Case 1. Ms. A, a healthy 75 year old, developed an intestinal obstruction and had surgery with construction of a descending end colostomy. Upon discharge from acute care, she went to her son’s home to recuperate and was followed by a home health agency. She used a 1-piece transparent flat pouch. Her daughter-in-law managed her ostomy care, but Ms. A wanted to be independent so she could return home as soon as possible. At 6 weeks postop, she had a slightly irregular, oval, moist, red, bud stoma, 1 inch long x 1¼ inch wide. Her bowel movements consisted of formed stool, once daily. Her peristomal contour was flat when she was supine, sitting, and standing.
When Ms. A tried to learn ostomy care, she had difficulty cutting the pouch opening to the shape of her stoma and also had difficulty seeing well enough to correctly position her ostomy pouch around the stoma. She often placed the pouch on a portion of the stoma mucosa, which caused premature leakage and required more frequent pouch changes.
Interventions and outcome. The CWOCN instructed Ms. A to place a barrier ring on her skin close to the stoma (see Figure 1a). Mrs. A could check placement of the ring with a mirror and if it was not positioned correctly, she was able to lift and reposition it without difficulty until the peristomal skin was completely protected with the ring. A round, 1¾-inch opening was cut in the pouch. Because the peristomal skin was protected by the skin barrier ring, exact placement of the ostomy pouch was not critical. The enlarged opening on the ostomy pouch could be placed anywhere on the skin barrier ring, as long as the stoma was not covered (see Figure 1b).
Using this technique, Ms. A quickly became independent in her ostomy care and no longer had to depend on her family for assistance. She moved back home and was able to independently change her pouch twice weekly using a 1¾ inch precut pouch, which made the process even easier.
Case 2. Healthy, 65-year-old Mr. B presented to the WOC nurse clinic at a community hospital. He was post radical cystectomy and had an ileal conduit/Bricker urinary diversion for bladder carcinoma. This surgery had been performed at a nearby medical center; his pouch — a convex pouch with an opening 3/32 inch larger than the stoma, with an integrated extended wear skin barrier backing and a belt — had been selected immediately postoperatively by the Center’s WOC nursing team. His wear time was 3 days or less. His chief complaint was discomfort from the rigid faceplate and belt.
On examination, Mr. B was noted to have a 7/8 inch round x ¼ inch high stoma that was hidden in a skin fold when he was in the sitting position (see Figure 2a). The stoma could only be visualized if the skin fold was lifted (see Figure 2b).
Interventions and outcome. The CWOCN instructed Mr. B and his wife to cut a flexible pouch with a transparent film backing 1 inch larger than the stoma size, apply skin cement to 2 inches on the skin around the stoma (see Figure 2c) and 1 inch on the pouch around the opening (see Figure 2d); wait for the cement to dry; and apply the pouch over the stoma (see Figure 2e). Mr. B returned to the nursing clinic 1 month later; he was able to wear the new pouch for 7 days. He had no leakage and his skin was intact. Mr. B immediately noted increased comfort without the convexity and the belt. He was able to decrease the cost of his pouching supplies from $125.77 to $38.31 per month.
Case 3. Ms. C was a 94-year-old woman with a loop colostomy for 7 months due to a ruptured diverticulum. She was considered a problem resident by the staff at her assisted-living facility (ALF) because her ostomy pouch usually required twice-daily changes. The staff insisted that she picked at the pouch, loosening it and causing it to leak. She also was followed by a home health agency. The staff always performed her ostomy care when Ms. C was supine. In this position, the stoma was 1¾ inches long x 1¾ inches wide, slightly raised, moist, and red, with a flat peristomal area (see Figure 3a). When the CWOCN asked Ms. C to sit and stand, she developed a large peristomal hernia that significantly enlarged the size of her stoma to 3½ inches long x 2½ inches wide, with a depression at the 6:00 o’clock position where the appliance usually leaked (see Figure 3b). Ms. C had peristomal medical adhesive-related skin injury (MARSI) because the enlarging hernia caused skin stripping from the adhesive on the pouch backing. The MARSI caused itching that Ms. C frequently scratched. Additionally, her enlarged stoma extended beyond the wafer opening, so moisture from the stoma mucosa weakened the seal. The challenge was to find a flexible large appliance to accommodate the changes in stoma size and abdominal contours that occurred with position changes.
Interventions and outcome. The CWOCN for the home health agency arranged for a meeting with the ALF staff in the patient’s room to educate them on changes to the pouching procedure. Using a large, 2-piece pouch with a flexible adhesive flange, an opening was cut to the size of stoma that expanded when sitting or standing (see Figure 3c and Figure 3d). Skin barrier powder and a moisture insoluble skin barrier were applied in 3 alternating layers to the exposed peristomal skin for protection. A skin barrier strip was molded and tapered to the back of the pouch at the 6:00 o’clock position to accommodate the depression that developed with position change.
Using this new procedure, the ostomy pouch was changed every 3 days by the ALF staff. The peristomal skin remained intact, and Ms. C did not disturb the pouch. The MARSI and peristomal itching resolved, so Ms. C stopped scratching her skin. She was no longer considered a problem patient by the ALF staff.
Case 4. Seventy-five-year-old Ms. D was undergoing treatment for metastatic ovarian cancer. Following her complicated surgery (that included colon resection), she returned home with a heavily draining enterocutaneous fistula and instructions to change an ABD pad dressing 6 times a day. The dressing change was very time-consuming and painful due to skin breakdown from the liquid effluent and frequent tape removal. Attempts to use a pouch with the opening cut to the size of the fistula consistently failed within a few hours after placement. The liquid effluent followed a depression in the skin and broke the seal. Like many fistulas, Ms. D’s had deep crevices in her skin from scars, and irregular perifistula abdominal contours had developed as the wound healed. Ms. D depended on her family and a caregiver to provide her care.
Interventions and outcome. Although fistulas are not ostomies, clinicians use the same products and principles to contain effluent. The home care CWOCN instructed the caregiver on how to protect the perisfistula skin using 3 alternating layers of skin barrier powder and a moisture-insoluble skin barrier (see Figure 4a) and using skin barrier paste and strips to fill the perifistula creases (see Figure 4b). A fistula pouch was cut with the opening large enough to bypass the numerous creases and depressions surrounding the fistula. Skin barrier paste was placed around the pouch opening, and the pouch was applied to the level perifistula abdominal plane (see Figure 4c). Mrs. D’s paid caregiver, who came to her home on weekday mornings, quickly learned the pouch change procedure as instructed by the CWOCN. Ms. D’s fistula pouch was changed Mondays, Wednesdays, and Fridays without leaking. Ms. D appreciated the extra time she had to spend with her family and her improved quality of life.
Case 5. Ms. E, 62 years old, developed a pelvic mass and was diagnosed with metastatic ovarian cancer. She had surgery for a total hysterectomy, colon resection, and colostomy with a Hartman’s pouch. Her postsurgical recovery was complicated by pleural effusion and respiratory failure. Ms. E was admitted to home care services 3 months post op with some memory deficit. She had a very stenosed stoma in her right lower quadrant that measured ¼ inch long x 3/8 inch wide, and her stool was liquid to mushy. Her peristomal area was flat when she was supine, but her stoma retracted with sitting and standing. Ms. E used a 2-piece, flat transparent pouch; she could remember to change her pouch every 3 days but she had difficulty comprehending that her pouch should be changed if the seal loosened, which was usually 1 day after a new pouch was placed. Consequently, she had peristomal skin breakdown from stool leakage.
Interventions and outcomes. Ms. E’s care involved several factors: her difficulty comprehending that she needed to change her pouch when it leaked, the potential for pouch leakage from forceful evacuations due to the stenosis,14 and a retracted peristomal plane around the stoma with position change. The CWOCN instructed her to protect her peristomal skin with skin barrier powder and moisture insoluble skin barrier, then cut her pouch opening to 1¼ inch round. The larger opening allowed for any potential increased force or volume of effluent and bypassed the retracted area that caused stool to leak under the wafer during position change. In addition, the larger pouch opening was easier for Ms. E to place. She continued to change her ostomy pouch every 3 days, and there was no leakage. Her peristomal skin healed, and she became independent in her ostomy care.