What are the best management strategies for a patient with an ileostomy experiencing leaking and skin irritation around the stoma site?

Management of Ileostomy Leakage and Peristomal Skin Irritation

For this patient with circumferential leaking and denuded peristomal skin, immediately switch from paste to barrier rings, ensure proper stoma measurement with appropriate cutting technique, implement crusting therapy for denuded skin, and reinforce proper appliance removal technique with adhesive remover to prevent further mechanical trauma. 1

Immediate Interventions for Leakage Control

Optimize Pouching System

• Replace paste with barrier rings applied circumferentially, as rings provide superior seal and flexibility compared to paste for managing leakage 1
• Switch to pre-cut 1.5" (38mm) pouching system rather than cut-to-fit, as the patient has been using improperly sized barriers 1
• Cut the appliance opening 1/8 inch (3mm) larger than the stoma to prevent mucosal irritation while minimizing exposed skin surface 1
• Continue measuring stoma size at each change for the first 8 weeks, as stoma dimensions change significantly during this period 1

Address Mechanical Factors Contributing to Leakage

• Implement proper appliance removal using adhesive remover rather than pulling off the barrier, as mechanical trauma from improper removal exacerbates skin breakdown 1
• Trim peristomal hair weekly with electric razor to prevent hair follicle irritation and improve barrier adhesion 1
• Apply heat to the appliance with a hair dryer before application to enhance adhesion 1
• Have patient lie flat for several minutes after application to optimize seal formation 1

Manage the Parastomal Hernia

• Fit for a hernia belt (already ordered: catalog #[CATALOG_NUMBER]) to reduce hernia protrusion and improve pouching surface 1
• The hernia is contributing to irregular contour and leakage; the belt provides external support until planned reversal next month 1

Treatment of Denuded Peristomal Skin (6-9 o'clock position)

Crusting Technique for Broken Skin

• Apply stoma powder to denuded areas, dust off excess, then seal with barrier film - this "crusting" technique creates a protective layer over broken skin 1
• The powder absorbs moisture while the barrier film seals it, allowing the pouching system to adhere despite compromised skin integrity 1
• Repeat this crusting process with each appliance change until skin is completely healed 1
• Discontinue crusting once skin integrity is restored to avoid unnecessary product buildup 1

Skin Protection Strategy

• Use zinc oxide-based skin protectants on intact peristomal skin to prevent further breakdown from effluent exposure 1
• Apply non-sting barrier film to all peristomal skin before barrier application 1
• Ensure skin is completely dry before applying any products or the pouching system 1

Management of High Ileostomy Output

Stool Thickening Approach

• Continue loperamide (already prescribed) to thicken effluent and reduce leakage risk 1
• Thicker output is less likely to undermine the barrier seal and cause leakage 1
• Consider dose adjustment if output remains liquid despite current therapy 1

Monitor for Complications

• The patient's 40-pound weight gain since surgery suggests adequate absorption, but continue monitoring hydration status 1
• Watch for signs of high output syndrome if reversal is delayed beyond planned timeline 1

Appliance Change Protocol

Optimal Timing and Technique

• Change every 3-4 days proactively rather than waiting for leakage (currently changing almost daily due to leakage) 1
• Cleanse skin with warm water only, pat completely dry 1
• Avoid soap on peristomal skin as it can leave residue that interferes with adhesion 1

Product Regimen

• 1-piece flat drainable pouching system with 1.5" pre-cut opening 1
• Barrier ring applied circumferentially (not paste) 1
• Stoma powder for denuded areas only 1
• Barrier film over entire peristomal area 1
• Adhesive remover wipes for safe removal 1

Critical Pitfalls to Avoid

Do not pull the barrier off without adhesive remover - this mechanical trauma is a primary cause of the current skin denudement and perpetuates the leakage cycle 1

Do not continue using paste instead of barrier rings - paste is less effective for managing circumferential leakage and does not accommodate the irregular contour created by the hernia 1

Do not cut the barrier opening too large - excess exposed skin increases risk of chemical injury from effluent 1

Do not ignore the peristomal skin folds/creases - these are significant risk factors for both leakage and skin complications, requiring convexity or rings to level the surface 2

Risk Factors Present in This Patient

This patient has multiple factors predisposing to complications:

• Ileostomy type (higher risk of severe peristomal skin complications compared to colostomy) 2
• Parastomal hernia creating irregular pouching surface 1
• Improper removal technique causing mechanical trauma 1
• Recent weight gain (40 pounds) altering abdominal contour and stoma relationship 1

Follow-Up Considerations

• No routine follow-up scheduled; patient instructed to call PRN 1
• Consider scheduled follow-up in 1-2 weeks to assess skin healing and barrier effectiveness, as PSC likelihood increases over time and structured follow-up improves outcomes 2
• Reversal planned for next month, which will resolve the underlying issue 1
• If reversal is delayed, reassess hernia belt fit and pouching system as body habitus continues to change 1