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Caring for the stoma patient in the community: part two

Currently there is a wide-ranging choice of stoma appliances available on prescription to the patient with a stoma. Many healthcare professionals consider this choice to be quite bewildering,1 leading to much confusion among community nurses, pharmacists and GPs alike. Advances in research and development have allowed product development to occur, focusing on the needs of the stoma patient.

It is widely accepted that patients who undergo stoma surgery go through a period of adaptation, both physically and psychologically. A secure, comfortably-fitting and discreet appliance plays an important part in the rehabilitation of the patient2 with a newly-formed stoma. The more confident the patient feels with regards to the practicalities of stoma care management, the sooner they will return to the activities of daily living they fulfilled prior to surgery.

A new stoma patient will be reliant upon the expertise of the stoma care nurse specialist in order to make an informed decision of which appliance is best suited to them. The presence of a stoma complication may well restrict product choice, therefore it is very important for healthcare professionals working alongside people with stomas to not only develop a comprehensive knowledge of appliances and accessories available on prescription, but also be aware of potential complications associated with stoma surgery.

The incidence of stoma complications is difficult to identify,3 although Buckmann and Huber4 state that the “creation of a stoma is related to up to 50% of complications,” attributing the main issues to be general stoma management and stoma position. Most complications occur within the first twelve months following surgery.5 Known stoma complications include skin excoriation, retraction, mucoseparation, parastomal hernia, prolapse, stenosis, appliance leakage, constipation and diarrhoea.6 Conservative management is usually the first line of treatment, however surgical modification may be necessary, and on occasion the relocation of the stoma.

In order to minimise complications following stoma surgery, the patient is in most instances sited for their stoma.7 Pre-operative siting of the stoma is essential, as a badly positioned stoma results in subsequent stomal complications and difficult management. Discussions take place with a specialist nurse in stoma care and the patient to determine the optimal place for the stoma to be situated. Taking into consideration the type of stoma to be formed, the patient's visibility and manual dexterity abilities, their occupation and the way they wear their clothing, a mark is placed on the abdomen using an indelible marker so to guide the surgeon as to the most favourable stoma position.

Post-operatively, the new stoma patient is taught to manage their stoma independently, so that when they return home they will only require minimal support to manage their stoma. In some cases this is not possible, so district nursing services or a carer might be needed to offer that additional support.7 Once prepared for discharge, the patient is supplied with enough stoma appliances so that a delivery service can be arranged, or the patient can get their products from their local pharmacy.  

The nature of the effluent from the stoma will determine which appliance is used whether it is a closed, drainable or taped stoma appliance. A new stoma patient will be reliant upon the expertise of the ward staff or nurse specialist in order to make an informed decision of which appliance is best suited to them. It is therefore very important for nurses to work closely with new stoma patients and develop a comprehensive knowledge of appliances and accessories which are available on prescription.

A thorough assessment of the new stoma patient is of the utmost importance, as the patient's preference and ability to manage their stoma will reflect on which type of appliance is appropriate. During the assessment the following points should be considered:
    - The type of stoma created.
    - The type of effluent being passed.
    - The patient's manual dexterity.
    - The patient's visibility of the stoma.
    - The patient's lifestyle.
    - Any skin sensitivities.
    - Position of the stoma.
    - The patient's preference with regards ease of use, appeal, comfort, reliability and availability of the stoma appliance.

There are four main categories of appliance:
    - One-piece.
    - Two-piece.
    - Clear.
    - Opaque.

One-piece appliance
As the name suggests the one-piece appliance incorporates the bag and adhesive base plate together. The adhesive base will have either a hydrocolloid skin barrier and/or a hypoallergenic adhesive. The hydrocolloid component of the base plate acts as a skin protective barrier and additional security is provided by the hypoallergenic adhesive.1

If the stoma is irregular in shape, it is appropriate to use an appliance with a cut-to-fit opening. This enables a template of the actual stoma size to be created and used as a cutting guide to cut the aperture of the appliance accurately. When the stoma is regular in shape, a pre-cut opening is available to fit securely around the stoma, although the correct sizing must be ascertained. Too large an aperture may lead to excoriated skin, and too small an aperture may lead to constriction of the stoma. In severe cases ischemia can occur.8

One-piece appliances are considered to be the most simple to apply as they are soft, flexible and discreet under clothing. For these reasons the one-piece appliance is suitable for patients whose manual dexterity is reduced, or for new patients since fewer learning stages are required. The appliance can be simply applied as one and removed as one.2 A one-piece appliance is available as a closed, drainable or taped (urostomy) appliance and is offered as a clear or opaque option.

Two-piece appliance   
Again as the name suggests the two-piece appliance is applied as a two piece system; a base plate (flange) and appliance. The skin barrier to the base plate has properties similar to that of the one-piece and is available with or without the hypoallergenic adhesive.

Generally, the base plate requires cutting to the stoma size at each appliance change and a cutting guide may be required. It is possible to arrange for dispensing appliance contractors (DACs) to cut the base plates. This is only possible to arrange if a guide to the actual stoma size is supplied. Cutting devices are also available which punch out a hole to the exact size of the stoma in the base plate.

Once the base plate is in place on the abdomen, over the stoma, the appliance is clipped or stuck onto the base plate. This enables the appliance to be renewed regularly while the base plate remains in place. It is usual for the base plate to be renewed once or twice a week and the appliance renewed as required.

The advantage of this system is that the appliance can be changed without disturbing the surrounding peristomal skin. In view of this there is a lower incidence of skin irritation when using a two-piece system.9

An additional advantage is that smaller sized appliances can be interchanged during the day when discretion would be considered more important than capacity, for example, for sports and sexual intercourse. Two-piece appliances are available as a closed, drainable or taped (urostomy) appliance and are offered in clear or opaque.

Clear and opaque appliances
Clear appliances allow the stoma and effluent to be easily observed, which is of particular importance when the stoma is newly formed. Some patients prefer to continue using a clear appliance as it enables them to see the stoma when placing the appliance on the abdomen and therefore increasing the patient's confidence that the appliance is secure.

Opaque appliances are used by many patients who prefer to disguise the effluent. As with all modern appliances, disposable stoma care products are made from odour-proof laminated plastic. Opaque appliances generally have a soft material outer cover to ensure comfort against the ostomist's skin. Some clear appliances have a split soft outer covering so that the stoma can still be easily observed while still concealing the effluent.

Basic stoma care
Stoma care is generally best kept as simple as possible, with many ostomists achieving self-care with the use of minimal or no stoma accessories. One of the goals of good stoma management is to maintain integrity of the peristomal skin. Before guiding the stoma patient in the section of a suitable appliance the nurse must be mindful of several aspects relating to the surgical procedure, the stoma itself and the patient's abilities and preferences.

Problems with established stomas become more evident in the long term. This is generally because the person is likely to have made lifestyle changes to accommodate the stoma.10 In most cases stoma problems can be managed by educating the ostomist to make certain changes to their stoma management with the use of stoma accessories.

Accessories and aids for stoma appliances make up a large part of the GP budget on stoma care. Expenditure in England alone is in excess of £1 million per annum.1 Modern appliances often reduce the incidence of skin trauma and sensitivity,11 however increased financial constraints result in the need for patients to be assessed with regard to the need for accessories in the first place.1 Assessment should include:
    - The condition of the peristomal skin.
    - Whether the skin is sensitive.
    - Type of effluent from stoma.
    - Patient's ability.

Table 1 offers an overview of stoma accessories and their sugested use as a guideline for clinical practice.

The stoma patient is likely to experience a variety of physical and practical problems with their stomas which can cause distress and embarrassment; this in turn may hinder their rehabilitation towards returning to the lifestyle they enjoyed prior to surgery. Most simple problems can be treated by educating the ostomist in the practical management of their stoma. The early detection and treatment of problems can in some cases alleviate further surgery, but above all ensure a better quality of life for the patient.

1.     Black P. Holistic Stoma Care. Edinburgh: Baillère Tindall; 2000.
2.    Cottam J, Porrett T. Choosing the correct stoma appliance. In Porrett, T and McGrath, A. Stoma care - essential clinical skills for nurses. Oxford: Blackwell Publishing; 2005.
3.     Cottam J, Richards K, Hasted A, Blackman A. Results of a nationwide prospective audit of stoma complications within 3 weeks of surgery. Colorectal Disease 2007;9(9):834-8.
4.     Buckmann P, Huber M. The complicated stoma - late complications, conservative and surgical management. Journal of the World Congress of Enterolstomal therapist 2007;64(9)537-44.
5.     Wade B. A stoma is for life. London: Scutari Press; 1989.
6.     Burch J. The management of a stoma and its associated complications. Gastrointestinal Nursing 2005;6(4):21-3.
7.     Breckman B. Stoma Care and Rehabilitation. Edinburgh: Churchill Livingstone; 2005.
8.     Taylor P. Care of patients with complications following formation of a stoma. Professional Nurse 2001;17(4):252-4.
9.     McPhail J. Selection and use of stoma care appliances. In: Elcoat C, ed. Stoma Care Nursing. Reading: Hollister; 2003.
10.     McGrath A, Johnson A. Accessories in stoma care. In Porrett, T and McGrath, A. Stoma care - essential clinical skills for nurses. Oxford: Blackwell Publishing; 2005.
11.     Borwell B, Breckman B. Practical management of bowel stomas. In: Breckman, B. ed Stoma Care and Rehabilitation. Edinburgh: Churchill Livingstone; 2005.