The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [205]
Preprocedural considerations
Equipment
Many of the appliances now available are very similar in style, colour and efficiency and often there is very little to choose between them when the time comes for the ostomate to decide what to wear.
The aim of good stoma care is to return patients to their place in society (Black 1994). One of the ways in which this can be facilitated is to provide them with a safe, reliable appliance. This means that there should be no fear of leakage or odour and the appliance should be comfortable, unobtrusive, easy to handle and disposable. The ostomate should be allowed a choice from the management systems available. It is also important to identify and manage early on problems with the stoma or peristomal skin. When choosing the appropriate management system for the new ostomate, factors which need to be considered include:
type of stoma
type of effluent
patient’s cognitive ability
manual dexterity
lifestyle
condition of peristomal skin
siting of stoma
patient preference (Black 2000, Kirkwood 2006).
Pouches
Although some people whose stomas were created several years ago are wearing non-disposable rubber bags, most appliances used today are made from an odour-proof plastic film. These pouches usually adhere to the body by a hydrocolloid wafer or flange (Taylor 2000). Pouches may be opaque or clear and often have a soft backing to absorb perspiration. They usually have a built-in integral filter containing charcoal to neutralize any odour. The type of pouch used will depend on the type of stoma and effluent expected. Refer to Figure 6.15 to assist pouch selection.
Figure 6.15 Flow chart for choosing appliances. International Ostomy Forum group (2006) Observation Index. Dansac Ltd.
Choosing the right size
It is important that the flange of the appliance fits snugly around the stoma within 0.3 cm of the stoma edge (Kirkwood 2006). This narrow edge is left exposed so that the appliance does not rub on the stoma. Stoma appliances usually come with measuring guides to allow for choice of size. During the initial weeks following surgery, the oedematous stoma will gradually reduce in size and the appliances will be changed accordingly.
Fear of malodour when using pouches
Pouches usually have a built-in integral filter containing charcoal to neutralize any odour when flatus is released; therefore, smell is only noticeable when emptying or changing an appliance (Rudoni and Sica 1999). There are also various deodorizers available.These come in the form of drops or powders that may be put into the pouch or sprays, which can be sprayed into the air just before changing or emptying the pouch (Burch and Sica 2005). The individual should be reassured that any problems with odour or leakage will be investigated and that in most circumstances the problem will be solved with alternative appliances or accessories (Black 1997, Bryant 1993).
Drainable pouches are used when the effluent is fluid or semi-formed, that is, ileostomy or transverse colostomy (Figure 6.16a). These pouches have specially designed filters, which are less likely to become blocked or leak faecal fluid. They need to be emptied regularly and the outlet rinsed carefully and then closed with a clip or ‘roll-up’ method. They may be left on for up to 3 days.
Figure 6.16 Stoma equipment. (a) Drainable bowel stoma pouch. (b) Urostomy pouch. (c) Closed bag.
Urostomy pouches have a drainage tap for urine and should be emptied regularly (Figure 6.16b). They can be attached to a large bag and tubing for night drainage. These pouches can remain on for up to 3 days.
Closed pouches are mainly used when formed stool is expected, for example sigmoid colostomy (Figure 6.16c). They have a