The Ostomy Files: Minding the Gap: The Art of Managing Peristomal Topography

    Since the inception of Enterostomal Therapy more than five decades ago, clinicians have struggled to make uneven peristomal skin surfaces smooth and even platforms on which to securely attach an ostomy pouching system and attain a leak-proof seal. As the number of elderly grows and obesity increases in patients of all ages, the problem escalates. The need for non-specialized nurses (ie, non-WOC Nurses) clinically skilled in complicated stoma management has become more critical.

    As the skin ages, tone and turgor are lost, causing the skin on an elderly abdomen to wrinkle and sag. If an individual is overweight, skin folds and creases in the peristomal skin increase the potential for leakage between the skin barrier and the abdominal skin. If stoma site marking is not part of the preoperative procedure, a poorly located stoma on the type of abdomen just described exacerbates the problem. In such cases, clinicians must have a working knowledge of effective ways to use conformable materials to “caulk” and “fill in” the various wrinkles and creases frequently found in the peristomal plane to ensure an effective seal and to level the area between the skin and the pouching system. An indepth knowledge of convex pouching systems is a valuable tool in resolving these issues. In addition, the method selected to address the problem should be easily and quickly reproducible by the patient and/or caregiver; hence, patient/caregiver dexterity and visual acuity must be evaluated.

    Patients complaining of frequent leakage or peristomal skin irritation should be carefully evaluated in a sitting, supine, and standing position. Often, creases and wrinkles are not immediately evident when a patient is lying in a hospital bed or on an examining table. A helpful clue to finding the “culprit” crease is to ask the patient if the leakage always occurs in the same place. For example, the patient may tell you that the leakage always occurs next to the umbilicus. Moving the patient into a sitting position may immediately identify the location of a medial skin fold or crease near the stoma that continues to the umbilicus. Filling this crease with conformable material may halt the leakage problem and protect the peristomal skin from further breakdown.

    Conformable materials include skin barrier strips, Cohesive® seals, skin barrier washers, and an assortment of skin barriers that can be cut into a variety of shapes to accommodate individual patient needs. Skin barriers vary in their composition and ability to withstand temperature and high-volume liquid output. Some are more resistant than others.

    Cohesive® seals are donut-shaped rings that can be molded into a range of shapes. Rolled between the palms into thin tubes, they can be used to fill in deep creases, helping create a flat surface on which to attach the pouching system. They also can be used as rings to increase the convexity of a pouch faceplate, a one-piece pouch, or a skin barrier with flange. Cohesive® seals act as a gasket or barrier and provide enhanced skin protection for hard-to-fit stomas. The unique moldable hydrocolloid barrier forms a gel that helps prevent skin breakdown by enhancing the ostomy pouching system-to-skin interface. Skin barrier strips may be used in the same fashion by laying them in creases and wrinkles in the peristomal area.

    Skin barrier pastes often are considered (erroneously) to be adhesives. Patients and non-specialized nurses often apply a thick layer of skin barrier paste on the entire peristomal skin area or all over the back of a skin barrier or skin barrier with a flange, believing it will fasten the pouching system to the skin. Skin barrier pastes should be used to fill in uneven skin (creases and folds), provide additional protection at the base of the stoma, or address situations where skin barriers erode more quickly than desired. They should be used as “caulking” by applying a thin bead of paste where needed.

    Leveling uneven peristomal skin with conformable materials takes patience, a clear understanding of the product used, consideration of the functional and cognitive abilities of the patient, and practice. However, once mastered, this art may help prevent surgery and peristomal skin problems and promote patient security and confidence.

    The Ostomy Files is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ.