Peristomal Skin Care & Repositioning Protocols

Peristomal Skin Care & Repositioning Protocols

Ostomy Types & Chemical Effluent Risk Stratification

Peristomal Moisture-Associated Skin Damage (PMASD) is a major complication in ostomy management. The chemical composition, enzymatic activity, and consistency of ostomy effluent vary significantly according to the anatomical site of the stoma:

OSTOMY EFFLUENT CORROSIVENESS SPECTRUM:

• Sigmoid / Descending Colostomy: Solid / Formed stool -> Inactive enzymes -> LOW SKIN RISK
• Transverse Colostomy: Semi-formed / Soft stool -> Moderate enzymes -> MODERATE SKIN RISK
• Ileostomy: Continuous Liquid effluent -> Active Trypsin/Lipase & Bile salts -> EXTREME CHEMICAL RISK
• Urostomy (Ileal Conduit): Continuous Liquid urine -> Alkaline pH encrustations & Candida -> HIGH SKIN RISK

1. Sigmoid & Descending Colostomy

• Effluent: Solid, well-formed stool.
• Enzyme Content: Inactive digestive enzymes.
• Skin Erosion Risk: Low. Drainage is predictable and non-corrosive to peristomal skin.

2. Transverse Colostomy

• Effluent: Soft, semi-formed, or paste-like stool.
• Enzyme Content: Moderate proteolytic enzyme activity.
• Skin Erosion Risk: Moderate. Requires consistent skin barrier protection.

3. Ileostomy

• Effluent: Continuous, liquid-to-paste effluent.
• Enzyme Content: Rich in active proteolytic digestive enzymes (trypsin, chymotrypsin, lipase) and corrosive bile salts.
• Skin Erosion Risk: EXTREME CHEMICAL RISK. If ileostomy effluent leaks onto bare peristomal skin, active digestive enzymes rapidly digest epidermal proteins, causing painful chemical denudation, ulceration, and severe PMASD within hours.

4. Urostomy (Ileal Conduit)

• Effluent: Continuous liquid urine containing mucus threads.
• Skin Erosion Risk: Alkaline urine (pH > 7.0) promotes alkaline encrustations, pseudoepitheliomatous hyperplasia (thickened, warty peristomal skin lesions), and fungal skin infections (Candida albicans).

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Peristomal Skin Protection & Pouching Mechanics

Maintaining an intact, leak-free seal between the ostomy pouching system wafer (skin barrier) and the peristomal skin is the cornerstone of peristomal care:

The 1/8 Inch (2 to 3 mm) Wafer Sizing Rule

• Standard Protocol: The opening in the hydrocolloid skin barrier wafer must be cut 1/8 inch (2 to 3 mm) larger than the base of the stoma.
• Clinical Rationale:
  • If cut too large (>3 mm clearance): Exposed peristomal skin is directly subjected to corrosive effluent, resulting in rapid chemical denudation.
  • If cut too small (flush against stoma): The rigid wafer edge rubs against the highly vascular stoma mucosa during peristalsis, causing stoma laceration, ulceration, and bleeding.

Convex vs Flat Wafers

• Flat Wafers: Indicated for protuberant stomas located on a flat, smooth abdomen without skin folds or creases.
• Convex Wafers: Feature a outward-curved flexible or rigid plastic faceplate. Indicated for flush, retracted, or recessed stomas, or stomas located within deep abdominal skin folds. Convexity presses down into the peristomal skin, forcing the stoma spout to protrude forward into the pouch cavity. An ostomy belt is attached to the convex wafer loops to maintain constant inward pressure.

Hydrocolloid Barrier Rings, Seals, & Paste

• Barrier Rings / Seals: Malleable hydrocolloid rings shaped by hand to fill uneven skin contours, dips, or scars around the stoma ("caulking effect"), creating a flat plane for wafer adhesion.
• Ostomy Paste: A pectin-based filler used to level skin crevices. Note: Standard ostomy paste contains alcohol and will produce an intense stinging sensation if applied to raw, denuded skin. Barrier rings are preferred for denuded skin.

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Patient Repositioning & Pressure Redistribution Protocols

Immobile bedbound and chair-bound patients require structured repositioning protocols to prevent tissue ischemia over bony prominences (sacrum, ischial tuberosities, greater trochanters, heels):

1. Q2H Bed Repositioning Protocol

• Immobile bedbound patients must be repositioned at least every 2 hours (q2h) around the clock.

2. Q15Min Seated Repositioning Protocol

• Chair-bound or wheelchair-bound patients must perform weight shifts every 15 minutes (if independent) or be assisted with repositioning at least every hour.

3. The 30-Degree Lateral Tilt Position

• Clinical Standard: When positioning patients on their side, place them in a 30-degree lateral tilted position supported by 30-degree foam wedges behind the back and hips.
• Tissue Offloading: The 30-degree tilt distributes body weight across the fleshy gluteal muscles, simultaneously offloading the sacrum and the greater trochanter.
• HAZARD WARNING: Avoid placing patients in a 90-degree direct side-lying position, as this concentrates body mass directly onto the greater trochanter, causing rapid pressure necrosis.

4. Head of Bed (HOB) $\le 30$ Degrees Shear Limit

• Keep the Head of Bed elevated to $\le 30$ degrees except during meals or aspiration risk protocols.
• Shear Mechanics: Elevating the HOB above 30 degrees causes the patient's skeleton to slide downward under gravity while the skin remains fixed against the bedsheets, generating intense sacral shear forces that stretch and sever microvascular capillaries in the deep fascia.

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Microclimate Management & Tissue Integrity

Microclimate refers to the localized temperature, humidity, and airflow at the interface between human skin and a support surface:

• Elevated Temperature & Moisture: Excess heat and sweat increase the metabolic demand of skin cells while softening the stratum corneum (maceration). Macerated skin has a significantly lower coefficient of friction and degrades easily under shear.
• Interventions: Utilize breathable, moisture-vapor-permeable support surface covers, specialized moisture-wicking dry-pads, and low-air-loss mattresses. Avoid non-breathable plastic chux or multiple layered bedsheets, which trap heat and moisture against the skin.

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Ostomy Classification & Effluent Risk Matrix

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Repositioning & Shear Reduction Protocol

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ABWM Exam Scenarios & Clinical Guidelines

Scenario 1: Peristomal Denudation in Ileostomy

A patient with a new ileostomy presents with severe peristomal erythema, erosion, and burning pain. The wafer opening is cut 1/2 inch larger than the stoma base.

• Clinical Diagnosis: Peristomal moisture-associated skin damage (PMASD) caused by digestive enzymes in ileostomy effluent contacting exposed skin.
• Corrective Action: Remeasuring the stoma base and cutting a new wafer with strictly 1/8 inch (2 to 3 mm) clearance, applying stoma powder and non-sting barrier film (crust method), and inserting a hydrocolloid barrier ring.

Scenario 2: Sacral Shear Reduction

A CWCA clinician is training staff on repositioning protocols for bedbound patients with Stage 3 sacral pressure injuries.

• Mandated Positioning: Place patients in a 30-degree lateral tilt using foam wedges and keep the head of bed elevated $\le 30$ degrees.
• Rationale: The 30-degree tilt offloads both the sacrum and greater trochanter, while limiting HOB elevation prevents sacral shear breakdown.