DURING A ROUTINE physician visit, Amy Thompson, 67, reports trouble with her colostomy pouch, which "slides off" and won't adhere to her peristomal skin. She also complains of pain around the stoma. Mrs. Thompson is being cared for at home by her husband. As wound, ostomy, and continence nurse, you prepare to evaluate the pouching system.
When you interview the Thompsons, you learn that her colostomy was created 3 years ago because of ulcerative colitis complications. About 18 months ago, a wound started to develop around the stoma and gradually increased in diameter. At first, Mrs. Thompson was able to get the pouch to adhere with various pastes and powders. But lately, she says, the pouch starts leaking the day after it's applied.
You remove the two-piece drainable pouching system. The stoma is bright red and the mucocutaneous junction is intact. However, the peristomal skin is severely compromised, with a well-- defined, circular, full-thickness wound (see Figure 1). The borders of the wound are irregular. You see no satellite lesions (which would indicate a fungal infection) on the periwound skin.
Remembering Mrs. Thompson's history of ulcerative colitis, you suspect peristomal pyoderma gangrenosum (PPG), an unusual wound that occurs almost exclusively in patients with inflammatory bowel disease. Pyoderma gangrenosum, an autoimmune disease characterized by painful ulcers that may communicate with the bowel, also can occur on the abdomen, buttocks, face, and legs, so carefully assess all other lesions. This wound is diagnosed by exclusion: A skin biopsy, for example, can't diagnose pyoderma gangrenosum, but it can rule out other problems.
Managing the peristomal wound and the pouching system can be a challenge when your patient has PPG. Systemic steroid therapy is commonly the first line of defense. Stoma relocation is another option, but because new lesions often develop at the new stoma site, the physician and the Thompsons decide against it.
You manage the pouching system as shown in Figures 2 through 5. Give the Thompsons complete directions and extra supplies and teach them how to use the new pouching system. Also teach Mrs. Thompson to report any signs of PPG promptly if they recur.
BY CATHY THOMAS HESS, RN, CWOCN, BSN
President * Wound Care Strategies, Inc. * Harrisburg, Pa.
Copyright Springhouse Corporation Jul 2001
Provided by ProQuest Information and Learning Company. All rights Reserved
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