A Prospective, Experimental Study to Assess the Effectiveness of Home Care Nursing on the Healing of Peristomal Skin Complications and Quality of Life
Home care services are effective in many patient groups. Purpose: The authors examined the effect of specialized ostomy care in the home on peristomal skin complications and patient quality of life (QOL).
Method: A prospective, experimental study was conducted among 35 people >18 years old with a colostomy or ileostomy and peristomal skin complications who were listed in 2 ostomy supplier databases. Participants were alternatively allocated to 6 home care visits (intervention [IG], n = 18) or 2 outpatient/clinic care [CG] visits (control, n = 17). Demographic and patient variables were assessed at the initial visit in both groups. The Ostomy Skin Tool (OST) and the Stoma-Quality of Life instrument were used to assess study characteristics; data were statistically analyzed. Results: The Discoloration, Erosion, Tissue Overgrowth scores of the OST of the 2 groups were similar in the first assessment (IG = 6.22 ± 1.47; CG= 6.11 ± 1.96; P = .776), but a statistically significant difference was noted between groups at the end of study (IG = 0.44 ± 0.85, CG = 4.76 ± 2.30; P = .00). At the first assessment, QOL scores of the IG and CG groups were 72.63 ± 11.48 and 66.73 ± 17.52, respectively (P = .197). At the final assessment, QOL scores were 78.12 ± 9.66 and 71.83 ± 18.37 for IG and CG, respectively (P = .390). Conclusion: Home nursing care was found to be effective in treating peristomal skin complications. The QOL scores achieved at the final assessment were significantly improved compared with the initial assessment. The results demonstrated the importance of follow-up after stoma surgery.
Stoma complications can be designated early- and late-occurring. Early complications are defined as those occurring within 30 days following stoma creation and include ischemia/necrosis, retraction, mucocutaneous separation, and parastomal abscess; late complications include parastomal hernia, prolapse, retraction, and varices.1 Peristomal skin complications can occur in either period and according to review and descriptive studies,2-7 they are the most frequently observed stoma complications. Peristomal skin complications can be divided into 5 groups: irritant dermatitis, allergic dermatitis, mechanical trauma, complications caused by the underlying disease, and complications induced by infection.8
In the literature, prevalence rates for both early and late peristomal skin complications vary greatly. Park et al5 performed a retrospective chart review of 1616 patients of all ages with an ileostomy or colostomy. According to their results, skin irritation was both the most common early (12%) and late complication (6%). A systematic review by Salvadelena9 of stoma complication prevalence (N = 21) also showed that both early (16%) and late (12%) peristomal skin complications were the most common stoma complications. Likewise, a retrospective study by Sung et al10 among 1170 patients with a colostomy or ileostomy found peristomal skin complications (at a rate of 15.5%) were most common. A prospective study by Ratliff11 showed peristomal skin complications were the most common stoma complications among individuals with an ileostomy or colostomy, with a 47% prevalence. The latter rate was high in comparison with other studies, possibly because a standardized tool was used, yielding a more objective evaluation. Results of a prospective audit by Cottam et al12 of 3970 colostomy and ileostomy patients 3 weeks after surgery found 1329 (34%) stomas were problematic, most commonly due to retraction.
In Turkey, a wound ostomy continence (WOC) nurse is not available in all hospitals and no standard protocol exists for patients with stoma complications. In the postoperative period after discharge from the hospital, patients can go to a physician or they can visit a WOC nurse (if available) when they have a stoma-related problem. WOC nurses typically schedule the patient for outpatient clinic follow-up of his/her stoma and peristomal area 2 weeks after hospital discharge, with subsequent visits according to the patient’s needs.
According to an experimental study13 and a literature review,14 a stoma adversely affects quality of life (QOL). Gooszen et al15 performed a cross-sectional, descriptive study among 43 individuals with a colostomy or ileostomy at least 6 months post ostomy surgery using the Stoma Quality of Life (Stoma-QOL) scale to measure QOL. The authors found 70% of patients’ QOL scores were low. Kuzu et al16 conducted a retrospective study among 178 patients who had colorectal surgery. Patients were divided into 3 groups according to surgery type. Results showed stoma patients had the lowest QOL score compared with the patients that did not have stoma surgery. Prospective, descriptive studies by Ross et al17 (N = 249; 3, 6, 12, and 24 months after surgery) and Sideris et al18 (N = 132, with a cross-sectional component) show similar results. In the former,17 QOL scores for patients with a stoma were poorer than nonstoma patients; in the latter,18 QOL scores of stoma and nonstoma patients were not significantly different, but stoma patients had more complaints about body image.
Prospective and retrospective follow-up studies15-18 have shown stoma complications to be the cause of reduced sexual activity, sleep disturbances, fatigue, and deterioration in body image. Moreover, stoma complications have an adverse effect on social life, work satisfaction, and fiscal concerns,15-18 issues that adversely affect QOL.
Home care services provided by health care systems often include rehabilitation, support, health promotion or disease-prevention, and technical nursing care for both chronic and acute conditions.19 Although descriptive and experimental studies20-22 indicate home care services have been effective in the care of many patient groups, no studies have been published regarding the effectiveness of home health care specializing in peristomal skin complications and QOL of people with a stoma. In the United States, WOC nurses are employed in many home care facilities. However, the newly constructed home care services in Turkey have hired no nurse specialists on wound and ostomy care.
The aim of this research was to examine the effect of home health care on the healing of peristomal skin complications and QOL. The study question was: Does the provision of home health care affect peristomal skin complication healing and patient QOL?
Study design. This experimental study used a control group through a “time series” research model.23 The research data were collected in the city of İzmir, Turkey, between July 1, 2012 and February 1, 2013.
Study participants. Stomatherapy units are not available in every hospital in Turkey; therefore, no formal record system (number, complication rates, and so on) exists for individuals with a stoma. The intent was to use patient records of the 3 companies that sell stoma supplies in the city of İzmir as the study population, but 1 of the companies did not allow the use of patient records for research purposes. Patient lists obtained from 2 companies were alphabetically ordered by initials, and patients were contacted by phone, given information about the research, screened, and invited to the stomatherapy unit. Persons who were at least 18 years old, had a colostomy or ileostomy, experienced peristomal complications, and were living in central İzmir were eligible to participate in the study. Persons who agreed to participate were examined by a WOC nurse for the purposes of this study, yielding the final number of participants. Participants were alternatively allocated to the intervention or control group based on consecutive stomatherapy unit visit order. The intervention group received 6 home care visits once every 5 days over 1 month and the control group had 1 outpatient clinic visit. Both groups had an initial assessment visit.
In order to determine the strength of the sample size, a power analysis was performed. The efficacy of home nursing care in healing peristomal skin complications could be expressed by 0.05 in terms of its level of significance (N1 = 18, N2 = 17) and determined to be at 100% power. Participant enrollment was discontinued when the target sample was reached in accordance with the result of the power analysis.
Ethical considerations. Written permission was granted by Ege University (İzmir, Turkey) Faculty of Nursing Ethics Board and Dokuz Eylül University (İzmir, Turkey) Clinical Research Ethics Committee. Written informed consent was obtained from all individuals participating in the research.
Patient confidentiality. Patient confidentially was maintained by separating the personal data page from the Diagnostic Form (the first 12 questions) and by using a coding system for the remaining questions. Only the investigators had access to these data. Patients were informed of the precautions that would be taken to protect the confidentiality of the data and who would or might have access.
Data collection instruments.
Diagnostic Form. This form was created by experienced researchers who had reviewed the corresponding literature. It included 4 sections and a total of 28 questions. Section 1 (12 questions) addressed personal information including the patient’s initials, address and telephone number, age, gender, educational status, marital status, income status, occupation, social health insurance plan, person living with the patient at home, height, weight, body mass index (BMI), and the presence of chronic disease.
The second part of the diagnostic form consisted of 13 questions about the stoma, including date of stoma surgery; stoma duration, type (colostomy/ileostomy), and status (permanent/temporary); assumed stoma closure time for temporary stomas; the patient’s medical diagnosis; the person responsible for care of the stoma at home; the title of a person who provided the patient stoma care education; and whether the patient had a problem purchasing basic and accessory stoma materials.
The third section included 2 questions on the duration and treatment history of peristomal skin complications, and the fourth part was designed to assess factors that may adversely affect wound healing including diabetes, anemia, immunodeficiency, immobility, vascular problems, chemotherapy and/or radiotherapy, or other conditions/circumstances.
The Ostomy Skin Tool (OST). The OST was developed in 2009 by an international group of 12 expert ostomy care nurses working in collaboration with Coloplast A/S (Humlebaek, Denmark) and with advice from a dermatologist. The OST provides a common language to describe the severity, extent, and likely cause of a peristomal skin disorder.24
The OST consists of 2 parts:
1) The Discoloration, Erosion, Tissue Overgrowth (DET) Score Calculation Guide. The DET is the sum of the extent and severity scores given to discoloration, erosion, and uncontrolled tissue size (in terms of growth) in the peristomal area (minimum: 0, maximum: 15; high score shows worse peristomal skin condition). The guide for calculating the DET score yielded an intraobserver concordance coefficient of 0.84 and an interobserver concordance coefficient of 0.54.24 To establish the reliability and validity of the DET, photographs of 30 peristomal skin complications with different levels were shown to 2 stoma care nurses twice at 1-hour intervals. The nurses were asked to evaluate the photographs and calculate the DET scores; the results of this exercise showed that intraobserver agreement was very good (K = 0.83–1) and interobserver concordance (K = 0.51–0.77) was adequate. In the current study, DET scores were calculated at every home visit and assessments and nursing interventions were implemented according to the Assessment, Intervention, Monitoring (AIM) guide by researcher. Additionally, at the last/sixth home visit, the Stoma QOL scale was administered again.
2) AIM Guide. This guide includes the identification and classification of peristomal skin complications according to their causes as well as appropriate interventions. The AIM guide includes 22 factors (aimed at 5 categories) causing complications and 78 nursing interventions prepared to address these problems.25 As a part of Turkish validity and reliability testing, 10 experts provided feedback on the content, language conformity for the Turkish society, clarity, and understandability and were asked to grade the AIM entries on a scale of 1 to 4. The AIM guide’s content validity index was found to be 0.99 among these experts, and it was concluded to have met the criteria for compliance (ie, content validity).26 Necessary adjustments were made in accordance with the experts’ feedback.
Permission for the use and translation of the Peristomal Skin Tool was obtained and language validity, content validity, intraobserver, and interobserver concordance coefficients of the Turkish OST were calculated before the data collection period.
Quality of Life Scale for Stoma-QOL. The Stoma-QOL was created in 2003 to measure the QOL of patients with a stoma. The 20 items in the scale are assigned a value between 1 and 4. The overall QOL score is obtained by summing all values attached to each item.27 The validity and reliability of the scale in terms of Turkish language compliance was studied by Harputlu et al28; the Cronbach α coefficient was found to be 0.89 for the entire scale. The test/retest reliability coefficient of correlation between the 2 measurements was found to be 0.83.
Data collection procedures. The initial clinical assessment was conducted in the stomatherapy unit for both the intervention and control groups. At the initial assessment, the Diagnostic Form was completed; DET scores were calculated; assessments regarding the complications, causes, and necessary nursing interventions were implemented according to the AIM guide; and QOL scores were calculated for both groups. Patients could complete the questionnaires (diagnostic form and Stoma-QOL) by themselves; researchers read and filled in the answers when participants with difficulty reading and writing needed help.
For the intervention group, research data were collected over the 7 visits (initial monitoring and 6 follow-up visits at home once every 5 days). For the control group, 2 follow-up visits (initial monitoring and an outpatient visit after 30 days) were provided. Because acute peristomal skin wound healing typically takes 2 to 3 weeks, the follow-up period was used for follow-up assessment.
For the control group (after initial assessment), owing to the fact no special home health care is available for the individual with stoma in Turkey, patients received outpatient nursing care. No formal protocol exists for provision of outpatient care control, so the WOC nurse decided care mostly based on his/her knowledge. Control group patients in this study received interventions according to the AIM guide. Treatment suggestions were given, and patients were provided proper stoma care information according to AIM guide and were invited to visit the stomatherapy unit if they needed further nursing care. Individuals in the control group cared for their complications on their own without having any home visits and were re-evaluated in the stomatherapy unit after 30 days, at which time the final DET and QOL questionnaires were completed.
Statistical analysis. Data were collected using paper and pencil and entered directly into the Statistical Package for the Social Sciences (SPSS for Windows, version 15.0; Chicago, IL) by the researchers for data analysis. The hypothesis tests in the research were evaluated in accordance with an α = 0.05 level of significance. Frequency and percentage distribution, chi-squared analysis, 2-paired sample t tests, Linear Weighting Kappa analysis, Mann-Whitney U-test technique, Lawshe, Friedman’s chi-squared, and the Wilcoxon Signed Ranks tests were used to analyze data.
General participant characteristics. From the total manufacturer database population of 1269, 76 patients (5.99%) agreed to participate and were examined for peristomal complications. Thirty-five (35) patients met the inclusion criteria and were accepted for participation; 18 were enrolled in the intervention and 17 in the control group. The average age was 57.45 ± 14.70 years and the largest age group was 60–69 years (12, 34.3%) old. Twenty-two (22, 62.9%) were women, the most common highest educational level was elementary school (14, 40.0%), 25 (71.4%) were married, the largest employment portion was the working class (16, 45.7%), and most were retired (18, 51.4%). All 35 (100%) had a social health insurance plan, 32 (91.4%) lived with their families, and 19 (54.3%) defined themselves as being financially solvent in terms of income. The most prevalent medical diagnosis/reason for the stoma was rectal cancer (14, 40%); 20 (57.1%) had no chronic disease. Seventeen (17, 48.6%) study participants were overweight. Twenty-one (21, 60.0%) had an ileostomy, 18 (51.4%) had a permanent stoma, and 8 (22.9%) were 1 month postsurgery at the time the study was conducted. Nineteen (19) individuals (54.3%) reported that they performed their own stoma care, and 27 (77.1%) stated their first instruction regarding this self-care was provided by their stoma care nurse. No statistically significant difference was found between intervention and control groups in terms of sociodemographic characteristics (P >.05).
The distribution of individuals according to their peristomal skin complications is shown in Table 1. The most common peristomal skin complication for the intervention group was irritant dermatitis (12, 66.7%). Three (3) individuals (16.7%) had mechanical trauma, 2 (11.1%) had allergic dermatitis, and 1 (5.6%) had both allergic and irritant dermatitis. Similar to the intervention group, the most common complication in the control group was irritant dermatitis (14, 82.4%), with 2 people (11.8%) experiencing mechanical trauma and 1 individual (5.9%) with allergic dermatitis. The groups were homogeneous in terms of factors that may adversely affect wound healing such as diabetes mellitus, immobility, and undergoing chemotherapy or/and radiotherapy.
In the intervention group, 3 of 18 (16.7%) patients with a colostomy and 9 of 18 (50%) with an ileostomy had irritant dermatitis. Of those, 2 individuals with a colostomy and 3 with an ileostomy were in their early postoperative period (0 to 29 days). In the control group, 4 of 17 (23.5%) people with a colostomy and 10 of 17 (58.8%) people with an ileostomy had irritant dermatitis. Of those, 3 individuals with ileostomy were in their early postoperative period, but no one with a colostomy was in the early postop period.
The effect of nursing care on healing peristomal skin complications. The mean DET score of the individuals in the intervention group at the first assessment was 6.22 ± 1.47 (range 4–9), and the mean DET score at the sixth home visit was 0.44 ± 0.85 (range 0–2). Further, it was found that mean DET scores decreased gradually with every home visit. The mean DET score of the individuals in the control group was 6.11 ± 1.96 (range 3–10) at the first assessment and 4.75 ± 2.30 (range 0–10) at the final assessment (DET = 6). The results from the initial assessment of both the intervention and control groups showed homogeneity in terms of DET scores (P = .776, U = 144). However, in the final assessment, a statistically significant difference was noted between the intervention and control groups in terms of DET scores (P = .00, U = 15000) (see Table 2).
Irritant dermatitis and applied nursing interventions. At the initial assessment, 12 in the intervention group and 14 in the control group were diagnosed with irritant dermatitis. In the intervention group at the first assessment, 3 people had problem 1 (P1), 12 had P2, 4 had P3, and 11 had P4. For these problems, all the appropriate interventions noted in the AIM guide during the home visits were provided. At the last assessment, 3 had P4 and the other problems were healed. In the first assessment of control group, 4 people had P1, 9 had P2, 1 had P3, 12 had P4, and 1 person had P5. All necessary interventions described in the AIM guide were applied. In the last control group assessment, 2 people had P1, 6 had P2, 12 had P4, and 1 had P5 (see Table 3).
Allergic dermatitis and applied nursing interventions. Two (2) participants from the intervention group and 1 participant from the control group were diagnosed with allergic dermatitis. At the first intervention group assessment, 1 person had P7 and 2 had P8. At the last assessment after the interventions, 1 person had P7. At the first and last control group assessments, 1 person had P7 (see Table 4).
Mechanical trauma and applied nursing intervention. Three (3) participants from the intervention group and 2 from the control group were diagnosed with mechanical trauma. In the first assessment of intervention group, 1 person had P10, 2 had P11, and 1 had P13. All appropriate interventions were applied, and by the last assessment all problems were healed. In the first assessment of control group, 1 person had P11 and 1 had P12. At the last assessment after interventions were applied, 1 person in the control group had P12 (see Table 5).
QOL in individuals with a stoma. At the first assessment, mean QOL scores for the intervention and control groups were 72.63 ± 11.48 (range 53.75–96.25) and 66.73 ± 17.52 (range 28.75–92.50), respectively (P = .197). At the final assessment, the QOL mean scores also were not significantly different between groups (78.12 ± 9.66 [range 58.75–96.25] and 71.83 ± 18.37 [range 25–95] for the intervention and control groups, respectively; P = .390). However, the difference between intervention group’s first and last QOL scores was statistically significantly different (first QOL score = 72.63 ± 11.48; last QOL score = 78.12 ± 9.66; t = -3.078; P = .007), as was the difference between the control group’s first and last QOL assessment scores (first QOL score = 66.73 ± 17.52; last QOL score = 71.83 ± 18.37; t = -2.252; P = .039).
Peristomal irritant dermatitis. When experimental and systemic review studies3,29,30 involving peristomal skin complications were examined, it was noted that skin contact with feces or urine leaking from the stoma was the most common factor involved in irritant contact dermatitis. The current research also shows that at the initial assessment of individuals with irritant dermatitis, the complication was caused by feces or mucous coming into contact with the skin as a result of the wafer being larger than the diameter of the stoma as well as poor adhesion of the wafer (see Table 3). Specifically, in the first 6 months following surgery, edema reduction causes the stoma to decrease in size, and measurement of the stoma diameter and the dimensions of the wafer often have to be recalibrated in order to accommodate the shape of the stoma.31 If this information is not shared with the patient or if the patient fails to understand its importance, the patient will cut the wafer according to the size of the stoma postoperatively in the hospital, increasing the risk of skin irritation. At the initial assessment, 12 people from the intervention group and 9 from the control group had their wafer fittings adjusted according to the appropriate stoma diameter measurement in each individual to avoid irritant dermatitis resulting from this problem. At the final assessment, this intervention was no longer needed in the intervention group. However, in the control group, 6 individuals were found to have an improperly fitting wafer and this intervention had to be applied again. Correct wafer application was performed in the control group at the initial assessment, and individuals were informed about the measurement of the stoma diameter; during later applications, the participants in the control group changed their own wafers. However, individuals were noted to have failed to cut their stoma wafer properly when they visited the stoma unit for research and peristomal skin controls. This demonstrates that individuals could not carry out proper application and were not aware of their improper application. At the same time, it also suggests that a single training session is not enough and that, if possible, home visits may be needed to reinforce proper application techniques.
For individuals with complications resulting from poor adhesion of the wafer to the skin, 11 members of the intervention group and 12 members of the control group were treated with additional products such as stoma powder. In the final assessment, 3 members of the intervention group and 12 individuals from the control group continued to need additional product applications. The fact that 12 individuals in the control group still needed additional products may suggest that the recommendations were not followed (see Table 3). However, the control group may not have achieved the level of improvement of the intervention group for many reasons; for example, the stoma powder recommended for care is an additional product not covered by a social health insurance plan, stoma products are available for sale in only some parts of Turkey (they are not available in every pharmacy or drug store), and when the investigator conducted a home visit she brought basic and additional products that might be necessary so patients in the intervention group had no difficulty obtaining products. Also, persons in the control group who needed additional products in the final assessment could have difficulty obtaining them.
Peristomal allergic dermatitis. Peristomal allergic dermatitis is a reaction to the product used on the individual’s skin.31 A case study by Martin et al25 of a 63-year-old patient with an ileostomy sought to determine the cause of the patient’s dermatitis. The authors performed a patch test that showed the patient was allergic to the stoma paste. In a case study by Gallo et al,32 patch test results from a 76-year-old patient with an ileostomy also showed the allergen was stoma paste, as did another case study by Scalf and Fowler,33 who found an allergy was caused by stoma paste and the substance gantrez. As part of a study on allergic dermatitis, Landis et al34 conducted a retrospective review of medical records of patients with ostomies and peristomal dermatitis who underwent patch testing during a 10-year period in their hospital. Of the 10 patients with peristomal allergic dermatitis, 3 were allergic to stoma paste and the rest were allergic to several substances in stoma materials. In their case study, Lazarov and Trattner35 reported on a patient with a colostomy and allergic dermatitis due to the adhesive remover.
In this sample, 3 participants from the intervention group and 1 participant from the control group were diagnosed with allergic dermatitis. One (1) individual in the intervention group and 1 individual in the control group had allergy-related complications presenting in the form of papules, plaques, edema, and/or discoloration (P7) despite proper use of products (see Table 4). The individual in the intervention group was found to be allergic to the stoma paste (initial DET = 6). Interventions for the individual included avoiding allergenic materials (I20) and the use of barrier products (I22). At the final home visit, the skin was almost completely healed (DET = 2). Patch test results of the individual with the same problem in the control group showed the allergen was the stoma wafer (initial DET = 7) and a nonallergenic stoma wafer was recommended. At the final assessment, the individual’s complication was not yet healed (DET = 5). Observed skin improvements suggested that the individual followed the recommendations. Although the individual from the control group and the individual from the intervention group at the initial assessment had similar complication scores, causes, and interventions, the individual from the intervention group experienced better recovery, suggesting that home care visits were effective in treating the complication.
Peristomal mechanical trauma. Mechanical trauma is caused by the continuous application of stoma materials to the skin, removing the sticky edges from the skin, or damage caused by stoma materials related to peristomal entrapment, excoriation, friction, and tear.8-36 Nybaek et al4 performed a systemic literature review on the complication of mechanical trauma. From the 98 studies they reviewed, they concluded the most common causes of mechanical trauma were pressure, friction, rubbing, stripping, and tearing.
In the current research, 3 participants from the intervention group and 2 from the control group were diagnosed with mechanical trauma (see Table 5). In the initial assessment that compared the DET scores of individuals with allergic dermatitis or irritant dermatitis, individuals with mechanical trauma had lower scores, suggesting they could recuperate more expediently. When the applied nursing interventions and problems of individuals with mechanical trauma from both the intervention and control groups were analyzed, all but 1 of the patients showed improvement in peristomal skin problems.
QOL. Although definitions of the concept differ, QOL often is defined as “subjective well-being” or “an individual’s happiness with his/her life.”37 Regardless of the reason it was created, the opening of a stoma is known to adversely affect QOL.13,14 In both groups, the QOL scale scores of individuals in this study increased significantly between the first and last assessment.
While some time passed between these 2 assessments, which may lessen the adverse impact of stoma creation on QOL,15-18 it also is known that individuals with a stoma and peristomal skin problems have a lower QOL.4 In the current study, the intervention and control groups had differing levels of recovery from peristomal skin complications after 1 month. The factors involved in the improvement in QOL scores in both groups could have been related to healing of peristomal skin complication, the 1-month period between the initial and final assessments, and/or the nursing care and support provided.
Because stomatherapy units were not found in every hospital in Turkey, the records of 2 companies that sell stoma products were utilized in order to reach the individuals with stoma; the authors did not contact all the ostomates who live in İzmir, Turkey. Because the researchers live in city of İzmir, Turkey, the research was limited to persons who live in that city. Because of the small study population, observed rates and scores do not apply to general ostomate population. Also, some of the patients were unaware they had peristomal skin problems.
An experimental study was conducted among ostomates to examine the effect of home health care on the healing of peristomal skin complications and patient QOL. Home nursing care was found to be effective in treating peristomal skin complications, although it should be mentioned many control group patients also improved. In both groups, the QOL scores achieved at the final assessment were significantly improved compared with the initial assessment. The results of this study demonstrated the importance of follow-up after stoma surgery to address peristomal complications and help improve QOL. Additional research is needed to add to clinician knowledge of their role in follow-up care for persons with an ostomy.
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Potential Conflicts of Interest: none disclosed
Dr. Harputlu is an Assistant Professor, Ankara University, Faculty of Health Sciences, Department of Nursing, Ankara, Turkey. Dr. Özsoy is a Professor, Ege University, Faculty of Nursing, İzmir, Turkey. Please address correspondence to: Deniz Harputlu, RN, PhD, Ankara University, Faculty of Health Sciences, Department of Nursing, Aktaş Mahallesi, Plevne Caddesi, No: 5, 06080 Altındağ/Ankara, Turkey; email: firstname.lastname@example.org