency, severity, and diversity of peristomal skin disorders among 202 individuals with a permanent stoma in Denmark as part of a 2-phase, cross-sectional study. In the first phase, an anonymous questionnaire was used to collect data; in the second phase, participants completed a questionnaire and a stoma care nurse filled out a registration form and performed a clinical examination of the peristomal skin. Healthy peristomal skin was defined as the complete absence of any visible skin change of the peristomal area. Peristomal skin disorders were classified as mild (slight skin involving only a small portion of the skin, usually 0.1 cm to 0.5 cm requiring minor adjustment), moderate (definite skin changes — eg, ulcers in the peristomal region involving an area of at least 2 cm2, adjustment of the pouching system, and/or a suggestion of treatment), or severe (conditions requiring immediate medical attention or substantial involvement of the skin beneath the ostomy appliance interfering with appliance adhesion). The number of peristomal skin disorders was higher for permanent ileostomy (57%) and urostomy (48%) than colostomy (33%). In persons with skin disorders, 77% were related to stoma effluent. However, 38% of participants failed to recognize they had a skin disorder before clinical examination confirming the disorder, and more than 80% did not seek professional care. These findings suggested a need for education and regular evaluation of the peristomal skin by a professional.

Pittman et al18 conducted a secondary analysis of data collected from veterans by Krouse et al.13 The authors examined the relationships among City of Hope-Quality of Life-Ostomy Questionnaire (COH-QOL-OQ) scores and ostomy complications. Ostomy complications were defined as “skin problems,” “leakage,” and “difficulty adjusting.” The instrument has 4 domains (physiological, psychological, social, and spiritual) which are scored on a scale of 1 to 10 with 10 being the highest or best QoL score.10 The mean total QoL score was 7.67 ± 1.47 for individuals with mild and 5.06 ± 1.78 for persons with severe skin problems. Mean total QoL scores for study participants with mild leakage was 7.46 ± 1.58 compared to 5.02 ± 1.81 for persons with severe leakage problems and 7.99 ± 1.27 for persons with mild difficulty adjusting compared to 4.39 ± 1.41 for persons with severe difficulty adjusting. Although QoL scores were lower for persons with severe skin problems, leakage, and difficulty adjusting, no significant differences were noted in the severity of complications when the researchers examined race/ethnicity, gender, or education. 

In a systematic literature review regarding the incidence of complications related to the stoma and peristomal skin, Salvadalena30 concluded the exact incidence and prevalence of complications are unknown due to differences in the way data are collected and stomal and peristomal complications are defined. Few studies report the use of measurement instruments and many fail to provide descriptions of the reliability or validity of methods used for evaluation. Due to inconsistencies in data collection, operational definitions, and study design, it is difficult to pool data; Salvadalena recommended the development of instruments to investigate stomal and peristomal complications.

Ratliff 25 prospectively investigated peristomal complications as reported by WOC nurses who completed a peristomal skin complication form for 89 patients with an ostomy regardless of whether they had a complication. Patients were seen within the first 2 months of ostomy surgery in hospital, home health, or outpatient clinic settings. Of the 42 (47%) patients who had peristomal complications, 31 had irritant dermatitis, 5 had mechanical injury, 4 had Candida infections, 1 had an allergic reaction, and 1 had pyoderma gangrenosum. Because studies are limited, the author suggested a central repository for peristomal complications data collected over time and in multiple settings.

Erwin-Toth et al8 evaluated skin condition and health-related QoL (HRQOL) in 743 persons in North America with a colostomy, ileostomy, or urostomy present for at least 6 months. Volunteers solicited via mail and advertisements, as well as patients who sought care from clinicians serving as data collectors, completed self-report surveys including the Ostomy Skin Tool (OST)34 and the Stoma Quality of Life questionnaire.35 The OST evaluates the presence and severity of 3 conditions (domain): discoloration (D), erosion or ulceration (E), and tissue overgrowth (T); each domain score ranges from 0 (normal skin) to 15 (indicating severe discoloration, ulcerations, denuded skin, and extensive overgrowth). The instruments were self-administered at baseline and again after 6 to 8 weeks, at which times a WOC nurse evaluated the peristomal skin using the OST.34 Interestingly, many participants did not recognize their peristomal skin was not considered “normal.” During the first visit, 29% of the participants reported a peristomal skin disorder; however, visual assessment by a WOC nurse revealed 61% of patients had objective signs of a peristomal skin disorder. In essence, a skin disorder was twice as likely to be detected by a WOC nurse; 32% of patients were unaware they had a peristomal skin disorder. Similarly, on the second visit, 30% of patients did not report any peristomal skin disorder, which was then subsequently noted by the WOC nurse. After the first visit, a double-faced adhesive pouching system was initiated; upon follow-up, participants reported improvement of skin condition and overall significant improvement (P <.0001) in mean QoL scores also was noted. The greatest change in QoL was observed in the quartile of participants with the lowest QoL at baseline. The researchers concluded regular contact with a WOC nurse combined with the use of an appliance with double-layer adhesive led to significant reduction in leakage and accessory use, improved skin condition, and significant improvement in HRQOL.8 

Meisner et al21 used a population-based, cost modeling study to investigate peristomal skin complications using the OST and concluded peristomal skin complications are common, expensive, and difficult to manage. Their work further supported the premise peristomal complications are common and their frequency and severity are underrecognized and underreported.21 

Gray et al36 performed a comprehensive review of the literature and summarized consensus-based statements outlining best practice for assessment, prevention, and management of peristomal moisture-associated dermatitis among patients with fecal ostomies. The authors concluded peristomal moisture-associated skin damage (MASD) is a prevalent and clinically relevant complication. 

Salvadalena30 also examined stomal and peristomal complications as well as related variables among adults with ostomies. Data collection occurred in 2 university hospital-based outpatient ostomy clinics and included 43 adults with newly created colostomy, ileostomy, or urostomy stomas. Patients were examined by a specialized nurse for the presence of complications up to 4 times during a 3-month period (within first 7 days and at 2, 6, and 12 weeks postoperatively). Peristomal complications were found in 27 (63%) of the participants, with onset most frequently occurring within 21 to 40 days. Of the 18 participants observed 70 days or longer, 7 (38%) remained free of complications and 6 developed 1 or more complications. The most common complication was irritation (MASD) and infection. 

Although stomal and peristomal complications are receiving increased attention in the literature and it is generally agreed QoL is affected, research shows inconsistencies in the way clinicians report stomal and peristomal complications. Valid and reliable definitions have been lacking. In 2007, Colwell and Beitz32 surveyed a group of ostomy nurses to ascertain consensus for common terminology. The survey revealed most nurses considered peristomal complications to include peristomal varices, peristomal candidiasis, peristomal folliculitis, mucosal transplantation, pseudoverrucous lesions, peristomal pyoderma gangrenosum, peristomal suture granulomas, peristomal irritant contact dermatitis, peristomal allergic contact dermatitis, and peristomal trauma. Respondents considered stomal complications to include parastomal hernia, stomal prolapse, stomal necrosis, mucocutaneous separation, stomal retraction, stomal stenosis, stomal fistula, and stomal trauma. As a result of the study, the authors validated definitions and interventions for both stomal and peristomal complications and promoted use of this terminology for ostomy-related research endeavors.32

The purpose of this descriptive study was to explore the relationship among QoL scores and 6 peristomal complications: peristomal candidiasis, peristomal folliculitis, pseudoverrucous lesions, peristomal irritant contact dermatitis, peristomal allergic contact dermatitis, and peristomal trauma as validated by Colwell and Beitz.32

Methods and Procedures

Institutional review board approval was obtained from Teachers College, Columbia University (New York, NY) after the proposal for dissertation research was approved. Participant volunteers were solicited during the second annual United Ostomy Associations of America (UOAA) conference held in New Orleans, LA, in 2009. Participants were eligible for participation if they 1) had a permanent ileostomy, colostomy or urostomy; 2) were at least 18 years of age; and 3) were able to read and speak English. 

Conference attendees who volunteered to participate were provided a self-administered survey packet (consent, pen and paper survey, and a large brown envelope). The consent was signed and kept separate from the completed survey, which was filled out during the 4-day conference. The researcher remained in attendance and was available to answer any questions about the research. Demographic, medical and surgical history, and data related to QoL were collected.

Instruments. 

Demographic survey. The pen-and-paper demographic data survey included questions on age, gender, race (optional), marital status before and after ostomy surgery (if there was a change in marital status, the survey asked whether the ostomy surgery influenced this change), income, education, and employment. Clinical factors surveyed were type of ostomy (colostomy, ileostomy, or urostomy), illness or diagnosis leading to need for ostomy surgery, date of surgery with ostomy creation, and if more than 1 ostomy surgery was performed. If more than 1 ostomy surgery was performed, the respondent answered the question, “How many ostomy surgeries?” and “List the year of each ostomy surgery."

Peristomal complications were assessed in the demographic survey using a photograph accompanied by a definition of each peristomal skin complication. The respondents were asked to answer yes or no to the following question: “Looking at the past year, please answer the following questions: Have you had any of the following peristomal (area around your stoma) complications: peristomal candidiasis, peristomal folliculitis, pseudoverrucous lesions, peristomal irritant contact dermatitis, peristomal allergic contact dermatitis, or peristomal trauma?” If the response was “Yes,” participants answered the question, “How many times?” 

Respondents also were asked, “Looking at the past year did you see any of the following persons for help with peristomal (skin around your stoma) complications?” Responses included not applicable (“I had no complications”), ostomy nurse (Certified Wound Ostomy, Continence Nurse [CWOCN], WOC nurse, or ET nurse), registered nurse at skilled nursing facility, surgeon, primary care provider (family doctor, or nurse practitioner), dermatologist, home health care nurse, ostomy support group, other (please specify), or no one, even though they had complications. The participants were asked to rate their level of satisfaction with the help received using a Likert-type scale where 0 was not at all satisfied and 100 was very satisfied. 

QoL. QoL data were collected using the COH-QOL-OQ, a comprehensive, multidimensional, self-report, disease-specific instrument designed to assess QoL for individuals with intestinal ostomies.10,37 The pen-and-paper instrument consists of 2 sections — Lifestyle Impact and Quality of Life Impact — and measures 4 QoL domains: physical, psychological, social, and spiritual. The domains are scored on a scale of 1 to 10, with 1 indicating lower QoL and 10 indicating higher QoL. Psychometric analysis of the instrument confirmed a 4-dimensional model and established initial reliability and validity; the researchers confirmed the scale could be used to describe adjustment to colostomy, ileostomy, or urostomy for adults.10 Study participants were guaranteed anonymity, given a consent form, survey packet, pen, and a large brown envelope as previously noted. 

Data collection. Data were entered into the Statistical Package for Social Sciences, version 17 (SPSS, Chicago, IL) and analyzed. Study variables included participant demographics, QoL scores, ostomy type (colostomy, ileostomy or urostomy), peristomal complications, who was seen for help with peristomal complications, and the level of satisfaction with help received.

Descriptive statistics (means, standard deviation, frequencies, percentages) were used to describe the demographic composition of the sample as well as participant’s surgical history, the number of peristomal complications, whom they saw for help with peristomal complications, and how satisfied they were with the help received. 

To investigate the relationships among QoL and peristomal complications, 6 univariate analyses of covariance were completed. QoL total scores were used as the dependent variable, and the presence or absence of peristomal complications was the independent variable, while controlling for age and the number of years since first and most recent surgery. The number of different complications reported by the participant was tabulated and then correlated with QoL total score using hierarchical multiple regression analysis. Age and year since first and most recent surgery were used as covariates by entering these variables into the regression equation in the first step and entering the number of complications in the second step. 

Results

One hundred, forty (140) respondents met both inclusion and exclusion criteria and had complete data on 1 or more of the independent variables with sufficient demographic data to be included in data analysis; 1 person (0.7%) missed a significant portions of the QoL section in the COH-QOL-OQ. All 140 persons with completed demographic data were included to maximize the size of the sample and analyzed as missing information. Of the 140 participants (age range 23–89 years), the majority were female (83, 59.3 %) with a mean age of 59.06 ± 13.62 years (see Table 1). For male respondents, the mean age was 65.02 ± 13.06 years. The majority of the respondents had an ileostomy (86, 61.4%), and the most frequent diagnosis leading to the ostomy surgery was ulcerative colitis (39.3%), followed by cancer (27.9%) (see Table 2). The majority were married both before (97, 69.3 %) and after (88, 62.9%) surgery; of those who reported a marital change after surgery, 27 (84.38%) said the change was unrelated to the surgery and 4 (12.5%) said the change was related to the surgery (see Table 1). The mean QoL total score for the total sample, as measured by the COH-QOL-OQ, was 7.56 ± 1.59 (range 3.84–10.00). 

owm_0517_maydick_table1owm_0517_maydick_table2

Number of complications. The mean number of complications reported was 0.83 ± 1.03; at least 1 complication was reported by 72 (54.1%) in the past year. Of those who reported peristomal complications, many did not report/left the item blank on how frequently the complications occurred but some reported a complication occurred anywhere from 3 to 30 times and 1 experienced a problem 100 times. Approximately one third of the participants reported episodes of allergic contact dermatitis occurring anywhere from at least once (7, 16.3%) to as many as 100 (1, 2.3%) times in the past year (see Table 2). 

Help for complications. When asked to whom they turned for help when they experienced peristomal complications, the majority (33, 47.8%) saw an ostomy nurse or turned to an ostomy support group (14, 20.3%); however, 24 (16.3%) saw no one even though they had complications. The mean degree of satisfaction with the help received for complications was 77.94 ± 24.71.

Relationships among QoL and peristomal complications. The 1 significant relationship found was that persons with irritant contact dermatitis as a complication reported significantly lower QoL scores than those without irritant contact dermatitis (6.64 [SD 1.64], P = .02) (see Table 3). owm_0517_maydick_table3

Discussion

Peristomal complications. Inconsistent terminology in the literature contributes to a wide range of reported stomal and peristomal complications, making it difficult to determine the exact incidence and prevalence of these conditions. Standardized terminology and definitions are needed in this and future investigations to yield more consistent reporting.26,32 In this investigation, clearly defined and validated definitions of peristomal complications were used to gather data32,38 similar to that of other investigators.25,26 

Peristomal complications are common, and it is possible both frequency and severity are underreported.19,32 This has been affirmed in several studies where participants often failed to notice the existence of peristomal skin irritation or that it was problematic.20,23 Herlufsen et al20 evaluated peristomal skin in persons with a colostomy, ileostomy, or urostomy for a mean of 8 years; 202 (45%) had a skin disorder categorized as mild (57%), moderate (33%), or severe (10%). Only 38% who were diagnosed with a skin disorder recognized it as a problem. Nybaek and Jemec23 examined 199 persons, 98 (50%) with a colostomy, 82 (41%) with an ileostomy, and 19 (19.9%) with a urostomy; among them, 90 (44%) had a peristomal skin complication; of these, 39 (43%) were unaware of the skin problem and 14 (<16%) sought help.

In this study, the majority of persons who reported experiencing a peristomal problem had allergic contact dermatitis (see Table 2). This phenomenon is of particular concern because skin barriers, as part of a pouching system, are purported to protect the peristomal skin. In an investigation by Omura and Anazawa,38 the skin barrier was thought to be both protective and irritating. By proactively assessing the individual’s skin type, stoma output, frequency of changing the skin barrier; and by having knowledge about the properties of different skin barriers, some researchers28 believe the incidence of peristomal skin problems can be reduced. Continuing to collect data regarding the prevalence and potential etiology of allergic contact dermatitis is imperative to determine the scope of the problem. 

The second most frequently reported peristomal complication was irritant contact dermatitis (see Table 2), which was associated with significantly lower QoL scores than if irritant contact dermatitis was not present (see Table 3). A properly sized pouching system is necessary to protect the peristomal skin from exposure to urine and stool. Within the first several postoperative months, the stoma decreases in size. If the size of opening to accommodate the stoma is too large, the skin is exposed to stool and urine, resulting in irritant contact dermatitis. Assessment and pouch re-fitting by an expert is recommended periodically throughout the patient’s life. Ostomy nurses are familiar with a large variety of ostomy products and can apply their nursing expertise to recommend an appropriate and secure pouching system.

The respondents who experienced peristomal complications turned to a variety of caregivers or to a support group for help; however, as many as 24 (16.4%) of the participants who reported complications said they saw no one. Among persons who sought help, approximately 48% consulted with an ostomy nurse. It is possible individuals become used to the skin irritation or have not been educated about the assessment and treatment of peristomal skin complications.23 Peristomal skin complications are common, may be expensive to treat, and affect QoL. In this investigation, 72 participants self-reported they had experienced peristomal complications. Other investigators have compared self-reporting of peristomal complications and found many people do not recognize a peristomal skin disorder that was subsequently discerned when examined by a health care professional; consequently, early diagnosis and treatment by a health care professional may prevent long-term debility.20,21

Overall, participants who sought help for a peristomal skin problem were 78% satisfied with the help received; more than half were not seen by an ostomy nurse but turned to different caregivers or an ostomy support group. This issue warrants further exploration. Lack of access to or reimbursement for outpatient ostomy nursing services might be a contributing factor.21 Many persons suffer in silence because they lack access to specialty services and they do not know where to turn for help.

The UOAA,3 the Wound Ostomy and Continence Nurses Society,28 and the International Ostomy Association39 continue to advocate on behalf of individuals with ostomies for general access to quality care. Documents such as the WOCN Guiding Principles for Sustainable Access to Ostomy Services, Technologies and Innovation40 and recent joint position statements by the WOCN Society and the American Society of Colon and Rectal Surgeons,41,42 and the WOCN Society and the American Urological Association43,44 encourage access to preoperative stoma marking and education for persons undergoing ostomy surgery; they tout the value of such care to improve outcomes. 

QoL and peristomal complications. Overall, the QoL total scores for the participants in this investigation were closely related to QoL total scores for a normative sample when validity and reliability were investigated by Grant et al.10 However, QoL total scores for persons with peristomal complications were highest in the group with peristomal trauma (mean = 7.41 ± 1.92) and lowest in the group with irritant contact dermatitis (mean = 6.64 ± 1.64). Irritant contact dermatitis had a significant effect on QoL (P = .02) (see Table 3). As the number of complications increased, QoL total score decreased significantly. These findings are similar to those expressed in the white paper by Pittman et al,18 who reported lower mean QoL scores for higher levels of skin irritation.

Nursing implications. Following ostomy surgery, patients should be thoroughly assessed by a qualified ostomy nurse for skin type, stoma output, and the frequency of changing the skin barrier. Once a thorough assessment has been conducted, a plan for an appropriate pouching system should be developed. Providing patient education and further follow-up to evaluate the effectiveness of the intervention is imperative.

Because individuals generally do not recognize peristomal skin irritation as a problem, they should be routinely assessed for short (<30 days) and long-term (>30 days) peristomal skin complications by an ostomy nurse. This would allow for early detection of a problem and intervention to resolve the problem. 

In general, skin barriers are designed to be protective. However, ostomy skin barriers have been shown in case reports45,46 to affect peristomal skin due to occlusion and irritation of the skin upon removal. Because some ostomy products are approved as devices, extensive research may not be conducted. If an allergic reaction to an ostomy product is suspected, a report can be filed with the manufacturer or the United States Food and Drug Administration Safety Information and Adverse Reporting Program.47 Information and online reporting can be found at: www.fda.gov/Safety/Medwatch. This is 1 mechanism to alert the manufacturer to investigate the device for common irritants, hopefully leading to product improvements. 

The need to investigate the frequency of peristomal skin complications and the differences in actual versus reported complications is ongoing. Additional studies should be designed to investigate the influence of ostomy nursing interventions for prevention or resolution of peristomal skin complications that negatively impact QoL. 

Limitations 

The results of this survey can be generalized only to individuals with a permanent ostomy between the ages of 18 and 89 who were represented in this sample. Inherent bias may result from self-reporting peristomal skin complications. The survey did not query individuals about the availability of ostomy nursing services or access to other health care professionals in their home community. Further investigation should be designed to evaluate the effect of ostomy nursing services on both the occurrence and severity of peristomal complications and on QoL total scores using standardized terminology and care instructions. 

Conclusion 

A descriptive study was conducted to explore peristomal skin complications and their effect on QoL reported by adults with a permanent ostomy. In this investigation, the overall rate of peristomal complications reported in the previous year was 54.1%; many could not recall how frequently the complication occurred but some reported anywhere from 3 to 30 times and 1 person had experienced the problem 100 times. QoL scores were lower for those with complications than they were for those without complications. Allergic contact dermatitis was reported by approximately one third of the respondents, and irritant contact dermatitis significantly affected QoL. The findings of this study confirm peristomal complications are problematic and that irritant contact dermatitis negatively affects QoL. 

If individuals are unaware of a peristomal skin problem, it may go unreported in a self-report survey. To mitigate this effect, research using self-report survey data should be corroborated with clinical examination by someone qualified to perform an assessment, such as a WOC nurse. Research also should focus on access and reimbursement for outpatient ostomy services to determine if routine postoperative follow-up care and long-term follow-up care with a qualified ostomy nurse are universally available. 

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36. Gray M, Colwell JC, Doughty D, et al. Peristomal moisture-associated skin damage in adults with fecal ostomies: a comprehensive review and consensus. J Wound Ostomy Continence Nurs. 2013;40(4):389–399.

37. City of Hope Quality of Life-Ostomy Questionnaire. Available at: http://cityofhope.org/prc/pdf/Quality%20of% 20Life%20Ostomy.pdf. Accessed April 11, 2016.

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Potential Conflicts of Interest: none disclosed 

 

Dr. Maydick-Youngberg is a Clinical Nurse Specialist/Program Manager, WOC Nursing, New York University Lutheran Medical Center, Brooklyn, NY. Please address correspondence to: Diane Maydick-Youngberg, 54 Valencia Avenue, Staten Island, NY 10301; email: dmaydick@gmail.com.

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