New Ostomate Information/Overview
What is an ostomy?
An ostomy is a surgical procedure diverting or re-routing the gastrointestinal (GI) tract or the urinary tract through an opening (stoma) onto the abdomen. The most common ostomies are intestinal diversions; if the diversion is in the last part of the small bowel it is called an ileostomy or in the large bowel it is a colostomy. The most common type of urinary diversion is an urostomy.
At any given time, there are 800,000 to 1 million people with ostomies in the United States. That is roughly 1 in 400 people. An ostomy can be temporary (meaning reversable) or permanent (non-reversible). Speak with your surgeon about your procedure, where in the bowel your ostomy is located, and is it considered temporary or permanent. You should keep a copy of the operative report as well to describe the type of surgery you had to share with your medical team.
Reasons for a fecal (diversion) ostomy
Common causes for the need of a GI or fecal ostomy include ulcerative colitis, Crohn’s disease, diverticulitis, familial polyposis, perforated bowel, a mass in the bowel whether it is a non-obstructing or an obstructing mass.
Reasons for a urinary (diversion) ostomy
Common causes for this type of ostomy include bladder cancer, nerve issue causing the bladder not to function, or an obstruction of the bladder outlet.
Encouragement
A new ostomy can be difficult to wrap your mind around, especially if it was placed emergently. The first 6-8 weeks can be the most challenging time with a new ostomy. Your abdomen is likely swollen after surgery, the stoma is swollen, you likely will have leaks of the pouching system as the swelling resides, and just the issues of learning about an ostomy can be frustrating. YOU CAN DO THIS! You really can.
Ostomy Care
Each type of ostomy has slightly different issues, yet the basics are the same.
Goals: 1) Maintain a good seal on the pouching system;
2) Maintain intact skin around the stoma known as peristomal skin.
Tips to help maintain a good seal:
Emptying the pouch is recommended at 1/3 to 1/2 full to decrease the weight pulling on the seal.
Avoid using soaps with moisturizers or oils in them on the peristomal plane for the residue will interfere with the adherence of the skin barrier.
Warm the skin barrier and skin barrier ring (if used) in your hands, or against your skin for a couple of minutes to help activate the properties that help the products stick better and flow over your skin.
Apply the skin barrier and barrier rings (if used) to dry skin.
If the stoma output is more liquid in nature, using an extended wear skin barrier is useful with a barrier ring. With extended wear products it is recommended not to use skin prep or skin protectant under the main area of this barrier. The skin prep/protectant can interfere with the adhesion of the skin barrier to the skin.
Stoma shape and height can add challenges to maintaining a good seal. The desired stoma is round, with the os (opening) right in the middle and the stoma height of 1/2 to 1 inch. A flush stoma is at skin level, a low -profile stoma is less than 1/2 inch in height, and a retracted stoma is under the skin level. Low profile, flush and retracted stomas may need a type of product that is convex in shape. A convex product can also be helpful with loose abdominal skin to give added support to the skin around the stoma.
Convex products bow out on the skin side of the barrier ring or skin barrier which allow these products to push into the skin helping the stoma to protrude out slightly more, so it can be pouched to avoid leaking. There are various levels of convexity from shallow to deep. There are cautions in the use of convexity such as using with a hernia, using with a separation of the skin from around the stoma, and skin pressure sores/wounds.
An ostomy belt that is specific to the brand of ostomy products being worn helps give extra support which can help support the seal.
Body hair in the peristomal plane can keep the skin barrier from sticking well, shave the hair with a small battery-operated hair trimmer. Do not use a razor with a blade for this tends to nick the skin and cause local skin infection/infection of hair follicles. Some have had laser removal of thick hair in the peristomal plane which can work well to help improve wear time of the pouching system.
Ostomy pouching terms and products
Pouching system: includes all items that can be used to pouch the stoma. Noted with an *
*Adhesive remover– aides in removing the skin barrier with starting at an edge of the barrier on the skin. Use the wipe or spray under the skin barrier as it is pealed back. Gently use a push – pull movement to remove the skin barrier. Push on the skin as you gently pull the skin barrier off. Be careful not to shear or tear the skin.
*Skin barrier prep– the protective liquid formula that when dries provides a thin layer on the skin that helps any effluent leaked from breaking down the skin. It also provides easier removal of the skin barrier when changed. This is optional yet many ostomates use this as standard practice. Use not recommended with extended wear products.
*Skin barrier– the adhesive base plate that is cut or molded to fit the stoma. Wafer and flange are older terms.
*Skin barrier ring—used to improve the seal of the pouching system for more liquid stoma output such as ileostomies or urostomies. This acts as a gasket or o-ring fitting between the skin and the skin barrier. It can be used to fill in any creases to help make a level plane to pouch on too.
*Pouch—the odor proof, plastic reservoir that holds the effluent. Closures can be Velcro, a clamp or a port for the drainable pouches. There are also closed non-drainable pouches for one time use, then they are to be discarded.
*One piece systems include the skin barrier and pouch attached together. These have a lower profile, can be more difficult to cut and put on.
*Two piece systems- have the skin barrier separate from the pouch. The pouch attaches by a snap, click or a tape seal depending on your manufacturer. The skin barrier and the pouch are ordered separately in the two-piece system.
*Stoma paste– Used as caulk to fill in gaps around the stoma, between the stoma and skin barrier. Stoma paste has no adhesive properties. Some use a light ring around the skin side of the skin barrier instead of a skin barrier ring. This is best used for colostomy patients with more solid output.
Steps to pouching (using items of the pouching system description)
- Remove old pouching system with a gentle push-pull action and optional use of adhesive remover
- Clean skin-using a moisture/lotion/oil free soap like Ivory or use plain water. If have hard well water, consider using filtered or bottled water
- Dry skin—using soft cloth like paper towel can be more economical than using wash cloths or gauze
- Measure the stoma with each change until the swelling resolves then measure the stoma periodically. Measure the stoma adding a margin of 1/8 inch around the stoma when marking the skin barrier cut.
- For cut to fit skin barriers, mark and cut the stoma measurement. Warm the skin barrier and skin barrier ring if used with your warm skin. If using a moldable barrier, follow the directions provided in packaging.
- Prep the skin with skin prep if used. Let dry.
- Place skin barrier ring if used on the skin directly or on the skin side of the skin barrier around the cut opening.
- Place the skin barrier on skin, attaching the pouch if using a 2- piece system. Hold in place with your hand for 10 minutes to ensure a good stick utilizing your body heat.
- Use stoma paste as a caulk to fill in gaps between the stoma and skin barrier if needed.
Definitions, procedures and uses:
Crusting procedure—see separate detailed description
Effluent—the output from a stoma
Ostomy – the procedure or surgery to create the diversion and stoma. It is often used interchangeably with stoma, yet they are not the same thing.
Ostomy belt– available in 1 inch or 2 inch soft adjustable belt meant to provide some mechanical support to your pouching system. Each manufacture has this belt specifically to fit their pouching systems.
Ostomy Support Belt—is a special made belt to help support the abdomen around the stoma to help prevent or decrease a hernia. There are a few of specialized companies that make this type of belt–Nu-Hope, Celebration, Safe-n-Simple, and Coloplast. Contact the company get the instructions on how to measure for the proper sized belt. Your insurance may cover the belt; you will need a prescription from your primary physician or surgeon for an “ostomy support belt”.
Pancaking is the term used when thick effluent comes out of the stoma, stays in the stoma area and does not go into the pouch. Pancaking can cause a build-up which will pull at the appliance seal setting up a pouching system leak and failure. This pancaking can be caused by a vented pouch causing a vacuum, the static cling from the pouch walls and thick effluent.
Using a non-vented pouch or cover the vent with tape to keep a vacuum suction from forming, adding air into the pouch by opening the pouch and pulling the pouch walls away from each other, and using an ostomy lubricant deodorant will help decrease the static cling in the pouch. If you have thick effluent a product to help soften up the effluent may be needed.
Peristomal or parastomal plane—the 4 inch plane around the stoma
Peristomal or parastomal hernia—a defect in the abdominal muscles allows for a portion of the bowel to move into the area between the muscle and the skin forming a hernia which can be small to large in size. This can be through any weakened muscle or incisional area including the area around the stoma. This is most common in persons with colostomies but can occur with any ostomy. A hernia can change the shape of the abdomen and the stoma causing pouching issues. It can also cause a bowel blockage that may require surgical intervention. To help prevent a hernia, support your abdomen with coughing or sneezing and use an ostomy support belt. Ask your surgeon about exercising to strengthen your abdominal muscles. Many hernias can be repaired yet there is a reoccurrence rate of up to 50%.
Silent erosion-the breakdown of the backside of the skin barrier or skin barrier ring from the effluent which is invisible to the eye. The sensations of burning or itching are often indications of this erosion. When removing the skin barrier, note where the seal has been compromised, so you can reinforce this area on the next system to prevent leakage.
Stoma — the section of bowel that is on the surface of the abdomen through an opening in the muscle and skin.
Wear time– the amount of time the pouching system can be worn before changing the system. Optimal wear time for ileostomies and urostomies is 3-5 days, colostomies 5-7 days. Always change a leaking pouching system.
Help for moist, broken peristomal skin
Crusting (procedure) helps when in the peristomal skin plane there is moisture from damaged, irritated or broken skin. Moisture prevents a good seal of the pouching system and crusting helps absorb the moisture by creating an artificial scab allowing you to pouch over the irritated skin.
On clean skin, sprinkle stoma powder over the area that has moisture, allow the powder to adhere to the area, gently dust off excess powder with clean gauze or tissue, use sting free skin prep to dab or spray over the powder, then allow to dry completely. Repeat the powder and skin prep up to 4 times if needed, ending with the skin prep. Then once dry, pouch as normal. Crusting will no longer be needed once the skin has healed.
Diet and Nutrition
After surgery, ostomates normally have a low fiber diet for the first 6-8 weeks of recovery, follow your surgeon’s advice. It is suggested that you add one food at a time back into your diet to see how it affects you.
Other dietary guidelines:
Eat in moderation, consider eating 6 small meals/snacks a day, chew your food well, avoid using a straw and talking while eating for these practices add air into your digestive system increasing gas.
Avoid foods with seeds and skins-like grapes, beans, strawberries in large amounts for these can cause an impaction/obstruction when eaten in large amounts. Avoid foods that are hard to digest such as cabbage, apples.
Be cautious of foods that cause gas such as cauliflower and broccoli. Avoid sugar substitutes as several can cause intestinal cramping. In addition, too much sugar intake can cause intestinal cramping and increased in volume of output.
Keep hydrated- unless contraindicated for another disease process, it is recommended you have the 8-12 glasses of water a day.
Depending on where your ostomy is located within your bowel, you may have malabsorption concerns. The small intestine is where most of the nutrients from food is absorbed including protein, Vitamin B 12, while the colon absorbs water, some electrolytes and is a storage place for stool. The higher up in the bowel your ostomy is placed the more liquid output (effluent) you will have. Output more than 1100 ml a day is considered diarrhea for the ostomate and 2000 ml or more in 24 hours is a high output ostomy. The more liquid the effluent, there is increased risk of losing important nutrients such as potassium, magnesium, sodium and calcium. These nutrients are responsible for muscle control, heart rate control.
If you have muscle cramps or weakness, dizziness, extremity numbness, heart rate issues, decreased urine output these are some of the signs of dehydration and/or electrolyte imbalance. Dehydration can cause kidney injury as well. Make sure to get these symptoms address promptly with a medical professional.
Foods that can help to thicken up output include potatoes which are high in potassium, pumpkin, oatmeal, foods containing pectin like pudding. Follow your doctors recommended diet if you have one as well. Oral fiber products like Metamucil may help. Your doctor may suggest other medications as well.
Pharmacy concerns
Ileostomy patients may not digest and absorb medications well, especially extended release medications. Speak with your pharmacist to update them on your ostomy and ask for assistance in getting medications in a form that can be more readily absorbed such as chewable, meltaway, non-enteric coated pills.
Hints to resolve an intestinal blockage
Blockages can be caused by adhesions from surgery, impacted food, or gastrointestinal illness such as a virus. Symptoms of a blockage can include mild to intense cramping and abdominal pain, lack of output out of stoma to liquid output, nausea and vomiting.
Do not eat solid foods when you think you have a blockage. If you are nauseated and/or vomiting call your doctor promptly.
Otherwise, drinking grape juice, a warm shower or bath, a heating pad placed on the abdomen but not over the stoma, and drawing knees up to your abdomen or other stretches that help change the shape of the muscles can help reduce or alleviate the blockage. If the pain and blockage does not resolve with these steps, contact a medical professional.
Rectal output
If you have a rectum, then you likely will have output through it. A section of colon left in place or just a rectal stump which is part of the bowel, after your surgery you may have some old stool and blood along with mucous in it that will need to be excreted. Mucous will continue to develop and from time to time you may feel pressure and need to pass the mucous. This is normal.
Resources
Home Health RN should be set up for you prior to discharge from the hospital or skilled nursing facility. The RN will see you for a few visits to reinforce teaching of ostomy care and help trouble shoot issues that arise. Home Health will provide your ostomy supplies while you are on service with them. Upon discharge from home health, the RN should help coordinate your ostomy supplies through a contracted medical supply company.
Primary Care Physician – your PCP will provide ongoing care for your ostomy needs. Annually, your PCP will need to write a prescription for ostomy supplies along with documentation of the type of ostomy you have and your need for the supplies. This is required by your insurance and medical supply company.
United Ostomy Association of America (UOAA) is the national support group for ostomates and their support persons. You will find that Ostomy.org has many educational articles and links.
Colorado River Ostomy Chapter (CROC): Mohave County’s UOAA affiliated chapter meets the second Monday of the month from 1-3 pm at Joshua Springs Senior Living in Bullhead City. Check the website for up to date information and resources— http://www.coriverostomy.com
Any of the ostomy product manufacturers have how to videos on their websites: Hollister, Coloplast, ConvaTec are the largest 3 companies and there are others.
New Ostomy Patient Guide is published by the UOAA and is free to patients. The Phoenix ostomy magazine is the only magazine of its type in the US. It is a quarterly publication by subscription and can also be found on the UOAA website. Both publications are very informative for any ostomate-new or established.
Wound Ostomy Continence Nurse (WOCN) and Ostomy Management Specialists (OMS) are certified in ostomy care and education to help assist ostomates in managing their stomas
Information compiled and written by Stephanie Short, RN, BSN, RN-BC, ACM-RN, OMS
General Ostomy Tips
Appliance Adherence Issues
Letting pouch get too full. The weight of the output (aka effluent) pulls at the seal of the skin barrier to your skin.
Empty pouch when 1/3 -1/2 full, preferably when 1/3 full.
If you have high output overnight as some urinary diversions do and some ileostomies, use an extra collection bag that connects the pouch with tubing to a larger bag known as a bedside drainage system.
Use a belt to provide a mechanical support if your stoma is near the waist line. If the stoma is elsewhere on the abdomen a binder or a hernia belt may help add extra support.
Moisture under the skin barrier not from output leakage—If you tend to sweat/have moisture under the skin barrier try applying an aluminum chloride hexahydrate antiperspirant to skin prior to a skin barrier application. Example: Drysol, Driclor.
Too much hair on skin- the skin barrier cannot adhere well if there is a lot of hair to pouch over. Use a battery or electric razor to prevent nicks of the skin that can lead to infections. It is preferred to have one razor dedicated for this purpose. There are little wand battery operated razors for roughly $10-20.
Warming the skin barrier and barrier rings next to your skin for a minute or so prior to putting them on. This activates the polymers (which then flow onto the skin filling creased and crevices) and tackifers (the adhesives that provide the stickiness) in the skin barrier. The moldable barriers may not need warming. Skin barriers also need gentle mechanical pressure applied after placed on the skin using your hand and possibly an ostomy belt.
Having clean skin—make sure to clean off old adhesive by using an adhesive remover, rinse off any soaps used, no oily products/ointments on the peristomal skin that will cause adherence issues.
Use of hydrocolloid flange extenders (semi-circle or straight in shape) that go over the edge of the skin barrier backing thus giving extended support to help increase the wear time of the appliance system.
Peristomal Hernia
Ostomates can develop this problem when the muscle around the stoma is weak and allows loops of bowel to push up next to the stoma under the skin. It is a defect in the muscle/fascia. A hernia may look like a hump, bulge, or flat area around the stoma.
It can present an issue with getting a good pouch appliance seal.
50% of colostomy patients develop a hernia like this and often in the first 2 years. If there is pain, cramping, nausea/vomiting, abdominal distention in the area, or decreased output with a hernia consult your doctor right away. Urostomy patients aren’t as likely to develop a hernia but it is a possibility to be aware of and to monitor.
To help prevent a peri-stomal hernia—support your cough by using your hand to hold your abdomen, use support garments like Spanx, bike shorts, abdominal binders, or a hernia (ostomy support) belt. Make sure none of these items put pressure directly on the stoma. There are ostomy support belts/hernia belts that are made especially for ostomy patients with an opening for the appliance to fit through. If your insurance will cover the support belt, obtain a prescription from your doctor for an “ostomy support belt”. Celebration, Nu-Hope, Coloplast are 3 of the companies that carry ostomy support belts.
UROSTOMY TIPS
Alkaline Encrustations (AE) and Urostomies
These are Crystal-like formations on exposed peri-stomal skin. Associated with alkaline urine and/or concentrated urine that pools on the skin, renal stones, and urinary tract infections.
Tips to combat AE:
Karaya (Hollister) barrier is a hydrophilic which is mildly acidic pH and helps with decreasing encrustations.
Use a pouch with anti-reflux mechanism.
Control moisture leakage— maintain a good seal.
Maintain urine pH as close to 6 as possible by increasing oral fluid intake if no contraindication for this, take ascorbic acid- 1 gram a day is recommended.
Apply vinegar soaks at 33% or 50% strength during pouch changes—2 times for 5 minutes then lightly flick or gently rub the encrustations to loosen them. The skin may bleed some when manipulating the AE with treatment or pouch changes. If bleeding becomes an issue, silver nitrate treatment may be needed at the doctor’s office or wound care center.
Dietary Concerns
High fluid intake to help prevent Urinary Tract Infections –8-10 glasses of water a day
Drink cranberry juice instead of OJ or citrus juices for these juices make urine more alkaline, while cranberry juice tends to make urine more acidic.
If okay with your doctor, take vitamin C daily.
Eat an Ash Diet—which is more meats and cereals rather than fruits and vegetables which cause alkaline urine. Again, if your doctors are in agreement based on other disease processes you may have, this is a recommended diet.
ILEOSTOMY/COLOSTOMY TIPS
Pancaking
This mostly affects the colostomy population but can also affect those with ileostomies. The fecal output sticks to the inner walls of the pouch and does not advance into the pouch.
The output can build up over stoma and lift the pouch off the skin.
Pancaking is caused by pouch static cling from the two sides of the pouch rubbing together and/or with filtered pouches–the filters on the pouches eliminate the air in the pouch causing a vacuum.
Fixes: pull air in the pouch–with either a 1 or 2 piece pouch system open up the pouch at the end (a 2 piece system can also be opened at the top seal) and pull the plastic layers apart; cover the pouch filter with a sticky patch that should come in the pouch box (except with Hollister)or use a piece of tape to cover the filter; use unfiltered pouches; or use a stomal pouch lubricant that prevents static formation. There are several pouch lubricants or deodorant- lubricants on the market, check with your manufacturer.
FLUID AND ELECTROLYTE BALANCE FOR THE ILEOSTOMATE AND ASCENDING/ TRANSVERSE COLOSTOMATES.
Diarrhea occurs when output is 1100 ml or more in 24 hours—roughly 4-5 cups of output. Diarrhea can/will lead to electrolyte wash outs of sodium, potassium, calcium and magnesium. All play a role in cellular function and muscle function. If you experience muscle cramps, muscle spasms, or numbness of extremities not related to diabetic or vascular problems then your electrolyte balance could be off. Don’t forget about the magnesium—it is the forgotten mineral/electrolyte but it has important roles.
Ask your doctor to do blood work looking for all these electrolytes when you are having a hard time keeping your fluid balance, balanced.
What to do if having increased output/diarrhea:
Eat thickening foods: bananas; boiled rice; potatoes without skins; cheese; gelatin products—jello, pudding, marshmallows; creamy peanut butter, tapioca pudding, pumpkin.
Drink fluids with electrolytes in them—be aware while sugar (glucose) is needed to transport the electrolytes into your body through digestion that those products with high glucose will not help as well. High glucose levels in foods can increase output. Consuming sugar substitutes may also cause bowel cramping and increased output.
Use oral re-hydration therapy to replace salt, potassium and other minerals when symptomatic of dehydration and your doctor agrees. You can make your own recipe or buy pre-made packets of powder to dissolve in water.
If not contraindicated by another disease process, add more salt to your diet during high output times.
Take magnesium supplements with food for it can increase output. Magnesium is not found in the sport drinks, but is found in small amounts in bananas and orange juice, chocolate milk.
General diet tips: a low glycemic diet or a FODMAP (from Stanford University studies) may be a diet style that helps decrease output for a high motility bowel. A dietician may also be able to assist in diet issues.
High Output Fecal Stomas/Ostomies
For high output stomas more than 2 liters of output in 24 hours, there is a danger of severe dehydration developing quickly that can affect one’s kidney function even causing kidney damage. Measuring your ostomy output is recommended and keeping your physician updated about the output volumes is a must. Keep an eye on your urine output too- for when the stoma output increases, often the urine output decreases.
Your physician may want you to utilize medications to slow your output, many of which need a prescription. At times there is a need for intravenous fluids to be infused in the hospital or an outpatient infusion clinic. Seek your physicians advice immediately when you have high output and especially if you have symptoms of dehydration and/or electrolyte issues such as tiredness, muscle cramps, weakness, dizziness, heart rate issues, or even plain just not feeling well.
Rectal Output
If you have a rectum that is intact after surgery, you will have mucous, old blood, and possibly old stool that will cause pressure and feel like you have to have a bowel movement at times in the post-op period. This is normal. It may cause an urgent feeling, you may have leakage at times, but the good news is– you will be able to develop control of the output. The mucous lining of the bowel/rectum will continue to produce mucous, and at times the output will be mucous like or possibly balled up dry mucous, this too is normal. Until control over the output is obtained, you may want to wear a small peri pad or liner.
Marshmallow Trick
When the pouch needs to be changed and there is high output, eating marshmallows 30-60 minutes before the pouch change can help stop output for a short time. Some report needing only 1 marshmallow while others say they have to eat 6. For some it does not work at all. The pectin/gelatin in marshmallows is thought to help slow the output.
Blockages
A blockage can occur for colostomy or ileostomy patients. It can be caused by scar tissue (adhesions) or food. Food can cause blockages most often for ileostomates. Symptoms of a blockage: pain, cramping, decreased output to no output, stoma changes may also occur.
Tips that may help avoid a blockage:
Remember moderation in food. Alternate between eating each item on your plate.
Chew food well, drink fluids with meal, avoid foods that are high in fiber and known to cause blockages (popcorn, corn, nuts, beans, strawberries, grapes, things with skins/peels that you eat), and limit conversation while eating. If you eat these foods, limit the size of the portion, eat them with other foods and you may want to peel the skins off foods to avoid the food getting impacted in your bowel near the area where the bowel enters the muscle of the abdomen.
After surgery start introducing foods into your diet slowly, adding one food at a time, and use low fiber foods. Also avoid straws for a lot of air will enter your gut by way of the straw causing gas and cramping.
If you notice symptoms of a blockage, try grape juice (can be a laxative effect), draw your knees to your chest to help relax muscles, and take a warm shower/bath or put warm packs on your abdomen avoiding the stoma. These ideas can often work.
If the blockage is not relieved by these methods quickly, and/or nausea or vomiting develop then seek medical assistance quickly.
Colostomies and Constipation
Colostomates often deal with constipation by making sure their fluid intake is adequate (8-10 glasses of fluid a day if not on fluid restrictions), eating a diet that has some fiber in it, chewing food well, and exercising. Many colostomates also utilize some sort of stool softener. It is recommended that you speak with your primary provider about the stool softener that is best for you before starting one.
Ideas compiled by Stephanie Short, RN, BSN, OMS
Other Source of Information is the Basic Ostomy Skin Care from the WOCN Society
United Ostomy Association of American (UOAA) at http://www.ostomy.org
Colorado River Ostomy Chapter 