The Ostomy Files: A Pressure Ulcer and an Ostomy: An Unlikely Combination?
Earlier this year, the National Pressure Ulcer Advisory Panel (NPUAP) updated its pressure ulcer definitions and staging system. A pressure ulcer is defined as localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.1 As the definition explains, pressure ulcers can occur not only over bony prominences, but also from pressure in combination with friction and/or shear.
Pressure ulcers in the peristomal area are not uncommon. They develop for several reasons and their increased occurrence may be related to the rapidly increasing level of obesity in North America. More commonly, however, excessive pressure on the peristomal skin results from the improper use of ostomy appliance belts and/or the use of rigid faceplates.
Ostomy appliance belts were designed to provide support to the ostomy pouching system, not to serve as the sole means for attachment. Ideally, the belt should provide equal support at the 3 o’clock and the 9 o’clock positions. If belts are used on patients who are overweight or who have spinal misalignment, poorly sited stomas, or an obese protuberant abdomen, the support (and hence the pressure) is not equally divided. These situations may cause the belt to find the “path of least resistance” and pull up on the patient’s back or roll into fat folds. When this happens, pressure on the skin barrier wafer subsequently increases, causing uneven skin barrier movement over the skin that predisposes to friction or shear and eventual skin breakdown in the peristomal skin as well as around the patient’s waist.
Poorly sited stomas also are prone to pressure necrosis. Stomas located at the patient’s belt line are subject to friction and shear from belts worn too tightly. Girdles and other excessively tight clothing also can predispose the peristomal skin to unnecessary friction and shear, especially if the peristomal skin is uneven. Clinicians should be aware of patient activities that may cause undue or prolonged pressure on the peristomal skin. For example, an automobile mechanic who spends 8 hours a day leaning over the fender of a car to work on the motor could easily create too much pressure and friction on the ostomy pouching system and present with a peristomal pressure ulcer. The clinician may be puzzled regarding the etiology until a thorough assessment of daily activities has been conducted.
Rigid faceplates and convex pouching systems used on peristomal hernias are also common culprits. Patients and clinicians might find most convex products too rigid to fit into deep skin folds or crevices around the stoma. Rigidity of any type prevents the faceplate from providing a secure seal on uneven peristomal skin and is uncomfortable for the patient as it “rocks” on the abdomen.2 Rigidity also can increase the potential for developing pressure ulcers in some higher-risk patients3 (for example, persons who are post radiation or chemotherapy treatment or others who may be immuno-compromised).
The development of a peristomal pressure ulcer can be prevented in several ways – the first of which is patient education. When clinically indicated, people with an ostomy who use an ostomy support belt should be thoroughly educated on its purpose and proper use. The reason for belt use as well as the patient’s abdominal contours should be carefully considered before an ostomy support belt is recommended.
Also, patients should be cautioned about excessive weight gain and avoidance (when possible) of rigid faceplates. Soft, flexible ostomy pouching systems are ideal for patients identified as at-risk for developing peristomal pressure ulcers. Clinicians should assess patients at each visit in a variety of anatomical positions and have knowledge of the patient’s activities of daily living. This type of investigation may help preclude the development of avoidable peristomal pressure ulcers. Patients with peristomal hernias should be fitted with appropriate hernia support belts designed especially for ostomy care.
Once again the clinician’s investigative and assessment skills are called into play. Peristomal pressure necrosis is preventable. A working knowledge of ostomy products – their purpose and proper use – as well as a thorough patient physical and lifestyle assessment can help achieve that goal.
The Ostomy Files is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ. This article was not subject to the Ostomy Wound Management peer-review process.