EXPERT OPINION CONSENSUS DOCUMENT ON PERISTOMAL SKIN HEALTH

Keep it simple: peristomal skin health, quality of life and wellbeing

Why are peristomal skin complications occurring? And why this needs to be prevented with better implementation of clinical best practice? This new, evidence-based, consensus document will help answer these questions, addressing intrinsic and extrinsic factors causing peristomal skin complications, and highlighting the impact on both physical and psychological health of patients. It covers:  How to assess an individual patient’s risk status  Strategies for risk prevention  Management of peristomal skin complications  Reported economic burden of stoma skin complication.

EXPERT OPINION CONSENSUS DOCUMENT

With contributions from leading clinicians in the sector:

Jennie Burch, Head of Gastrointestinal Nurse Education

Anna Boyles, Stoma Care Nurse Emma Maltby, Stoma Care Nurse Jenny Marsden, Stoma Care Nurse Nuria Martin, Tissue Viability Nurse Benjamin McDermott, Stoma Care Nurse

David Voegeli, Professor of Nursing

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This must-read consensus document is free to download and available here: www.magonlinelibrary.com/doi/full/ 10.12968/bjon.2021.30.Sup6.1

Keep it simple: peristomal skin health, quality of life and wellbeing

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SCNs also have an important role as patient advocates, using their expertise to promote the interests of ostomates within the wider healthcare system and ensure that they have access to the most effective treatments and services.

in the wider healthc access to the most effective treatments and This consensus document describes the fundamentals eristomal skin care and outlines best practice in the e vention,assessment and management of PSCs.It drawraws published evidence and the clinical experiencence of a

This consensus document describes the fundamentals of peristomal skin care and outlines best practice in the prevention,assessment and management of PSCs.It draws on published evidence and the clinical experience of a consensus panel to demonstrate how nurses at all levels of experience can make the best use of their knowledge and skills to support ostomates to maintain healthy peristomal skin,overcome challenges and improve their quality of life.

sensus panel to demonstrate how nurses at all all levels of erience can make the best use of their knoknowledge and ls to support ostomates to maintain heahealthy peristomal n,overcome challenges and improveove their quality of life.

OPTIMISING PATIENT CARE Early education and intervention Ostomates do not always recognise signs of a PSC or may be slow to report them,and many are known to tolerate PSCs for long periods without seeking help (Herlufsen et al,2006; Erwin-Toth et al, 2012).When a PSC is left untreated, the skin condition is likely to worsen,become more complicated to heal and more seriously impair quality of life.

including activities of daily living; their relationships with intimates, family, and friends; and their professional, social and leisure pursuits.The needs of someone who works might be different from those of a retired person. Someone who wants to pursue an active nightlife may have different requirements from someone with more leisurely outdoor pursuits.

Someone who wan have different requirements from someone w leisurely outdoor pursuits. lei

This article is reprinted from the British Journal of Nursing, 2021, Vol 30, No 6, Supplement 1, Consensus Document

The skin comprises subcutaneous tissue, the dermis and the epidermis. The outer layer of the epidermis is the stratum corneum, which is constituted of corneocytes and intercellular lipid (ceramide) layers. The stratum corneum is coated by a film of dead skin cells, sweat, keratin and lipids (sebum), known as the acid mantle. The pH of the acid mantle, normally 4–6, is one of

SCNs should use this information to guide all decisions SC

evention, assessment and treatment of PSCs.This is on preven empowering ostom important in selecting the right pouching routine especially imp

SCNs should use this information to guide all decisions on prevention, assessment and treatment of PSCs.This is especially important in selecting the right pouching routine from the wide choice of available products. Moreover, empowering ostomates to try different products, after demonstrating how they should be used correctly, can be an important part of finding the optimal pouching routine.

de choice of available products. Moreover, from the wide tomates to try different products, after demonstrating how the they should be used correctly, can be ding the optimal pouching routine art of finding the optimal pouching routine.

An experienced SCN will often be able to anticipate the signs of future problems and events in the ostomate’s life that increase their risk of PSCs, such as diabetes, vascular disease, immunosuppression, cancer and chemotherapy. These events require proactive prevention strategies, working in collaboration with other health professionals involved in the ostomate’s care.

The pH of the acid the most important regulators of skin functio the first line of defence for the skin’s many protective functions (Darlenski et al, 2011). The skin protects the body against trauma, infection and excessive fluids (Woo et al, 2017), and it is thought to have four distinct barrier functions: microbiological, chemical, physical and immunological (Eyerich et al, 2018).

the most important regulators of skin function. It is the first line of defence for the skin’s many protective functions (Darlenski et al, 2011). The skin protects the body against trauma, infection and excessive fluids (Woo et al, 2017), and it is thought to have four distinct barrier functions: microbiological, chemical, physical and immunological (Eyerich et al, 2018).

unctions to regulate the exchange

The skin also functions to regulate the exchange of substances between the body and the external environment. This includes transepidermal water loss (TEWL), the process by which moisture is evaporated from the skin (O’Flynn, 2019). Each layer of the skin is involved in absorbing, excreting, secreting and thermoregulating; the corneocytes provide resistance, while the lipid layers allow for substance exchange (Darlenski et al, 2011).

Therefore, SCNs need to educate ostomates about PSCs from the outset, ideally in both pre- and postoperative patient education, as well as give ongoing support throughout their life with a stoma.This education should involve face-to-face discussions, as well as written information online and in printed literature. It should aim to teach ostomates to recognise the signs of skin deterioration and remind them that regular leaks and PSCs are not normal.Ostomates should expect to be able to achieve a secure seal and healthy peristomal skin.This information should include guidance on when,why and how to access specialist advice and assistance in the event a complication develops.

Should a PSC be suspected, early assessment and intervention from an SCN is essential.This should be as early as possible to achieve optimal outcomes and prevent the skin deteriorating further and causing wider problems, especially as the complex and multifactorial nature of PSCs means that they can be difficult to resolve once they take hold (Steinhagen et al, 2017).

Personalised care The care provided by an SCN should be personalised to the individual needs of each ostomate. This means getting to know their clinical history, as well as their personal priorities and preferences. Ostomates will have different goals they want or need to achieve in their lives. Their experience and tolerance of discomfort will vary. A stoma will affect all aspects of life in different ways,

Therapeutic relationships Good long-term outcomes in stoma care require that SCNs develop strong therapeutic relationships with the ostomates they care for, and relationship-building is a core skill for nurses in this specialism.These relationships are facilitated by SCNs’rare advantage of seeing their patients over many years,and they can be built through proven pathways of care,

including annual clinical reviews.They can involve setting out the aims of care,treatment goals and expected outcomes, which will give ostomates an informed understanding of their situation and motivate them with something to work towards (LeBlanc et al, 2019).

In such a relationship, the SCN should have an informed and evolving knowledge of the changing needs of the particular ostomate.This means understanding what is most meaningful for each ostomate in achieving a good quality of life.This understanding puts SCNs in a good position to provide ongoing education and advice, as well as achieve concordance and optimal outcomes with prescribing and product use.

Therapeutic relationships need to be built on trust. This means holding honest conversations with ostomates that discuss the risks of products and interventions not working and the SCN’s expectations of outcomes.The panel’s consensus was that SCNs are gatekeepers,and trust is needed to encourage ostomates to be independent,while also providing a safety net that they feel able to call on for support when needed. ©

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Figure 1. Anatomy of the skin

CLASSIFYING SKIN CONDITIONS PSCs can result from a wide variety of complex chemical, physical and pathological processes. Each of these has its own way of interacting with the anatomy of the skin to cause breakdown in its integrity and damage to its function (Figure 1).These aetiological factors are typically interconnected and mutually reinforcing, and so PSCs are usually classified according to which of these causative factors appears to be predominant.This classification system is imperfect, owing to the multifactorial nature of most PSCs and variance in practice and terminology. However, it is valuable, as highlighting the predominant cause of a PSC will indicate the best way to treat it.

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Moisture-associated skin damage The most frequently diagnosed PSC is peristomal moistureassociated skin damage (PMASD) (Figure 2).PMASD refers to any PSC predominantly caused by prolonged exposure of the skin to moisture, typically containing chemical irritants.This moisture may comprise perspiration and/or exudate (Voegeli,2013),but PMASD is typically caused by leakage of effluent (stool or urine) from the stoma onto the surrounding skin (Burch, 2014).The Ostomy Life Study of more than 4000 ostomates from 11 countries found that leakage was very common.Three quarters (76%) had

Figure 2. Peristomal moisture-associated skin damage (PMASD)

experienced leakage in the previous 6 months, and 91% were worried about it (Claessens et al, 2015).

PMASD typically results in maceration, irritation (peristomal dermatitis) and/or breakdown of the peristomal

6, Supplement 1, Consensus Document

This article is reprinted from British Journal of Nursing, 2021, Vol 30, No 6, Supplement 1, Consensus Document

This article is reprinted from British Journal of Nursing, 2021, Vol 30, No 6, Supplement 1, Consensus Document

Peter Lamb

Peter Lamb

Cher yl Thomas

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