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Stoma Care

John23's picture

If you are having a problem keeping an Ostomy appliance
from leaking, or having a problem with "burning skin" under the
appliance ...... or the erosion of skin (blistering, etc) on the area
around the stoma (peristomal area), please consider the following
directions for the application of an appliance for the "normal" stoma:

Some added preamble:

At the hospital, in the recovery room, your nurse changed your
appliance while you lay in bed. The appliance's drain was facing
sideways, to accommodate discharge into a bed pan.

Well you're home now, and unless you're confined to bed and
unable to stand for fifteen or so minutes at a time, things are different!

You should NOT be laying down to change that ostomy appliance,
you should be standing.

Place ample newspaper on the floor, in front of the bathroom sink,
and lay out all the things you require on the sink counter to make
the change with the appliance.

If you see discharge happening, simply lean forward and allow
the discharge to drain onto those well-placed newspapers.

By leaning forward, the discharge will usually miss the area of
your body that you have so carefully cleaned, and make life a
bit more pleasant!

In preperation for the change, make sure that:

-The pouch should be closed at it's bottom and secured.

-The wafer opening is cut to the correct size for your stoma.

-A clean wash rag, or 4x4 non-sterile pads should be set where

they can be reached.

-The hot water running.

-The small bottle of Convetec Stomahesive Powder opened and ready to use.

-Paper towels or 4x4 non-sterile pads ready to use, to dry the peristomal area.

When you're done, the pouch should be facing downward, not to
the side, since you'll be emptying while sitting down at the toilet.

Normally when the pouch is placed properly, the opening will face
down the front of the leg. When sitting on the toilet, it will naturally
conform to the position between your legs for easy and neat emptying.

1. Use only warm/hot water to wash the peristomal area.
Do not ever use soap of any type, to wash the peristomal area.

2. Use a wash towel that has not been washed or dried with
any soap product, or fabric softener.

3. Use paper towels to dry the peristomal area. Cloth toweling,
toilet tissues, toilet paper, etc, have chemicals that leave
a residue; paper towels usually do not. (4x4 non-sterile pads are excellent)

4. Never use any adhesive remover, tape remover, etc, on or
near the peristomal area. They all leave a residue that is near
impossible to remove fully. That residue will degrade the adhesive
qualities, and greatly shorten the wear-time of the appliance!

5. Use -no- topical dressings, skin prep, etc on the peristomal area.

6. Use -no- topical dressings, skin prep, etc on the peristomal area.

I typed that twice for a reason. All skin preps prevent the appliance's
adhesive from working the way they are formulated to work.

All Manufacturers clearly state that their appliance should be
applied to "clean, dry skin". It is really that simple! There is no
"hidden message" in the manufacturer's instructions.

Their products and adhesives are designed and formulated to adhere
to clean, dry skin, and are formulated with specific skin and body
chemicals in mind. None are formulated to "adjust" to the various
chemical properties of other manufacturer's products.

Using any "skin prep", "adhesive remover", or other types of topical
dressings, will degrade the efficiency of the adhesive used for the
appliance itself.

7. To heal a sore area in the peristomal area, I strongly recommend:

Convetec Stomahesive Powder

Use it by itself; DO NOT use any other topical dressing or
skin prep under or over the Convetec Stomahesive Powder.

The powder was designed to be used by itself. It will "crust up"
on the weeping or wet areas.

If the powder is kept from touching the skin by the application
of another topical dressing (skin-prep), it will be prevented from
working properly.

If the powder is covered by another topical dressing (skin-prep),
it will be prevented from working properly.

Dab the powder on the sore areas, and lightly brush off the
excess powder from the areas where it is not needed. The
appliance will adhere to the powder and skin, and the sore
will usually heal overnight.

8. The appliance's hole for the stoma should be cut and fitted
as snugly to the stoma as possible. There should be absolutely
no skin exposed around the base of the stoma and the appliance's
opening for the stoma. For that reason, "cut to fit" appliances
are best to use and ready-cut appliances are not!

9. If the stoma does not protrude at least 3/4" from the skin,
if it is even with the skin, or below the skin's surface, you should
try using a convex appliance. The base of a convex appliance
bulges outward at it's base (into the skin) and presses down
against the peristomal area, pushing the stoma out and into the
pouch. That helps prevent seepage under the appliance, and
provides a better seal.

10. Use an Ostomy belt to help hold the appliance to the skin.

11. Handle the appliance's adhesive areas by the edges, as you
would handle a CD, or DVD. Oils from the skin (hands) can quickly
deteriorate the adhesive qualities of the appliance.

12. Do not use pastes or topical dressings on the peristomal area.
Pastes are like spackle, it's used for filling creases and crevices,
and will dissolve when wet.....it's useless as an adhesive, or as
a skin protectorate.

13. Place the appliance on the skin, and cup your hands around it,
pressing the appliance against the skin tightly. The heat from the
body will set the adhesive within 5 minutes. Body heat is all that
is required, too much heat degrades the adhesive, too little heat
will not allow it to set properly.

Back in 2006, I suffered peristomal damage so severe, that one night
I slept in the bathtub with a towel wrapped around me... I could not
get anything to stay on, and all but one visiting nurse had given up trying
to help. I found myself wishing I had died in the OR, rather than be
subjected to the grief I was in with this damned stoma.

I found that the manufacturers gave the correct methods for use,
but the nurses and staff disregarded the information, and insisted
on using methods they thought were better. I suffered for six
months, because some individuals can not follow basic instructions.

The sore I had, expanded beyond the peristomal area and wept
continuously, bleeding and causing pain. The weeping skin prevented
anything from sticking to it, and the stoma's waste output just ate
away at the skin, causing pain and infections.

The problem was finally resolved! I used the "Tagaderm" plastic that
is used for the "Wound-Vac" apparatus, and cut a hole in it for the
stoma. I put "Stomahesive Powder" on the wounded area, put the Tagaderm
on top, applying the appliance directly on top of that. The sore area
was healed within two days!

After that, the "Tagaderm" was no longer needed. I used the Stomahesive
powder until the sore was completely gone, and only the appliance thereafter.

The use of soap, the adhesive removers, the topical (skin-prep) dressings,
and the "skin soft" toweling, all were keeping the adhesives from doing their
job properly. It allowed waste to get under the appliance, and degrade
the adhesive qualities of the appliance.

I followed the above list, and since 2006, had not had a problem I
couldn't cure; I didn't "invent" those instructions, the manufacturers' did.

There are no problems that can't be solved! There's no reason
to live in pain and anguish with a stoma!

Oh.... and it takes between 6 months and a year for any ostomy
to "settle in". You will need to change the appliance's size for the
opening for the stoma, and possibly need other products to
compliment the appliance product you are using. There are various
types of add-on seals (Convetec's Eakin Seal, Hollister Adapt rings,
Coloplast's sealant rings), that can help the appliance adjust to
an uneven peristomal surface and add sealing qualities for other
natural conditions.

There are other reasons also, for an appliance to not work well.
If you do as listed above, and still have a problem, give me a yell....

Best wishes,

John

Comments

Tresia23's picture

Hi John, I have just read your blog on stoma care. I am a retired RN and was a community palliative care nurse. I think you should submit your story to a nursing journal. Preferably an ostomy or wound care journal. May co-author it with an RN too for added impact. It was clear, well written and better than any advice I have ever had from a stomal therapist when I was struggling to help patients with stoma problems such as you have described. I agree with what you said about the pastes. In my experience they do make a horrible mess and the appliance just falls off and yet stomal therapists still recommend their use.
I was interested in what you said about following the manufacturers instructions. I used to always keep wound product information especially for complex products such as vacuum pump dressings. I ended up being the expert on my team with vac pump wound care and yet all I did was follow precisely what the manufacturer had prescribed.
I think nurses are still in transition from the old ways of doing things instead of using scientific principles. Some of the old traditions do work, don't get me wrong. With sophisticated wound care products however best to follow the instructions. I hope you are doing ok with your health.

swordranch's picture

Hi John, Laura here...I am 7.5 months out of surgery.  My stoma is poorly placed sunken and retracted and then there are the two ditches that are finger width that go off of each side of it.  I have had heck finding anything that will fit it or work.  I finally herniated and now it is easier to deal with, but after I finish chemo (next week) and recuperate from that I am sure they will want to fix the hernia and possibly (if I am lucky) change the stoma.  Nonetheless, I have tried all kinds including the convex appliance.  I don't understand what you mean by if it is pushed down it will cause the stoma to bulge out.  I can't get the convex to go deep enough to even reach the stoma.  So if I cut the appliance to fit it the stool just pancakes underneath it and never gets to the bag.  I have to cut mine much larger then the stoma and then I protect the skin around it with the Eakin skin.  The rings just seem to make the appliance fit farther away from the stoma.  I was told to use the skin prep, the paste, the rings but I have found that I have had better luck when I am away from home, have a blowout, clean it up really fast and throw on an appliance that I hope will "get me home".  They seem to last the longest, after reading your post, I understand why...because I don't bother with using all the crap I have been schooled to use, just throw it on, warm it with my hand and go!  But still I can not make my stoma bulge out to meet any appliance so when I have a movement it still pancakes out.  The only time it goes into the bag is if I have diarrhea or am constipated (and then I just pull it out through the bag and let it drop into the bag). When I am home, I often go with no appliance and just use paper towel with a washcloth behind it so that my skin gets a break.  I am hoping to be able to irrigate after the chemo is done.  What is TCM? 

Any other ideas for me?

 

John23's picture

 

All stomas are not created the same (as you are finding out). An “innie” is always a problem, but it would be even worse if it was an Ileostomy rather than a Colostomy (an ileo is liquid 24/7)!

 

As you noted: “less is best”!

 

The paste is not an adhesive or a barrier, it’s only used as a filler (like wall spackle) to fill in big indentations. But any liquid dissolves it quickly.

 

The barrier rings are good for an Ileostomy, since they can add some adhesive benefits to the appliance being used. (I had used the Hollister “Adapt” rings to gain extra wear-time)

 

Each company makes their own version of the barrier rings, and some work better than others. And again, it’s an individual thing, just as the appliances themselves are! While one brand might work best for me, another brand might work better for you. The entire affair is one big experiment…. You can mix and match the barrier rings with other appliances, so the trial and error phase can take years!

 

The rings aren’t for adding to the “convextivity” of the appliance, since they “squish” down and really do not add much to press the peristomal area inward. They are used to add extra sealing and to add to the overall quality of the adhesive of the appliance you are using. Unfortunately, nearly all of the rings “melt” after a few days (or less) of use, and sometimes can be responsible for the erosion of appliance’s adhesive, depending on a bunch of variables. From 2006 to 2011, the rings added a week to my wear-time. After my resection in 2011 and ending up with a “short bowel”, the rings were the cause of the appliance failing after only a few hours! So one’s body chemistry can have a lot to do with adhesives and what you can expect from various manufacturer’s products.

 

Using a convex appliance will probably be your best bet. Coloplast makes a “light convex” and a deeper variety convex appliance.  I had to change from Coloplast due to my body’s chemical change, and found that now, Convetec appliances work better for me. Convetec has a fairly deep convex product, and may serve you better.

 

Convetec also makes a product that uses what they call a “Durahesive seal”; it’s a thin membrane that conforms to irregular stomas, and swells up when wet, providing a better seal for those that can use it. It might be something worth looking into?

 

There are also convex add-ons that can be used along with various appliances! I never tried them, but that too, might be what you can use.

 

Using an Ostomy belt has greatly improved my wear-time, and I strongly suggest using one! It holds the appliance tightly to your body, adding support.

 

And for your peristomal condition (with deep creases aside the stoma), you should measure the “good, flat area” of the peristomal area, and see if a smaller diameter wafer might better conform to the peristomal area that is without the deep creases. Doing that may allow the entire wafer to sit deeper, adding to the sealing of the appliance to your skin. Just make sure the smaller outside diameter product has an inside diameter that will properly accommodate the diameter of your stoma!

 

If you’re not using two-piece appliances, it would be worth your while to change to one. You can change pouches, or adjust it’s direction without removing the wafer. And you can experiment with a manufacturer’s product (pouches/wafers) easily. A one piece system has less protrusion and can lay flatter than a two piece system, but the two piece systems can add convenience and ease that a one piece cannot. Many ostomates use cut-to-fit two-piece systems until they find what works best, and change to the one piece system from the same manufacturer once they are settled into a working system.

 

Personally, when the wafer is sticking on perfectly I do not remove it until I sense it is about to fail, and change out the pouch when the filter fails, or the pouch looks too worn. The longer the wafer/appliance stays on without leaking, the better your skin will be. Removing the wafer/appliance needlessly, damages the skin at the peristomal area needlessly; “If it ain’t broke, don’t fix it”!

 

You didn’t mention if your stoma will be permanent or not. If not, don’t ask for another operation , you’ll be just asking for trouble. If a stoma will be part of your life forever, then it might be a good idea to look for a colorectal surgeon that is well practiced with the placement of an Ostomy. But do keep in mind, that it may be another extensive operation you will have to undergo. An experienced colorectal surgeon will have a Wound/Ostomy nurse (WOCN) mark out the best spot for a stoma well ahead of the operation, and the surgeon will attempt to fit the stoma to that precise spot; it’s not always possible to do so, but they do try to make things as good for their patient as possible.

 

Hopefully, something within all that text will help you? As I said, it’s “trial and error”, and often can be taxing on one’s disposition.

 

If you need further help, please drop me a PM here.

 

Best of health to you!

 

John

 

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