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Department: WOUND & SKIN CARE

Basic ostomy management, part 2

Deitz, Diane MSN, ACNP, CWON, CWS; Gates, Judy MSN, RN-BC, CWS, FAACCWS

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doi: 10.1097/01.NURSE.0000371138.55544.91
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In Brief

OUR PREVIOUS ARTICLE focused on colostomy types and immediate postoperative concerns. This article describes pouching systems, skin care, and dealing with complications.

Picking a pouching system

Figure
Figure

Most ostomy pouching systems are lightweight, odor-proof, and relatively low maintenance.1,2 Choosing the most appropriate system for your patient may involve some trial and error.

When choosing a pouching system, consider the size and shape of the stoma, anatomic location of the stoma, location of the stomal lumen, level of stomal protrusion, abdominal contour, type of drainage, and patient preference. You may need to cut or mold the skin barrier (the adhesive disk placed on the skin around the stoma) to accommodate the size and shape of the stoma. Leave no more than 1/8 inch of skin showing around the stoma. Skin barriers can be flat (recommended when the stoma protrudes at least 1 inch [2.5 cm] from the abdomen) or convex. The curved surface of the convex skin barrier puts gentle pressure on the skin around the stoma, helping to achieve a good seal and prevent leakage. The convex skin barrier is recommended for patients with a flush or retracted stoma, stoma within a skin fold or with surrounding skin creases, stomal opening at or near the skin level, or a very soft abdomen around the stoma.1,3

Pouches are available in various sizes and shapes to address different needs and preferences. A closed-end pouch is removed and disposed of one to three times a day. A drainable pouch, which has a clip or self-sealing closure at the bottom, may be emptied as needed and used for several days. A urostomy pouch has an "antireflux" valve that helps keep urine in the bottom of the pouch.

One-piece pouching systems, in which the pouch and skin barrier are a single unit, are also available, and provide more flexibility than the two-piece options described above.

Changing a pouching system

The time between changes of the pouching system varies by type of stoma, type of drainage, body shape, patient activity level, skin moisture, and patient preference. Some pouching systems are made to be changed daily, and others every 3 to 7 days.

Follow the same basic principles regardless of the system: Remove the skin barrier gently to prevent skin trauma. Applying warm water may help. Use an adhesive remover only if the patient's skin has a lot of adhesive residue. (The adhesive remover itself can leave a residue on the skin that interferes with adherence of the skin barrier.) Wash the skin gently with warm water and a washcloth or soft paper towels—soap isn't needed. Avoid products that contain alcohol and premoistened wipes or towelettes (which also can interfere with skin barrier adherence).

Be very gentle when cleaning the peristomal skin and stoma. Because the stoma contains few or no nerve endings, it's easy to cause trauma without the patient being aware. The stoma also is very vascular, so even minimal trauma can cause bleeding. If you use a skin sealant or barrier film, let it dry completely before applying the pouching system.3,4

Once you've cleaned and prepped the skin, apply the skin barrier, then apply the pouching system.

Dealing with complications

Stool or urine that leaks under the skin barrier can cause irritant contact dermatitis, characterized by pain, erythema, and skin erosion. Assess the stoma and peristomal skin carefully to determine the reason for the leakage. If necessary, remeasure the stoma to assure that the skin barrier fits properly. If the patient's skin surface is uneven, fill in gaps under the skin barrier with a paste or adhesive strip specially made for this purpose. Treat irritated areas with a special protective powder and a skin sealant.4

Allergic contact dermatitis is caused by an allergic reaction to a component of the pouching system. The patient may need topical treatments or an alternative pouching system.4

Other complications that can make pouching challenging include skin ulcers, a parastomal hernia (a loop of intestine protrudes through the fascia around the stoma), or a stomal prolapse, in which the bowel telescopes through the stoma.3,4

Consult a wound, ostomy, and continence nurse if your patient has a complicated stoma, you can't maintain a pouching system, or your patient has questions you can't answer. By understanding ostomy management, you can help your patient deal with the physical and psychological challenges of living with an ostomy.

REFERENCES

1. Pontiere-Lewis V. Basics of ostomy care. Medsurg Nurs. 2006;15(4):1–202.
2. Colwell C, Goldberg M, Carmel J. Fecal and Urinary Diversions: Management Principles. St. Louis, MO: Mosby; 2004.
3. Erwin-Toth P. Ostomy pearls: a concise guide to stoma siting, pouching systems, patient education and more. Adv Skin Wound Care. 2003;16(3):1–152.
4. Herbe L. Peristomal skin care. The Phoenix. 2008;3(2):1–29. http://www.phoenixuoaa.org

RESOURCE

Kent DJ. Changing an ostomy pouching system. Nursing. 2008;39(12):1–54.
    © 2010 Lippincott Williams & Wilkins, Inc.