You wouldn't carry a delicate, hand-beaded Gucci bag on a muddy camping trip. It's doubtful you will ever see a bride with a bulky denim bag slung over her shoulder. Just as you would choose the proper "bag" to accessorize your outfit, the correct bag must be chosen for successful pouching of various ostomy stomas.
There are three main categories of ostomy stomas: urostomy, ileostomy and colostomy. Each stoma has a unique shape, size and appearance. They should always appear red and moist. Stomas may bleed easily if rubbed. Because they are a piece of intestinal mucosa, they do not have pain receptors. Stomas take several months to shrink to their permanent size, so barriers must be cut to fit as size changes. If a pouch does not fit properly, it can lead to skin irritation or leakage.
A Closer Look
A urostomy is a surgically created opening usually found on the right lower abdomen. This procedure is frequently performed to eliminate bladder cancer, and it is permanent. It also may be referred to as an ileal conduit or urinary diversion. A urostomy allows urine to flow out of the body after the bladder has been removed; urine is no longer eliminated through the urethra.
There are several methods used to create the urostomy with the most common being an ileal conduit. The surgeon removes a short section of the ileum and uses it as a conduit (or pipeline) for urine to flow out through the abdomen. The ureters are brought through the conduit and drain freely since there is no sphincter muscle. The opening in the abdomen is the stoma, which will be covered by a urostomy pouch. The first several weeks after surgery, the patient will usually have small tubes inserted into the stoma. These are stints, which train the stoma to stay open and allow urine to flow unobstructed. After approximately 2 weeks, these frequently fall out during a pouch change or are removed by the physician.
An ileostomy is a surgically created opening into the small intestine through the abdomen. An ileostomy may be temporary or permanent, depending on the reason for the surgery. It is usually located on the right lower quadrant of the abdomen. The purpose of an ileostomy is to allow stool to bypass the colon. The stool from an ileostomy is generally liquid in large volumes and contains digestive enzymes that can be very irritating to a patient's skin.
A colostomy is a surgically created opening into the colon through the abdomen. Its purpose is to allow stool to bypass a diseased or damaged part of the colon. It may be temporary or permanent. Part of the colon is brought through the abdominal wall, usually located on the left lower quadrant of the abdomen. The stool from a colostomy is usually semi-formed.
Picking a Pouch
Most stomas are raised above the skin level. These require pouches with a flat wafer on the back. Some stomas are flat and even with the skin or even recessed below the skin level. These stomas require a special pouch with a curved back, called convexity.
Urostomy pouches have a small spout on the bottom to allow frequent drainage of urine. They also can be clipped to a continuous drainage bag with use of an adapter.
Colostomy and ileostomy pouches can be one piece or two pieces. They have a large opening at the bottom to allow drainage of stool. They can be shut using a Velcro closure or clamp. One-piece pouches are easier to apply if a patient has problems with manual dexterity, arthritis or limited vision. Two-piece pouches allow the user to unclip the outer pouch if they wish to reposition it or rinse it after emptying. Closed pouches don't have an opening for emptying. They get unclipped and thrown away after each use.
If a patient is having difficulty with the pouch not maintaining a good seal, an ostomy belt can be added to the side tabs to help secure the appliance to the abdomen.
If the urostomy patient has skin folds or a large abdomen, apply the pouch while lying flat or standing. Remove the old pouch and discard it. Clean the patient's skin with water using a soft washcloth, paper towel or cotton ball. Do not use wipes, as they frequently include chemicals that could prevent the pouch from adhering.
If the patient's stoma is flush with the skin, use a convex pouch to prevent leaks. Cut the wafer to fit as close to the stoma as possible. Cutting the opening too large will cause skin excoriation. You do not need to use paste; the adhesive on the wafer melts with urine.
Gently stuff the stints into the opening you cut in the pouch. Pat the entire area dry just before pressing the pouch over the stoma site. Any moisture on the back of the wafer will prevent it from adhering.
If the patient has an ileostomy, apply a thin line of paste around the opening you have cut. If there are any skin folds or valleys surrounding the stoma, fill these in with paste also. Use about the same amount you would put on a toothbrush. Apply a clamp to the bottom of the pouch.
Center the pouch over the stoma and press firmly to seal onto skin. Move your hand around the wafer to allow body heat to help adhere. Make sure the spout is turned so it will not drain contents onto the patient. Change the pouches every 4-5 days and empty when half-full to avoid leakage.
Choosing the proper ostomy appliance can protect healthy skin, minimize leakage and lengthen wear time. This will provide increased comfort and satisfaction for both the nurse and the patient. n
Dawn Engels is a wound ostomy continence nurse at Moses Cone Health System in Greensboro, NC.