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One- or two-piece systems

All types of pouch (closed, drainable or with a tap) fall into one of two broad categories: one-piece or two-piece systems.

One-piece: this comprises a pouch attached to an adhesive wafer that is removed completely when the pouch is changed. This is an easier system for an ostomate with dexterity problems, for example arthritis, peripheral neuropathy, to handle.

Two-piece: this comprises a wafer onto which a pouch is clipped or stuck. It can be used with sore and sensitive skin because when the pouch is removed, the flange is left intact and so the skin is left undisturbed.

Plug system

Patients with colostomies may be able to stop the effluent by inserting a plug into the stoma lumen. This plug swells in the moist environment and behaves as a seal. This system should only be introduced by a stoma nurse specialist (Taylor 2000).

Solutions for skin and stoma cleaning

Mild soap and water, or water only, is sufficient for skin and stoma cleaning. It is important that all soap residues are removed as they may interfere with pouch adhesion. Detergents, disinfectants and antiseptics cause dryness and irritation and should not be used. The stoma is not a wound or a lesion and should be regarded as a resited urethra or anus.

See Table 6.5 for a summary of products used in managing problems associated with stoma.

Table 6.5 A summary of products used in managing problems associated with stoma

Deodorants

Aerosols

Use: To absorb or mask odour. Method: One or two puffs into the air before emptying or removing appliance. Examples: Limone, Naturcare, FreshAire.

Drops and powders

Use: For deodorizing bag contents. Method: Before fitting pouch or after emptying and cleaning drainable pouch, squeeze tube two or three times. Examples: Ostobon deodorant powder, Nodor S drops, Saltair No-roma.

Preoperative assessment and care

Preoperative care can be divided into two sections: physical and psychological.

Physical

Firstly, physical care consists of surgical preparation, which can be in the form of bowel preparation where patients are required to take laxatives to cleanse their bowel prior to surgery. This arguably improves surgical visibility and prevents contamination. This depends on the surgeon’s preference and needs to be checked with the patient’s surgical team on admission.

Due to the current developments regarding reducing patients’ hospital stay, many hospitals are carrying out enhanced recovery programmes for colorectal patients. This involves intensive input preoperatively, where selected patients are required to take nutritional drinks and develop skills in changing a stoma bag. This will improve recovery and management and consequently reduce hospital stay. These enhanced recovery programmes are relatively new and are still being trialled in many centres.

Finally, stoma siting is one of the most important tasks to be carried out by a doctor, stoma care nurse or ward nurse or anyone with appropriate knowledge and skills. This minimizes future difficulties such as the stoma interfering with clothes or skin problems caused by leakage of the appliance due to a badly sited stoma (Bass et al. 1997, Qin and Bao-Min 2001).

Patient assessment is necessary taking into account:

physical problems

disabilities

mental state

visual impairment

manual dexterity

lifestyle

work

leisure/sporting activities

ethnicity.

The following guidelines should be adhered to when siting a stoma.

Locate the rectus muscle: this reduces the risk of herniation later (Myers 1996). The muscle can be identified by asking the patient to lie flat and raise their head. The muscle may also be palpated and easily felt when the patient coughs.

Identify a flat area of skin on the abdomen, as this facilitates safe adhesion of the appliance.

Avoid skin creases, especially in the region of the groin or the umbilicus, to avoid urine or faecal matter tracking along the skin creases.

Avoid any previous or proposed scars, which may lead to skin creases and difficulty