For more information and questions about Ileostomy visit our Forum.
Included in every package of ostomy supplies are instructions on how to apply that particular prosthetic devise. Over time people develop their own way to change the appliance most effectively. We have obtained some additional descriptions from our members that we hope may benefit you. We present information regarding the newer adhesive barriers only. Non-adhesive systems, which are an alternative for less active people, have there own set of issues which are not specifically discussed here.
Make sure your skin is dry. Today's modern barriers will not stick to moist skin. If your skin is healthy, and you have just washed the peristomal skin, many dry it using an ordinary hair dryer set to blow cold. Always be extra careful when using any electrical device around water because of the potential for serious injury due to electric shock. Cold air should dry the skin and close the pores leaving you ready to apply the barrier.
Most ET nurses do not recommend washing the peristomal skin with soap. It leaves a drying film, removes valuable nutrients from you skin, and will increase skin irritation and itching. Companies do manufacture special washes for this purpose for those with special needs. Wash your skin with clean water only. This is all that is usually needed. Clean dry skin without any soap residue is the best environment to apply the barrier.
There are many different skin types like oily skin, sensitive skin, dry skin, damaged skin. You must prepare your skin in the way that will best suit your exact skin type. There is not one best way of doing this, and this is an important point to make. We want you to realize there are many alternatives available. ET's and dermatologists are experts that should be used to obtain optimal results. We do not recommend self-diagnosis of serious or persistent conditions only self-education.
If you have a problem with your skin, treat it first. If your skin is moist due to an irritation, ostomy powders like Hollihesive or Stomahesive are made to dry the skin so a barrier will stick.
If there are red dots on your skin, you may have a fungus infection. We all get these. Your ET or pharmacist can recommend a micro-granulated anti-fungal powder and show you how to use it. This will usually clear up the infection.
There are creams that are made to help with adhesion and/or mild skin irritation from barrier chemicals. Never use anything that leaves an oily film. The barrier won't stick like it should to oil, chalk or greasy creams.
If you just had surgery, you have chemicals temporarily in your body that will cause you to itch, especially skin covered by a barrier. Although there are situations where one has an allergic reaction to a product, most of the time it is our own bodies causing the problem. You will probably notice a sensitivity to certain products at various times during your new life. This is normal.
There are many of good products on the market. Try them. There is a plethora of ideas on how to solve minor skin problems that if left untreated will make you miserable. See a dermatologist. They have easily implemented solutions for most of these problems. Don't accept anything less than perfect, un-irritated peristomal skin. In most circumstances, ET's and doctors will help you find alternatives that will greatly improve your life.
Measuring Your Stoma:
Measuring your stoma correctly is important. Use the guide provided in the product package, or make your own. Stomas come in many different shapes. Some are perfectly round with a one inch diameter and one inch long. They may be three inches around or a half inch, oval in diameter, mushroom or pear shaped in length, protracted or recessed. Some are sitting next to scars, hernias, fistulas or ulcers.
The goal is to cut the barrier opening as close as possible to the stoma without actually touching it. This is harder than it sounds. You may cut the perfect opening in the barrier, put it on just a hair crooked and have it touching the stoma. The barrier may cut the stoma, or give you an uncomfortable feeling, or pinch you.
People will sometimes complain about stoma pain. The stomas has no actual sensing nerves and cannot hurt as such, but the barrier may push on it and hurt the skin attached to it. The peristomal skin is extremely sensitive. When the stoma moves, it effects the attached skin. Having a barrier in contact with it restricts its movement and may hurt you. Of course, smashing it with clothes that are too tight sometimes hurts it. In fact, some people use two-piece systems because the flange protects the stoma to a certain degree from being smashed. Most of us cut the barrier a little bit bigger than the exact stoma size, 1/8 to 1/4 of an inch, to give us a margin of error.
The newer, extended wear barriers, ConvaTec's Durahesive and Hollister's Flextend, will actually swell around the stoma with an extremely soft substance to fill in any gap. All other hard barriers, meaning those with adhesives that melt, use a paste or other product to fill in the gap.
Even extended wear products benefit from paste because they fill in the gap until the barrier swells. Those with a nearly flat or recessed stoma may benefit from convexity. The barrier is made to push down on the surrounding skin helping the stoma to protrude. A protruding stoma works better because the discharge from it is directed more easily into the pouch. Many use a belt when using a convex barrier to secure it. It is under pressure and may pop off. The ostomy belt keeps it secure.
Now your skin is clean and dry, and your barrier has been selected and cut to the size desired. If you use a two-piece barrier with a rectangle shape, rotate it every time you apply a new flange. Try to avoid covering the same skin. Paste may be applied at this time. Paste is actually caulk. It is especially made to fill indentations on the skin, fill imperfections around the stoma, and mostly to protect the skin in-between the barrier and the stoma. Paste is made chemically neutral to be extremely non-irritating. Coloplast, ConvaTec Stomahesive, Hollister Karaya and Premium pastes are examples of quality products you could use regularly.
When applying paste to protect peristomal skin, you may apply the paste on the barrier first. This would be a thin bead, about 1/8" in diameter, around the stoma opening only. Never spread paste around like paint on the barrier or your skin. It is not made to be a base for the barrier and will cause unsatisfactory results if used this way. Some place the paste in a thin bead around the stoma itself. This works great, but there may be occasional, momentary stinging because of the alcohol carriers used. These solvents are made to evaporate quickly. Let the paste set up a minute before applying the barrier.
Companies are offering seals to apply before the barriers. Some of these can be molded exactly to your skin contours right up to the stoma. These are presented as alternatives to people who are having problems with wear time, leaks, skin irritation, etc. ConvaTec, Eakin, and Hollister all have seals for special needs. Remember, you can always contact the ostomy manufacturers directly. We have found them to have on staff leading experts who are happy to help with your individual circumstances. If you are in pain or uncomfortable, call someone immediately. If he/she cannot assist you, he/she is sure to refer you to someone else. Your probability of having a satisfactory prosthetic is very high. Don't settle.
Paste is made to be extremely non-irritating. Although each type has its own chemical composition, it should not cause a reaction. If it does, try another type, it may work fine. All pastes contain solvents to keep them soft. They have essentially an alcohol base. This may sting your skin when applied directly to it. It is minor and passes quickly as it dries.
If you fill deeper depressions from on the skin surface, it is recommended to layer the paste. Paste will start to set up in about a minute. Additional layers may be added as each preceding layer sets. As a practical tip, dampen your finger or wet the tool used if you tap the paste into place. This will help prevent the paste from sticking to your finger or tool. Otherwise, you will have paste all over everything within reach.
At this point, paste becomes a cement which attaches to anything dry. It is frustrating when paste is sticking to things it shouldn't. Recap the paste tube immediately after use to prevent it from drying out and becoming hard. For those of you extra sensitive to any stinging from the alcohol carrier, Coloplast Paste contains no alcohol, does not burn, and does not dry out as easily in the tube. It is a bit firmer in texture than the others which may offer longer wear time but be more firm around the stoma.
Powder is used to treat irritated skin or a fungal infection. Yeast (fungal) infections are very common, especially in the summer or when you perspire from regular exercise.
Micro granulated anti-fungal powder is used only when there are signs of a yeast infection present; i.e., an itchy rash, raised red bumps. Discontinue use when the fungus infection clears.
Powders with a pectin base—like Holihesive or Stomahesive—or karaya type powders are used to treat irritated skin.
To apply any powder: Clean the peristomal skin well with plain water and dry. The skin should be completely dry before applying the powder. Dust the skin with the powder, gently rub it around and then brush off any excess.
The barrier can be applied directly over the powder. You may also seal-in the powder by applying a skin sealant over the powder and allowing it to dry. Be careful…skin sealants retard the adhesion of the new extended wear barriers and are not recommended. The barrier is applied over the sealant covering the powder.
Powder is not needed routinely. Most modern, disposable barriers are designed to adhere to the skin by themselves. But keep some powder on hand for when you do need it.
Applying the Barrier (flange):
Now the paste is on, your skin in dry, and you're ready to apply the barrier. When using a two-piece system, most put on the barrier first without attaching the pouch because you can see how the stoma is placed better. Your body should be in an extended position. This means standing up if possible.
Wheelchair ostomates may place it on in a sitting position, and still receive excellent results because their limited mobility won't stretch the barrier like it will with walking people. Place the barrier over your stoma very carefully. Try and center it the best you can. Press it down gently upon your skin. A barrier is made special. You probably noticed it doesn't seem too sticky. It is made to melt onto the body. So if you put it on and it doesn't seem to be sticking, yet your skin is dry, just hold it in place for a while. Your body will warm the adhesive and you'll find it sticks just fine.
If there is tape on the barrier, make sure it doesn't fold back on itself. It ruins the barrier if it does. The instructions say to make sure the tape is not wrinkled, but this is sometimes hard to do. Depending on the hardness of the attached tape, manufactures make a variety of high quality tapes for ostomy appliances to be used for individual preferences, wrinkles can straighten out by themselves. Other tapes may actually cut the skin if put on wrinkled because of their hardness.
Some of the hard tapes actually have less irritating qualities than soft porous types. New appliances take a little time to set so the adhesive heats to your body temperature and adheres well. If you get red bumps or a rash under the tape, you may be having a reaction to the tape. You may react to a manufacturer's tan tape, because of the dyes, and not to the white tape, without dyes. Some manufacturers produce barriers without tape. We have member's that cut the tape off the barriers and use them plain. But be careful, if you are active you may need better protection and not less.
If you use a one-piece drainable ostomy system, you need to be careful when you put it on so that it is in the correct position. A few people like the pouch to hang straight down. Men especially find if the pouch is tilted outward a bit, it doesn't poke sensitive areas. Two-piece users make this decision when the pouch is snapped onto the barrier's flange.
Manufactures have different types of clips to secure the bottom of drainable systems. Don't worry about them falling off, if you use them correctly. Always wrap the tail piece only once around the clip so you don't spring the clip. This technique is demonstrated in every manufacturer's directions.
Change the clip every month as needed. Manufacturers include a clip for every 10 pouches, which is usually about a month's worth. Don't be too concerned. Some people get up to a year out of clip without problems. Use the correct clip on each particular brand. e.g. Convatec makes a clear pouch that is thin and slippery. If you use a two month old clip that you were using on a Hollister pouch, which is made with a heavier material, it has a good chance of slipping off.
When you put on a clip, be sure you take the extra second to make sure it secured correctly. Have the clip as high on the tailpiece as you can without clamping any comfort material that may be on it. Tug on the clip while holding the pouch. If it slips, it may fall off. If it doesn't slip, it will stay put. Don't take a chance.
Centering Your Barrier
A well-fitted barrier does not allow for much margin of error. Consider this: The correct opening size is determined by measuring your stoma's diameter or ellipse with a measuring card and adding about 1/16 to 1/8 of an inch depending on the type of wafer you use; e.g., Durahesive vs. Stomahesive. This means that your barrier must enter exactly and carefully every time.
How do you do this? Good lighting is important, preferably from both above and the side. If you are able, stand sideways to the light source for better visibility. A wall or hand mirror is a help to see that the barrier is applied straight.
Also, a pouch that is applied crooked may exert uneven pressure on the skin and stoma, and may lead to trouble. Although, many men wear their pouch to the side to avoid injuring sensitive areas with excellent results. Even more care needs to be taken when using a one-piece appliance.
Don't rush. Take your time to check the placement carefully before allowing your skin barrier to make contact. No time is saved if you must do the whole thing again because the barrier is crooked, touching the stoma or just plain uncomfortable.
Remember, if your barrier feels out of place, hurts or is uncomfortable … take it off. Don't wait for an injury to occur or suffer with an poor application. It is better to change unnecessarily than to risk damaging the precious stoma or living in pain. You have to live with your stoma for a long time so make it as comfortable and irritation free as possible.
Those First Few Changes
Zinging through another change of appliance the other day my mind wandered, as it often does when I am doing some routine chore. I’ve had an ileostomy for more than ten years and have gone through more than 600 appliances. I use the typical two-piece ostomy system with a flexible, adhesive wafer that sticks nicely to my abdomen.
What I recently thought about was a problem I had with my first few appliances—getting the old one off. To work correctly, the wafer must stick really well; otherwise, it will come loose and make a mess, usually at the worst time and place. The problem I encountered was that it hurt to pull off the used wafer.
I still remember the first one I had to remove. It was only a few days after surgery, and the nurse came in to teach me about changing the appliance. After she left, I went to work. But, every time I tugged at the wafer, it hurt like hell, just like pulling a giant bandage off tender skin. It took a half-hour ouching the whole time. I was extremely depressed when I finally removed the old barrier.
“How am I ever going to live with this?” I thought. Nowadays, removing the wafer takes about three seconds and is so routine there’s almost no sensation; in fact, my problem is keeping my mind on what I am doing. One detail that has made a big difference was a tip from my nurse, “Instead of grabbing the wafer and pulling on it, you hold one edge in one hand and push the skin away with the other hand.”
Believe me ... it works. The reason I am writing this note is to reassure all of you who are just starting out with an ostomy. Every appliance you change will get easier, and the pain of getting each appliance off your tender skin keeps getting less and less. Stick with it—with a little perseverance, you will overcome this minor obstacle.
Some people will have scars from surgery or skin folds that are right under the wafer. These issues can sometimes be handled by applying paste to the area. The goal is to cover this area so the wafer may be laid flat. If the wafer is flat it will perform better.
New products such as Durahesive Wafers, Eakin Seals and Hollister Flextend Rings provide a more durable alternative for these applications. These barriers may be used under a wafer to fill in gaps so that the chance of leakage from around the wafer is reduced. These seals are not recommended for normal applications, but for people who have challenges providing a flat even surface for the wafer. If you have smooth skin to apply the wafer, these products may not offer you any value.
Paste may be applied as a caulk between the stoma and wafer. Most people benefit from this application. Put a thin bead, about 3/16", either around the hole in the wafer or around the stoma itself. Paste may actually touch the stoma. It is made so soft that it should not cause any damage from abrasiveness.
This allows you to have a slightly larger opening in the wafer, and makes it easier to apply the wafer without it touching the stoma. You never want to do this. When you apply the wafer, press down gently to allow the paste to fill in all the gaps. If you use a two-piece system, you should make sure the paste is nicely presses around the stoma on the inside of the wafer.
This will improve comfort and wear time. Some people found a wafer lasts them longer than the paste. The paste usually melts in a few days. They clean it out and use new paste. This involves removing the pouch, using something like a Q-Tip to thoroughly clean the skin between the stoma and the wafer, and then applying a new coat of paste.
This application is used for hard wafers only. The newer extended wear appliances will "turtleneck" around the stoma so that paste is not needed. Paste is only used on these new wafers when they are first applied, to fill the gap between the wafer and the stoma. Once the wafer swells there is no longer a need to fill a gap because there isn't any.
As with any ostomy product, it is recommended to discuss all applications with your ET. They will be able to provide a knowledgeable interface to develop an ostomy system that will offer you the best performance available.
Too Much of a Good Thing
Do you need an hour and a half to change your ostomy system? Does your stock of supplies resemble the store front of the local pharmacy? Do you need a road-map to remember what product goes on first, second, etc.? If so, you may be the victim of the “too much of a good thing” syndrome.
Occasionally, an individual will come to a stoma clinic carrying a large sack with a vast array of skin care products. He/she explains, “all these items are needed in order for me to apply my appliance”.
Unfortunately, the reason he/she usually needs assistance is due to a problem with the adhesion of the barrier—usually due to scars, skin folds or weight changes; skin irritation or skin breakdown. One particular gentleman who comes to mind was utilizing a special skin cleaner and cream, two types of skin cement, a double-faced tape disc, a paste and a popular skin-barrier wafer before the pouch was applied.
He had started out with a fairly simple ostomy system right after surgery. However, in his quest to achieve what he felt should be a seven-day wearing time, he had been adding product after product. Besides the many items he was now using, he had what he described as a “closet full of products at home”.
After checking his abdomen, it became obvious that what he needed was a product change in the convexity of his barrier and not the addition of another product. He also needed a more realistic view of wearing time for his particular situation.
Practically speaking, not everyone may be able to achieve a seven-day, leak-free wearing time with no skin irritations. It is much better to anticipate leakage and establish a regular changing time prior to this. You know, there are ostomy systems for colostomates designed to be changed in about 30 seconds, whenever full—even several times a day. Europeans prefer this method. Here are a few hints to remember to help achieve a successful ostomy management system:
Keep it simple. Do not use extra cement, skin-care products or whatever unless medically necessary. Usually, extra products actually interfere with barrier adhesion or create skin problems—especially with the new extended wear systems. And as far as washing your peristomal skin, plain water is still the best cleaning agent.
Do not continue to use therapeutic products after a problem has been solved. As an example: A steroidal cream and an anti-fungal micro-granulated powder should not be used routinely when changing the barrier. These products are prescribed for particular skin problems. A steroidal cream is usually recommended for its anti-inflammatory effects, chronic skin itching and systematic relief of the discomfort associated with skin irritation.
However, continued and prolonged use of steroidal creams after the problem is resolved may lead to thinning of the outer layer of skin. This will lead to a greater susceptibility to skin irritations. Also, stop using an anti-fungal powder when the fungus—also called a yeast infection—is gone.
Defective Ostomy Products
There is a possibility that someday you will come across a defective ostomy product. If you ever do, it will probably be a pouch with a leak in it. You will usually not discover the leak until you find it has soiled your clothing.
If this ever happens to you, don’t get mad. Change your defective product with a new one yet save the defective one. Clean the defective item thoroughly and put it in a plastic zip-lock bag, Using a permanent marker—like a felt-tip pen—mark the area where the problem is located. Attach a detailed note explaining the problem and mail these directly to the manufacturer.
It is normally not a good idea to return a defective product to the place where you bought it. Your retailer may not handle it efficiently and may find it cheaper to just refund your money or exchange the defective product and then throw the item away. Or, he may keep it on a shelf for months until enough items have been accumulated to make a return shipment to a manufacturer cost effective.
In the meantime, the manufacturer may continue sending out defective items without knowing it. Make no mistake, most manufacturers of ostomy products want to produce the highest quality item possible. They take defective products very seriously, if they know about them. They will not allow a defective product to continue to be distributed. They will fix the problem.
For speedy action and to help prevent other ostomates from running into the same problem in the future, the best action is to go to the manufacturer directly to report defective products.
Factors Affecting Ostomy Function
Ostomy function may be changed by a variety of medications and medical treatments. This is common. The following are examples:
Antibiotics—These often cause diarrhea, even in patients without an ostomy. Make sure your doctor knows about your ostomy, and inform him/her of problems as they occur. Drink plenty of liquids and drinks which will help maintain your electrolyte balance if diarrhea strikes.
Pain Medications—These are often constipating. Extra irrigations or laxatives or stool softeners might be required for colostomates to combat the side effects of pain medications. Perhaps the dosage of pain reliever may be reduced to eliminate the situation. Again, be sure to drink plenty of liquids.
Chemotherapy—Many cancer patients have follow-up chemotherapy after surgery or as an alternative to surgery. that often produces nausea and/or vomiting. You need to drink fluids that help you maintain your body chemistry balance.
Radiation Therapy—This often produces the same effects as chemotherapy.
Travel—Travel may cause constipation in some people and diarrhea in others. Be aware of that these are possibilities. Altered diet when traveling accounts for some of this, plus the excitement of new surroundings. Allow sufficient time for irrigations and take along an anti-diarrhea medication.
Antacids—Some types of antacids may cause diarrhea—usually those with magnesium. There are many fine new products on the market. Find out which is best for you.
Drink plenty of liquids. You need to maintain your electrolyte balance in case of diarrhea. Tea, orange juice and even Coca Cola are sources of potassium. Bouillon cubes mixed in hot water are a source of sodium. Remember that some of the signs of electrolyte imbalance are irritability, nausea and drowsiness.
Common Questions Asked of ET’s
Question: Do you think it is a good idea to rinse out my colostomy pouch when I empty it?
Answer: I usually teach my patients the proper procedure for rinsing the pouch when emptying it, but leave it up to them if they want to continue to rinse or not. By proper procedure, I mean rinsing the pouch up to the level of the bottom of the stoma.
I find sometimes people rinse the pouch too vigorously and cause the adhesive seal around the stoma to loosen from the inside of the pouch and introduce water at the seal. Some people feel more comfortable using an opaque colored pouch and not worry about rinsing it at all.
Again, I think it is a personal preference with what you are most comfortable using. Many people get along just fine without ever rinsing the pouch.
Question: I have a urostomy, and my urine always looks cloudy. Is this anything to be concerned about?
Answer: If you have in ileal conduit or a colon conduit, remember—our urine will have mucus from the piece of intestine used to create the stoma. Sometimes this causes the urine to look cloudy. This is perfectly normal.
As an aside, if your adhesive is breaking down faster than usual, or your urine has a strong odor not caused from any foods which create their own special odors, you may have an infection. If you have a suspect an infection, you need to see your regular doctor—who may refer you to a urologist. A urine culture sample will then be taken to verify if an infection in present.
Question: What can you suggest for a deodorant to use inside the pouch?
Answer: Usually, ileostomy or urostomy output does not have much odor. For a colostomy, one might want to use a deodorant. There are many commercial deodorants available for use in the pouch or taken internally. They are available in liquid or tablet form. Years ago, aspirin was recommended to use as a deodorant in the pouch. Aspirin is not recommended any longer. It was found that it causes pinpoint bleeding of the stoma if it washes up onto it. Plus, it has not been shown to be effective in odor control. Probably, using a good room spray before opening the pouch could be partially effective. Remember, everyone with or without an ostomy has odor in their stools.
What’s Normal for Your Stoma
What is normal for my stoma? This is a frequently asked question. Here are some answers from your stoma to you:
My color should be a healthy red I am the same color as the inside of your intestine. If my color darkens, the blood supply might be pinched off. First make sure your pouch is not too tight. It should fit 1/ 16 to 1/8 inch from the base of the stoma—although the new extended wear barriers like the Hollister Flextend and the ConvaTec Durahesive may touch the stoma. If I should turn black—very unlikely but it does happen occasionally—seek treatment at once. Go to your local hospital emergency room if you cannot readily locate your doctor. Be sure to remove the pouch for them to examine the stoma and peristomal skin. Always take at least one extra change of system along.
I might bleed a little when cleaned. This is to be expected. Do not be alarmed. And please, just be gentle when you handle me. If I am an ileostomy, I will run intermittently just about all the time and stool will be liquid to semi-solid.
If you should notice that I am not functioning after several hours and if you develop pain, I might be clogged. Try sipping warm tea or taking a little mineral oil and then try walking or getting into a knee-chest position on the floor. Sometimes a hot shower with your barrier removed will relax you enough to loosen the obstruction. If I do not begin to function after about an hour of this, call your physician. If you cannot locate him/her, go to the emergency room. In the meantime, I might have begun to swell. Remove your barrier and put on one with a bigger opening.
If I am a colostomy located in the descending or sigmoid colon, I should function according to what your bowel habits were before surgery. I can be controlled in some cases with diet and/or irrigation. This is a personal choice. There is no right or wrong to it, as long as I am working well, my stool will be fairly solid.
If I am a urinary diversion, I should work constantly. My urine should be yellow, adequate in amount and will contain some mucous. If my mucous is very much more excessive than usual, I might have an infection. I will probably also have an odor and possibly a fever. Consult your physician if that is the case. If at any time, you doubt that your stoma is functioning normally, please seek help ... call your ET. The cause needs to be evaluated. If your problem is a serious one, it needs correction. If it is not, you will be relieved to know your stoma is alive and well.
Note: If you do not have an ET, find one before you ever need help. Have his/her phone number in your wallet at all times—just in case. In addition, you should see your ET every year or two or three to have your stoma examined.
Apply and change a colostomy bag.