Urostomy Supplies - I-Piece Ostomy, Urostomy Pouches Bags

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1-Piece Ostomy

CONCISE GUIDE TO STOMA SITING, POUCHING SYSTEMS, PATIENT EDUCATION, AND MORE.

Ostomy surgery is performed on persons of all ages, from premature newborns to senior citizens, and it need not be a disabling procedure. Successful planning and management can offer patients the opportunity to lead full, normal, and productive lives.1-4

No matter how careful the planning is, however, alterations in elimination from urinary or fecal diversion will result in physiologic, anatomic, and psychological challenges. For example, patients often express concern about how secure the system's seal will be, how they will manage odor, and whether the ostomy system will be compatible with their activities of daily living. Whether the stoma is expected to be temporary or permanent, individualized preoperative and postoperative education and counseling will be essential to patient management and can help to allay their fears.1,3-6 One complication inherent in the placement of an ostomy is the risk for alterations in peristomal skin and tissue integrity.1,7 As with many incidences of skin breakdown, prevention is of great importance in ostomy care. Primary prevention of alterations in peristomal skin and tissue integrity begins preoperatively with stoma siting.

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STOMA SITING

Stoma siting a patient preoperatively, based on the surgical procedure and the patient's anatomic structure, can enhance postoperative fitting of the ostomy system. The advantages of stoma siting a patient preoperatively include:

identifying the role of the clinician in educating the patient

* assessing the physical characteristics and psychological needs of the patient

* initiating patient teaching

* selecting the stoma site.

Generally, the optimum site is below the umbilicus and within the sheath of the rectus muscle on the summit of the infraumbilical fat mound. The patient must be able to see and reach the site to manage the ostomy. Making an indelible mark with a surgical marking pen or tattoo is the accepted practice to ensure proper identification of the preferred site during the operative procedure.1,8

There are times when the best site lies in the upper quadrant. This may occur with patients using wheelchairs or with some obese patients who cannot see a lower quadrant site. Evaluation of the patient in supine, sitting, and standing positions to assess for creases, scars, and bony prominences can assist with identification of conditions that could interfere with adherence of the pouching system after surgery and the ability of the patient to master self-care.1,5,8

As mentioned, the location of an ostomy generally depends on the type of diversion to be performed. The following are a lew examples:

* ileostomy-right lower quadrant

* descending/sigmoid colostomy-left lower quadrant

* transverse colostomy-varies from midquadrant to upper or lower quadrants, depending on the location of the diversion in the colon

* urostomy (eg, Heal conduit)-right lower quadrant.

Even in emergent conditions, taking time to preselect the location of the ostomy can make a significant difference in the clinician's ability to obtain a secure pouching system postopera lively.

APPLIANCE FITTING

Postopcratively, the ostomy appliance is fitted according to stoma size and abdominal location, type and amount of effluent, and individual patient characteristics, including visual acuity and manual dexterity. This careful fitting is another way to prevent peristomal skin complications by ensuring an adequate seal.

Patients with a well-sited, budded stoma and a flat, fairly firm abdomen may be best served by a flat or flexible 1- or 2-piece pouching system. A skin barrier composed of natural, pectin, or synthetic substances protects the patient's penstomal skin. A patient with either high output or output capable of rapidly eroding a standard barrier may benefit from the use of an extended-wear barrier. 1,5,9

A patient with a soft abdomen and a well-sited, budded stoma may be able to wear a standard flat or flexible pouching system. If, however, the stoma is flush or retracted and the abdomen is soft, a small or moderate degree of convexity may be required. Convexity is achieved through an insert added to or integrated into the skin barrier flange or pouch. The downward pressure of convexity can enhance the seal around the base of the stoma to promote a secure fit and inhibit undermining of the pouch seal.

A patient who has a very soft abdomen, regardless of the protrusion of the stoma, may require deep to very deep convexity to obtain a secure seal. This type of convexity is offered in several commercially available 1- and 2-piece pouching systems. Use of accessory products in the form of pastes, skin barrier rings, and seals, and careful use of belts can further enhance the seal and support rendered to the pouching system.1,5,9

CHOOSING A POUCHING SYSTEM

Accurately measuring the stoma is an essential step prior to choosing a pouching system. Using a disposable measuring guide, the stoma should be measured at the base from mucosa to mucosa. The stoma should be measured and the plane of the peristomal region should be evaluated with the patient in the supine, sitting, and standing positions. The aperture of the skin barrier should lie within 1/8 inch of the base of the stoma, close enough to protect the peristomal skin yet large enough to prevent trauma to the stomal mucosa.

A properly fitting pouching system should move well with the patient, maintain a secure seal, and be comfortable. Pouching systems arc manufactured in precut forms with circular openings; however, custom-cut and special-order sizes and shapes can be obtained. During the first few weeks after surgery, changes in the size of the stoma, the abdominal contour, and abduminal firmness are common.1,4,5,7,9

Custom-cut systems prepared at the time of application arc often the most appropriate. Once stomal edema and abdominal contours have stabilized (generally after 6 weeks), precut or special-order systems may be obtained. Patients should be taught how to measure the stoma and inspect the peristomal skin for any signs of breakdown.

CHANGING THE POUCH

The frequency of pouch changes will vary according to the stoma and equipment `type and the patient's preference. The primary recommendation is for the patient to arrive at a changing schedule that maintains a secure, odor-proof seal. The patient should not wait until leakage occurs to change the system. Average wearing time ranges from 3 to 5 days, although some patients may require more or less frequent changing based on their individual needs. Self-care instruction and appropriate referrals to enhance the continuum of care arc needed. Follow-up services in the ambulatory, home, subacute, or long-term-care settings should be arranged prior to discharge.1,4,5

soiled system should be inspected for undermining or meltdown that may predispose the patient to breakdown of peristomal skin. If problems occur, the patient should seek assistance from a health care provider experienced in ostomy management. Adjustments to the aperture or pouching system, addition or change in convexity, and identification and treatment of peristomal skin problems can be addressed.1,4,5,7,9

Depending on the length of stay in the hospital, the patient may be seen in 1 to 6 weeks after discharge. Another follow-up visit in 3 months will assist with identification and treatment of physical and psychological complications. Annual visits to the clinician can provide preventive care, update the ostomy equipment, and offer ongoing psychosocial support. Special attention to age-related, cultural, and developmental concerns can be addressed during these visits. Interim visits by the patient to the clinician can be scheduled as the need arises. Patients should be encouraged to seek assistance early to prevent an escalation of complications.1,3,6,9,10

Prevention and early identification of peristomal skin conditions is an essential component of successful, cost-effective management of the patient with a stoma. Creation of an ostomy can be a lifesaving experience for a patient. Facilitating a successful adjustment from a physical and psychological perspective can make it a life well worth living.

REFERENCES

1. Lavery I, Erwin-Toth P. Stoma therapy. In: MacKeighan J, Cataldo P, editors. Intestinal Stomas: Principles and Management St Louis: Quality Medical Publishing; 1993. p 60-84.

2.VanHorn C, Barrett P. Pregnancy, delivery and postpartum experiences of fifty-four women with ostomies. J Wound Ostomy Continence Nurs 1997;24:302-10.

3. Golis AM. Sexual issues for the person with an ostomy. J Wound Ostomy Continence Nurs 1996;23:33-7.

4. Jeffers C, MacKay AT. Improving stoma management in the low vision patient. J Wound Ostomy Continence Nurs 1997;24:302-10.

5. Erwin-Toth P, Doughty D. Principles and procedures of stomal management. In: Hampton B, Bryant R, editors. Ostomies and Continent Diversions: Nursing Management. St Louis: Mosby; 1992. p 29-103.

6. Zoucha R, Zamarripa C. The significance of culture in the care of the client with an ostomy. J Wound Ostomy Continence Nurs 1997;24:270-6.

7. Hampton B. Peristomal and stomal complications. In: Hampton B, Bryant R, editors. Ostomies and Continent Diversions: Nursing Management. St Louis: Mosby: 1992. p 10S28.

8. Erwin-Toth P, Barrett P. Stoma site marking: a primer. Ostomy Wound Manage 1997;43(4):18-20, 22, 24-5.

9. Rolstad BS, Boarini J. Principles and techniques in the use of convexity. Ostomy Wound Manage 1996;42(1):24-6, 28-34.

10. Erwin-Toth P. The effect of ostomy surgery between the ages of 6 and 12 on psychosocial development in childhood, adolescence and young adulthood. J Wound Ostomy Continence Nurs 1999.

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