Chapter 6: Elimination
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Pre‐procedural considerations
Equipment
The appliances that are now available vary in style, colour, skin barrier types and efficiency. Patients need to learn the principles of stoma care while they are inpatients, and sometimes before, to ensure they are able to manage independently with the stoma on discharge.
The aim of good stoma care is to empower patients to return to their normality. One of the ways in which this can be facilitated is to provide patients 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 problems with the stoma or peristomal skin at an early stage.
When choosing the appropriate management system for a new ostomate, factors that need to be considered include:
- type of stoma
- type of effluent
- allergies
- condition of the skin
- cognitive ability
- manual dexterity
- lifestyle
- condition of peristomal skin
- siting of stoma
- abdominal topography
- patient preference (Black [28]).
Appliances
Stoma appliances (Figure 6.32) are made from an odour‐proof plastic film. They adhere to the peristomal skin using an adhesive hydrocolloid base or flange (Williams [250]). Appliances 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 appliance used will depend on the type of stoma and the expected effluent. Refer to Figure 6.33 and Table 6.12 to assist with appliance selection.
Figure 6.32 Examples of stoma pouches. (a) Closed pouch. (b) Urostomy pouch. (c) Drainable pouch.
Figure 6.33 Flow chart for choosing appliances: International Ostomy Forum Group ([106]) Observation Index. Source: Reproduced with permission of Dansac Ltd.
Table 6.12 A summary of products used for problems associated with stoma (the examples shown are not the only products; it is recommended to review full availability on the latest edition of the Drug Tariff: NHSBSA [168])
| Accessory | Product example | Use | Precautions |
|---|---|---|---|
| Protective films | Skin‐protective barrier films in spray or wipe form ( NHSBSA [165]) | To prevent irritation and give protection | If contains alcohol, avoid use on broken skin |
| Protective wafers | Skin barrier in wafer form ( NHSBSA [165]) | To cover and protect skin | Allergies (rare) |
| Seals/washers/barrier rings | See section in Drug Tariff ( NHSBSA [166]) | To provide skin protection around the stoma. Useful to fill gaps and dips in skin | Allergies (rare) |
| Caulking pastes |
Stomahesive paste
Adapt paste | To fill gaps and dips in skin and provide a smoother surface for applying the pouch, or to protect an area of dehiscence |
If contains alcohol, avoid use on broken skin
Should not be used as a solution to an ill‐fitting pouch |
| Protective pastes | Orabase paste | To protect excoriated, painful peristomal skin | |
| Powders | Ostomy powders: see section in Drug Tariff ( NHSBSA [165]) | To dry any wet, moist areas to aid adhesion of the skin barrier |
Can sometimes affect adherence
Need to ensure that excess is removed |
| Adhesive preparations | See section in Drug Tariff ( NHSBSA [166]) | To improve adherence of the product | Should not be used as a solution to an ill‐fitting pouch |
| Adhesive removers |
Hollister Adapt Medical Adhesive Remover
For more examples see Drug Tariff (
NHSBSA [164]) | To aid removal of the pouch if the patient is experiencing pain when the pouch is removed |
Some contain alcohol and should not be used on broken skin
Must not be used near naked flame (risk of burns) |
| Flange extenders ( Black [29]) |
Brava Elastic Tape
Dansac X‐tra Strips flange extenders | To improve patient security; useful for patients with parastomal hernias | Should not be used as a solution to an ill‐fitting pouch or if the pouch is leaking |
| Thickening agents | Gel‐X capsules, Ostosorb gel | To help solidify loose stoma output | If output is loose, cause should be investigated |
| Convex devices | Adapt Convex Ring | To prevent ostomy output from leaking under the pouch; particularly useful for retracted stomas | Bruising and ulceration may result if used incorrectly |
| Aerosol deodorants |
LiMone
FreshAire
(
NHSBSA [163]) | To mask and absorb odour | Must not be used near a naked flame (risk of burns) |
| Drops | Nodor S Drops | To deodorize the bag contents |
Choosing the right size
It is important that the flange of the appliance fits snugly around the stoma (Black [24]). The appliance must 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 appliance needs to be adapted accordingly, so a cut‐to‐fit pouch is used (Black [24]). After this time a pre‐cut pouch can be ordered.
Fear of malodour
As mentioned, colostomy and ileostomy appliances usually have a built‐in integral filter containing charcoal to deodorize any odour when flatus is released. Therefore, smell should only be noticeable when emptying or changing an appliance, unless the pouch is not adhering correctly. There are also various deodorizers (which may be put into the pouch) and sprays (which can be sprayed into the air just before changing or emptying the pouch) (NHSBSA [163]). 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 and accessories, or modification of their technique.
Types of pouch
Drainable pouches
Drainable pouches are used when the effluent is fluid or semi‐formed, in the case of an ileostomy or transverse colostomy (Figure 6.32a). These pouches have specially designed filters, which are less likely than other non‐drainable pouches to become blocked or leak faecal fluid. They need to be emptied regularly and the outlet rinsed carefully and then the integral closure should be sealed; rarely, a clip may be used. They may be left on for up to 3 days depending on the skin barrier and the patient's preference.
Closed pouches
Closed pouches are mainly used when formed stool is expected, for example in the case of a sigmoid colostomy (Figure 6.32c). They have a flatus filter and need to be changed once or twice a day depending on output.
Urostomy pouches
Urostomy pouches have a drainage tap for urine and should be emptied regularly (Figure 6.32b). They can be attached to a large bag and tubing for night drainage. These pouches can remain on for up to 3 days, depending on the skin barrier and the patient's preference.
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 (Burch [39]). The prescription cost analysis data for 2017 (NHSBSA [162]) indicates that the majority of individuals with a stoma in the UK use a one‐piece system. It also indicated that that this time there were 65,000 ileostomy patients, 43,000 colostomy patients and 12,000 people with a urostomy in the UK, giving a total population of people with a stoma of 120,000.
- One‐piece system: this comprises a pouch that is already attached to an adhesive skin barrier. The barrier is removed completely when the pouch is changed. Compared to a two‐piece system, this is an easier system for an ostomate with dexterity problems, such as arthritis or peripheral neuropathy, to handle.
- Two‐piece system: this comprises a skin barrier onto which a pouch is clipped or stuck. It can be used with sore and sensitive skin because when the pouch is removed, the skin barrier is left intact and so the skin is left undisturbed.
Solutions for skin and stoma cleaning
Warm water is sufficient for skin and stoma cleaning. All adhesive remover spray must be washed off as this may interfere with the pouch's adhesion. In addition, wet wipes are not recommended as they too can leave a residue on the skin and prevent the skin barrier from adhering. 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 6.12 for a summary of products used in managing problems associated with a stoma.
Deodorants
Aerosols
Aerosols are used to absorb or mask odour. One or two puffs are discharged into the air before emptying or removing the appliance. See the section on deodorants in the Drug Tariff (NHSBSA [163]).
Drops
Drops are used to deodorize bag contents. Before fitting a pouch or after emptying and cleaning a drainable pouch, squeeze drops into the colostomy or drainable bag, not the urostomy bag.
