Allergic Dermatitis:  this is a skin response to being allergic to any of the products the patient is using. (this is one of the reasons we use the least number of products needed). Allergy to the tape edge is quite common. You can switch the patient to an appliance without a tape border, or apply a barrier strip under the tape edge for the tape to sit on.

Fungal Rash: This is very common under the flange if the patient is on antibiotics, or lives in a warm/hot climate. This rash differs from the above skin irritations, in that is often little red dots, sometimes with white heads, that keep getting larger even if stoma powder is used (these are called satellite lesions). They are often weepy and itchy. This must be treated with anti-fungal powder.

Stomal complications and how to care for them

1. A Mucocutaneous Separation occurs when a stoma completely or partially separates from the skin. It can be very superficial or have deep wounds.  These often occur when patients have conditions or nutritional needs that make healing difficult. If they are small they can be treated with stoma powder. If they are larger and deeper, they can be treated like a wound--filling in the open area with a wound product, covering it with a hydrocolloid, and then applying the ostomy flange over the stoma.

2. A Stomal Retraction occurs when the stoma is pulled below skin level, often making pouching more difficult. These patients will almost always need a Convex barrier, ostomy ring and a belt.

3. Stomal Prolapse: A prolapse occurs when the stoma increases in length due to the bowel coming down out of the stoma. This happens more often with obese patients, patients with weak abdominal muscles, inadequate adherence of the bowel to the abdominal wall and increased abdominal pressure with coughing or tumors. Oftentimes a 1-piece appliance can be used which will decrease the risk of injury over using a 2-piece appliance. The stoma can take up a lot of space in the bag requiring more frequent emptying. Surgical repair may or may not be an option.

4. Challenging Stomal Placement: These are very common.  Due to surgical technique, limited length of bowel, obesity with folds and soft abdomens we often have patients with stomas in areas where it is very difficult to get a good seal. This is one reason  having a WOC nurse provide the stoma marking prior to surgery is VERY important. It can make all the difference in the quality of life for the ostomy patient. When the patient has a challenging stoma, if possible a WOC nurse should care for the patient. The WOC nurse is more likely to get the patient into the appropriate appliance quickly, decreasing the skin complications and cost of numerous supplies that don’t work.

When to contact your physician or WOC nurse

Here are some of the things you need to teach your patients to watch out for (as these should be triggers for them to call their MD/surgeon):

If a colostomy patient has no output for 2 days, they should let their doctor know. They are probably just dealing with constipation unless they are having other symptoms. They may need to take stool softeners, increase fluids, and fruits for more regular bowel movements.

If an ileostomy patient has no output for 4 hours they may have a blockage. Other symptoms can include abdominal pain, distention, nausea, vomiting.

Leaking around the flange that isn’t being managed needs a WOC nurse for assessment and to make recommendations.

Teach your patients the signs and symptoms of dehydration. This can occur very easily with ileostomy patients with re-hospitalization being common. They need to be drinking 8-10 glasses of fluids/day unless instructed otherwise by their doctor. Some patients need to take medication (like Imodium) to slow the output. Their physician should always be consulted before making this type of recommendation.

Stomas should always be bright pink. Pale pink may mean that they are anemic. Some patients may come home with some necrotic tissue on their stomas. Usually this will self debride. As long as the stoma is functioning well this is usually not an issue, but again, you should let the doctor know.

A purple stoma would be indicative of poor blood flow, necessitating a call to the patient’s doctor.

Teach your urostomy patients the signs and symptoms of a urinary tract infection (UTI--odor, cloudy, blood in urine, decreased appetite, nausea, fever) and that they should report these signs to their doctor immediately.