The history of ostomy surgery dates back to the 1700s. Throughout the 18th century, ostomy surgeries were considered a last resort and were associated with pain, high risk of infection, and high mortality rates.1 Throughout the years as knowledge and improved surgical techniques evolved, ostomy surgery became recognized as a survival procedure. Quality of life for certain conditions, such as colorectal and bladder cancers, Crohn's disease, and ulcerative colitis, was improved through ostomy surgery.
One of the most significant advances in stoma creation was a technique introduced in the 1950s and promoted by Dr Rupert Turnbull, MD, at the Cleveland Clinic to “surgically mature” the stoma. It was during this time, Dr Turnbull also became interested in the significance of stoma placement and created an awareness of the need for patient education. He enlisted the help of Norma Gill, an ileostomate since 1954, to work with actual and potential patients with ostomies. The profession of enterostomal therapy was born out of this collaboration.2
The American Association of Enterostomal Therapists, and, later, its evolution into the Wound, Ostomy and Continence Nurses Society in 1992, paved the way for certified ostomy care nurses (COCNs) to provide specialized ostomy care. An individual who has an ostomy can present with complex clinical needs that are challenging for the entire health care team. There are a host of physiological and psychosocial needs that require a well-coordinated plan to facilitate education, lifestyle adaptations, counseling, and long-term care planning.
A COCN is invaluable in leading the team in developing a plan, accessing resources, and directing and evaluating goal-oriented care. It is essential for the nurse preparing for initial and recertification to be well prepared for the WOCNCB Ostomy examination. There are several methods a candidate can choose to prepare for certification. Organization of material is key to understanding concepts. Creating lists is a standard study tool that can facilitate a visual map to map essential concepts.3 Using task 2 of the Ostomy content outline from the WOCNCB certification handbook as an example, here is a sample list that illustrates how material is grouped together for exam preparation and utilizes checkboxes to show which material has been reviewed.
1. A patient with an ileostomy is experiencing leakage. The stoma is flush with the skin. What would be the best option for the COCN to recommend?
- Skin barrier paste
- Liquid skin barrier
- Convex skin barrier
- Flat skin barrier
Outline location: 020202
Cognitive level: Application
Rationale: The correct answer is C. Stoma appearance must be taken into account when implementing interventions. Convex skin barrier products should be considered when a stoma is near or flush to the skin to prevent stool from leaking under the barrier. The convex adhesive applies pressure around the stoma, causing the stoma to protrude up over the skin barrier's edge. Skin barrier paste is used to caulk the edge of a skin barrier and used to fill in uneven areas. While it can assist with preventing undermining of effluent, skin barrier paste would not be the first choice if the stoma is flush with the skin. Liquid skin barrier is designed to protect peristomal skin from effluent but does not help with stoma protrusion to prevent leakage. A flat skin barrier is recommended if the peristomal skin is flat in all directions and if there is sufficient protrusion of the stoma above the skin level to prevent leakage.
2. A patient with a urostomy presented to the ostomy clinic with pseudoverrucous lesions around the stoma. On exam, the COCN notes that urine encrustations are also present and may recommend which of the following treatments:
- Apply dilute (30%-50%) vinegar solution to the affected area for 20 minutes during pouch changes.
- Use a topical corticosteroid spray to reduce inflammation and provide symptomatic relief during pouch changes.
- Cleanse with an antibacterial soap and apply a topical antibiotic gel during pouch changes.
- Gently cleanse the affected area and apply a topical antifungal agent during pouch changes.
Outline location: 020203
Cognitive level: Application
Rationale: The correct answer is A. Peristomal skin alterations are a common condition prompting a person with an ostomy to be seen by a COCN. The COCN is skilled in implementing interventions based on the peristomal skin alteration. Pseudoverrucous lesions are benign growths that can form around a stoma when urine or stool irritates the skin. With urostomies, pseudoverrucous lesions can develop alkaline encrustations in which crystal deposits occur when the urine is alkaline and concentrated. These encrustations can be broken up with dilute vinegar solutions soaks during pouch changes. Topical corticosteroid sprays are used to treat inflammation in cases of allergic contact dermatitis. Cleansing with antibacterial soaps and the application of topical antibiotic gels are common treatments for peristomal folliculitis. Application of topical antifungal agents is a treatment option for peristomal fungal/candidiasis infection.
3. Which location would the COCN consider when marking a stoma site for an obese patient with a soft, protuberant abdomen who is scheduled to have surgery for a descending colostomy?
- Right upper quadrant
- Left upper quadrant
- Right lower quadrant
- Left lower quadrant
Outline location: 020201
Cognitive level: Recall
Rationale: The correct answer is B. Recommending the optimal stoma location and stoma site marking is an important skill that helps reduce risk for future ostomy-related complications. In the obese patient with a protuberant abdomen, the beltline is usually below the lower abdominal fold. Marking a site in a lower quadrant will likely result in inability to visualize the stoma. Descending colostomies are typically marked on the left side to correspond with the general location of the appropriate section of the bowel. Therefore, marking a site in either quadrant on the right side would not be appropriate. A site selection in the left upper quadrant would be the recommendation in this case.
4. A patient with an ostomy presents with the following complaints in the peristomal area: a 2-day history of a diffuse, erythemic rash with small, nontender pustules, maceration, and satellite lesions. The patient also complains of feeling “itchy” under the barrier. Which of the following would be recommended as a treatment?
Outline location: 2B5
Cognitive level: Application
Rationale: Differential diagnosis and assessment are important when evaluating peristomal skin complications. Pay attention to the clues given in the question stem. On initial impression, this could appear to be folliculitis after observing a diffuse, erythemic rash with pustules. However, the pustules are nontender and therefore would not be consistent with folliculitis. Satellite lesions are a classic sign of the fungal infection, candidiasis. Itch and maceration are also signs and symptoms that are consistent with candidiasis. Given the diagnosis, the only antifungal medication listed is clotrimazole and therefore the recommended treatment.
Bryant R. Types of skin damage and differential diagnosis. In: Bryant RA, Nix DP, eds. Acute and Chronic Wounds: Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:103.
Clotrimazole. In: John Hopkins ABX Guide. POC-IT Guides. Charlottesville, VA: Unbound Medicine; 2019.