Preparing the Patient for Colostomy Care: A Lesson Well Learned
E ducation can be defined as experience that results in a change of behavior in some desired direction. Adults are strongly motivated to learn only when they perceive a possible application in their own lives.1 Education is a vital role of the nurse, particularly regarding colostomy care. Providing instruction on proper technique for changing a pouch system, as well as some important things to look for during the procedure, will help prevent problems and make living with a colostomy a bit more manageable. One patient's experience offered the opportunity to acknowledge the key points for patient education in this situation.
At the age of 78, Mrs. J had a new colostomy and no one to help her manage it once she went home. She had been admitted from a local hospital to a skilled nursing facility. After some preliminary questions and answers regarding what she knew and how she felt about this new aspect of her life, she was given written material to review in preparation for learning self-care techniques.
A new ostomate such as Mrs. J has many educational needs. Initially, she was taught how a colostomy works, different types of colostomies, and how and when to empty the pouch. She will acquire knowledge about how certain foods may affect the function of her colostomy, how gas as seen as air in the pouch can be managed, and how her lifestyle may need to be altered somewhat regarding clothing, travel, and her social life.
Measuring the Stoma and Applying the Correct Wafer Size
To prevent skin problems and stool leakage from the pouch system, the wafer must fit properly onto the peristomal skin. In order to accomplish this, the opening in the wafer must be 1/8-inch larger than the stoma. Two types of wafers are available. The pre-cut wafer is already cut to the correct size for the opening around the stoma. Usually, this type is recommended once the stoma has stopped changing size (usually 6 to 8 weeks after surgery); it can be of great benefit for a person who is unable to cut the wafer (eg, due to arthritis or poor coordination). To use the pre-cut wafer, the patient or caregiver needs to measure the size of the stoma using the measuring guide found in most commercially prepared wafer products, keeping in mind the opening needs to be 1/8-inch larger than the stoma. The size is selected and applied without making any changes to the wafer.
The cut-to-fit wafer needs to be cut to the correct size before use. The person can size the wafer each time a new one is applied, allowing for more accuracy regarding the stoma opening with each application. To use this wafer, the patient needs to determine the size of the stoma using the measuring guide. The selected hole size of the measuring guide is centered on the wafer. The patient or caregiver traces the hole on the wafer in the center of the flange with a marking pen. The wafer is cut along the pen marking as the guide, adjusting for irregular areas of the stoma.
Another wafer option is the convex style. If the stoma is flush or retracted, the use of convexity will help achieve a better wafer adherence. The convex wafer presses into the tissue around the stoma, which increases the degree of stomal protrusion and reduces the risk of undermining. Disposable wafers are available with convexity that ranges from shallow to deep. Convex inserts (plastic rings that fit inside the flange of the wafer) are sized according to the stoma assessment.
Assessing the Stoma and Peristomal Skin
The stoma and peristomal skin need to be assessed for abnormalities and treated according to the findings. Assessment of these areas should note the following:
* Color and turgor of the stoma. The stoma should be red and moist. A pale pink may indicate low hemoglobin and a dark red may indicate bruising, or ischemia (especially immediate post-op) (see Figure 1).
* Stomal height. A stoma that is at or below skin level can cause pouching problems because a good seal from the wafer is more difficult to obtain. Stool coming out of the stoma opening has a greater chance of going under the wafer, which can result in skin irritation and leakage. This stoma style would be appropriate for a convex wafer (see above).
* Location of the stoma. Proximity of the incision, waistline, abdominal folds or creases, and boney prominences to the stoma will be factors when pouching is performed.
* Post-op assessment of the mucutaneous suture line. Any separation at the suture line or any allergic reaction to the suture material should be noted.
* Intact and healthy peristomal skin. Skin damage such as erythema, maceration, denudation, rash, ulceration, or blisters should not be evident.2 If signs of a fungal infection (a red rash and sometimes "weepy" area) are noted, treatment may be necessary. Antifungal powders should only be used if candidiasis has been diagnosed. The powder is sprinkled sparingly over the area before applying the wafer. The wafer may need to be changed sooner than the recommended time of 5 to 7 days to assess the area (see Figure 2).
Selecting the Pouching System
Different pouching system options need to be considered based on the person's stoma, peristomal skin, and preference. Several options are available (see Figure 3). The one-piece pouch system (the adhesive backing and pouch are connected and cannot be removed from each other) offers some people a sense of security because the components do not come apart. This also offers a more flexible backing that can be an advantage to the person who has a peristomal hernia or abdominal fold near the stoma. One-piece systems also may have a convex wafer built into the system.
The two-piece pouch system (the wafer and pouch are separate) allows the pouch to be easily removed for emptying or to view the stoma for problems.
Other options include filtered and non-filtered systems. The filter is located at the top of the pouch and allows flatus to pass through a charcoal layer so gas may be vented without an odor. This is helpful for some people who have excess problems with flatus. The non-filtered system does not offer this feature.
Non-disposable pouch systems are also available in a degree of convexity. These are heavier and more durable because of the material used in the construction. Whatever system of convexity is used, the stoma needs to be measured and correct size determined with the 1/8-inch clearance around the stoma to prevent stomal damage.
Some accessories are useful for some people but a necessity for others. Belts and binders are indicated for a person who has a flush or retracted stoma. These products help hold the wafer securely against the abdominal wall. Belts are specifically designed to attach to the pouch system at the 9 o'clock and 3 o'clock positions. Binders are available in widths ranging from 2 to 6 inches. They have a Velcro® closure and can be customized to have the pouch opening at the center, top, or bottom of the binder. For some people, these products are not necessary because the stoma is above skin level, but they may feel more comfortable with the added protection of these devices.
Skin barriers such as paste, strips, or rings are also helpful for a person who has a flush or retracted stoma or if the person has creases or dips in the area where the wafer should adhere. The advantage of these products is a better seal of the wafer to the skin. If one of these products should be used, it can be applied directly to the abdominal skin where the crease or dip is located or around the stoma (making a thin ring around the stoma) before applying the wafer. Another option is to apply the paste around the opening of the wafer itself (easier for the patient) (see Figure 4).
Application of the Pouching System
1. Gently remove the old system by pushing down on the skin as the old wafer is lifted off the abdomen.
2. Save the tail closure of the old system for the new system.
3. Gently cleanse and dry the stoma and surrounding skin with water and a soft cloth or paper towel.
4. Cut the new wafer 1/8-inch larger than the stoma. (This step can be performed before Step 1 if the size of the stoma is no longer changing - usually 6 to 8 weeks after surgery).
5. Apply skin sealant to the skin around the stoma where the wafer will be placed. After the sealant is applied, air-dry the area before applying the wafer to avoid an irritation on the skin.
6. Apply the wafer to the area around the stoma. Make sure the abdomen is flat before applying the wafer. The patient can stand or lie flat to allow the area to become flat. As you put the wafer on the skin, make sure the stoma comes up through the hole that had been cut with an even amount of room around the stoma (see Figure 5).
7. Apply even pressure by pressing a finger on the wafer, going around the stoma inside and outside of the flange to help the wafer adhere to the skin.
8. Connect the pouch to the wafer by sealing the plastic circles together until a click is heard. A gentle tug on the pouch will ensure it is secure.3
9. Apply the tail closure to the open end of the pouch. The closure is placed on the opened end of the pouch and turned up once before closing it until a click is heard.
When to Notify an MD/ET Nurse
Clinicians should review with their patients information about specific times when a person with a colostomy should follow-up with a physician or an Enterostomal Therapy nurse. The patient should contact a professional if the following occur:
1. An increase in pain of the abdomen or incision, fever, redness, or drainage of the incision
2. Change of bowel habits - diarrhea or constipation
3. Skin irritation that is not relieved by proper fitting wafer application
4. A hernia is noted. This may appear as a bulge around the stoma
5. Problems obtaining a good seal of the wafer (eg, if the wafer does not stay sealed for at least 5 days without leakage)
6. A different type of pouch system is desired or if questions arise concerning the system already being used.
7. Medical follow-up should occur as the surgeon requests (usually 2 weeks after discharge from the hospital, 6 weeks, 3 months, 6 months, and 1 year).2
After instruction was completed, Mrs. J stated, "I'm so glad that is all there is to it. I have been so worried that it would be so complex that I would not be able to do the care myself." Mrs. J was eager to learn and she accomplished a great lesson - not just the care of the colostomy but also the fact that she had control over her life again. Teaching restored her independence and confidence. As her clinician, I was glad to be a part of that lesson. - OWM