Ostomy Care - Selecting an Appliance

The selection of appliances for ostomy care is based on a few basic principles:

• odour-proof
• leak-proof
• protects the peristomal skin from stool and trauma, irritation
• protects the stoma from damage
• promotes independence and comfort

Selection must also take into consideration how the stoma is constructed, what the surrounding skin and abdominal contours look like, the consistency of the stool, and the cost and availability of the product.

Ostomy appliances can either be a one-piece or two-piece system. In a one-piece system, the barrier, "sticky" portion, and the collection pouch are attached to each other and cannot be separated. In a two-piece system, the barrier portion (flange) and the collection pouch are two separate pieces and are connected by some sort of a locking mechanism. The flange and pouch can be separated. There are "pros and cons" to each system, and these can be discussed with an Enterostomal Therapy Nurse.

Stoma type and construction, body contours, personal capabilities (hand strength, eyesight, etc) and preferences will all contribute to the choice of appliance. Certain aspects such as stomal type and construction may dictate and limit product choices, but usually there is some degree of choice for an individual with an ostomy. After surgery, the selection process should be done with an Enterostomal Therapy (ET) Nurse. Subsequent changes should be done in consultation with an ET to ensure that unnecessary problems and expense are avoided.

Considerations

There are several considerations to make when selecting appliances.

Barrier Type

Two types of barriers exist: regular and extended wear. The barrier is fundamental to appliances since this is the substance that protects the skin from the stool.

• Regular Wear
  Regular wear barriers are ideal for colostomies where the stool is semi-formed to formed in consistency, and tends to not "melt" or "wash away" the barrier during use. Typically, those with a colostomy can wear a regular barrier product for five to seven days before requiring a change. While it is not wrong for individuals with ileostomies to use a regular barrier, the stool will wash away the barrier more quickly and more frequent changes are suggested so that peristomal skin will remain protected.

• Extended Wear
  Extended wear barriers are more resistant to "melt-out" and are ideal for ileostomies and urostomies (urinary stomas). Some of the extended wear barriers will actually form a thick "cuff" around the stoma (in about 24 hours after application) which enhances the seal and helps to extend the wear-time. Typically, those with an ileostomy or urostomy can wear an extended wear product for five to seven days. These products tend to be more "sticky", so slow, careful removal is suggested with each appliance change.

Full-Barrier versus Tape-Border

Appliances can either be full barrier with no tape at the edges or have the barrier in the Group with a tape border.

• Full Barrier
  Full barrier products are good options for those with known tape sensitivities or allergies. As tape is not used or required to secure these appliances, reactions can be avoided. Originally, full barrier products tended to be thicker and bulkier, but there are now significant improvements and these are now lighter and thinner.

• Tape Border
  Tape border products have a border of tape extending from the Group barrier which is intended to make the appliance lighter and more flexible. The tape border also has a slightly different adhesive than the barrier, so "tack" is often immediate. Sensitivities tend to happen more readily with tape borders, and sometimes with tape borders that are flesh coloured (due to dyes used).

One-Piece System

Advantages:

• Low profile: since there is no "locking" mechanism to connect separate pieces, these appliances lay flat against the body
• Increased security: there is no concern about incorrectly attaching the pouch to the flange, so unexpected leaks from the connection will not occur
• Increased flexibility: these appliances tend to be very flexible, so will curve/mold with gentle body contours

Disadvantages:

• Inability to change pouch type: one-piece appliances are generally meant to be worn for a period of time (four to five days), and so switching a short pouch to a long pouch to suit personal needs during the course of a day are not possible.
• Inability to use a belt as some one-piece appliances do not incorporate belt tabs, so if extra security is desired or required, this may not be possible.

Two-Piece System

Advantages:

• Ability to switch pouch type: if a short pouch is desired for day-time, a longer pouch for night time, and a stoma cap for swimming, then this can be done with a two-piece system. The flange remains in place for the pre-determined time, and the 'locking' mechanism allows for the pouch type to be changed.
• Ease of application: for some, being able to apply the flange first, then the pouch during routine appliance changes, makes care easier.
• Ability to use a belt: most two-piece systems have belt tabs which allow for the use of a belt.

Disadvantages:

• Increased profile: because of the locking mechanism. The profile of the appliance is raised; the degree of profile varies between product lines.
• Decreased flexibility: most locking mechanisms tend to be quite rigid, so conforming to body contours may be problematic.
• Decreased security: incorrectly attaching the pouch to the flange may result in leakage.

Flat versus Convex

Depending upon stomal construction and surrounding body contours, a flat appliance or one with convexity may be the optimal choice.

Flat
Flat appliances are literally flat. They work best with an abdominal surface that has sufficient flat area to allow for the appliance to adhere and a protruding stoma of some degree.

Convex
Convex appliances protrude at the adhesive surface (it looks like a curve or bulge), and are designed to help flatten some body contours and to assist with accentuating stomal protrusion. This is usually required when a stoma is flush or retracted, or perhaps "tips" down and rests against the skin. Sometimes, body contours (dips and creases of varying degrees) will also interfere with an adequate seal. A convex appliance will help to compensate for this. There are several degrees of convexity — from shallow to deep — and the best type can be determined in conjunction with an Enterostomal Therapy Nurse.

Pouch Length

Pouches can be of varying sizes, either mini (with virtually no capacity to hold stool), short (about 9 to 10 inches in length), or long (about 12 inches in length). Obviously the volume of stool held in the pouch is dependent upon the size. The choice can be made according to the volume of stool produced in a day, and the frequency by which the pouch must be emptied (remembering that pouches should be emptied when 1/3 full). Some people prefer shorter pouches during the day, as concealment under clothes is easier, and longer pouches at night to facilitate sleep. Mini pouches (or stoma caps) are for times when stool volume is known to be low and when discreteness is desired (i.e., swimming, sexual activity).

Drainable versus Closed-End Pouches

Drainable
Drainable pouches are those with an open "tail" that require a clip or velcro for closure. The clip or velcro is removed or opened when emptying of the pouch is required. Closed-end pouches are sealed at the bottom are thrown away when half filled with stool.

Drainable pouches are best used for ileostomies or for colostomies when the stool is thin and frequent. As emptying is frequent, the pouch is allowed to drain through the tail and into the toilet at the discretion of the individual. Because stool is thinner, it drains easily from the pouch. It is a more cost-effective means of management when emptying is frequent.

Closed-End
Closed-end pouches are primarily intended for individuals with a colostomy. As stool tends to be thicker, it may be harder to drain easily from a drainable pouch. A closed end pouch allows the individual to remove it in its entirety and discard it in the garbage, immediately replacing it with a clean new pouch. For most individuals with a colostomy, this means one to two pouches daily. Most closed-end pouches also have charcoal filters which releases deodorized gas.

Pre-Cut versus Cut-to-Fit

Pre-Cut
Pre-cut flanges imply that the opening of the barrier is pre-cut according to standard sizes determined by the manufacturer. Cut-to-fit implies that the barrier must be cut by the individual according to the size of his/her stoma.

Pre-cut barriers are best used once the post-operative swelling of the stoma has settled (at about 6 to 8 weeks). The chosen pre-cut opening should be 1/8 (3-4 mm) larger than the base of the stoma. As most manufacturers have standard pre-cut measurements, you may find that your size is not available. The stoma must also be essentially round in shape in order to use pre-cut barriers, as oval openings are not generally available.

Cut-to-Fit
Cut-to-fit barriers are a good choice in the initial weeks after surgery, as the stoma will shrink during this time and adjustments to the opening will be required. It is also a good option when stomas are oval or irregularly shaped allowing for a more precise cut and opening.

Accessories

There is certainly a wealth of additional products that can be used in conjunction with pouching choices. Not all are required, and use may be based on personal preference rather than need.

Belts
Belts may be required to ensure adhesion of an appliance, but also may be desired for personal comfort and security. Some prefer to use belts during physical activity to allow for extra support. Belts tend to provide support and security just at the lateral level (i.e. they pull at 3 and 9 o'clock of the peristomal area). Belts also work best if they are in-line with the natural waist and do not "ride-up" higher than the level of the pouch.

Stoma Protectors
Stoma protectors are hard plastic devises that are worn over the stoma and appliance to protect the stoma from any trauma. These are most commonly used during times of physical labor, or during sports activities when the risk of damage is high.

Additional Barriers
Barriers come in different formats, including pastes, plates or rings. These may be helpful to fill in dips and creases, accentuate convexity or assist with adding wear-time to an appliance. The appropriate choice and use of an additional barrier should be done in conjunction with an ET.

Deodorants
While appliances and pouches are odour-proof, pouch deodorants (as well as room deodorants) are available to alleviate odour while emptying.

Your ET or ostomy supply company can provide you with information regarding all of the products.