Stoma product selection: a guide for community nurses

There are now known to be over 200 000 people in the UK with a stoma (Burch, 2021), with this population predominantly living in the community. The three stomas that will be explored in this article are the colostomy, ileostomy and urostomy. The most common reasons to form a faecal output stoma are colorectal cancer, inflammatory bowel disease and diverticular disease. A common rationale for a urine output stoma to be formed is for bladder cancer, although this is the least common of the three stoma types.

Stomas

A stoma is formed during surgery to bring a piece of bowel through an incision made in the abdominal wall. The bowel can be used to pass faeces if the passage of faeces needs to be altered, such as due to a rectal cancer surgery. Alternatively, a small portion of bowel can be used as a conduit to pass urine. In appearance, a stoma will be red or pink; to touch, it is warm and moist. A stoma can be formed either as a temporary or permanent measure. In general, a temporary stoma is in place for several months to years, depending on the reason behind its formation.

Colostomy

A colostomy is formed from the colon and is usually positioned in the left iliac fossa. An ideally formed colostomy will be raised about 5 mm above the abdominal wall. A colostomy is most commonly formed at the end of the colon in the sigmoid or descending colon, but it can be formed in any part of the colon. A colostomy will usually pass formed faeces and flatus, in a similar consistency and volume as before surgery, often as one bowel motion a day. As the faeces that are passed from a colostomy are thick, the stoma appliance used is a closed type (Figure 1). Therefore, a colostomy appliance will often need to be replaced once a day; however, this can range from three times a day to three times a week. Using the Bristol Stool Chart (Lewis and Heaton, 1997), the faeces ideally will be type 4, described as soft and formed. Stool consistency will vary depending on diet and fluid consumed, as well as the exercise undertaken.

Ileostomy

An ileostomy is formed from the ileum and is usually positioned in the right iliac fossa. The ideally formed ileostomy will have a small spout of about 25 mm. An ileostomy is most commonly formed from the end of the small bowel, termed the terminal ileum, but it can be formed in any part of the ileum. An ileostomy will usually pass loose faeces and flatus; the usual output varies, but is often about 800 ml per day. An ileostomy appliance is emptied about four to six times each day and sometimes also once at night. Thus, an ileostomy appliance is drainable, usually with a Velcro-type fastening (Figure 2). An ileostomy appliance is often replaced every 1 to 3 days.

Urostomy

A urostomy is usually formed from a small segment of ileum and is commonly positioned in the right iliac fossa. Ideally, a urostomy will have a small spout of about 25mm. A urostomy will pass urine and a small amount of mucus; the usual output varies from about 1000-1500 mls per day. A urostomy appliance is emptied about four to six times each day. A urostomy appliance needs to be able to drain urine, so the fastening is usually a tap or bung. It is common to attach a drainage bag at night to collect urine. An ileostomy appliance is often replaced every 1 to 2 days.

Stoma appliances

A stoma appliance is often termed a stoma pouch or a stoma bag by patients. The appliance is made of an adhesive that is adhered to the abdominal wall around the stoma. This part is termed the flange, faceplate or, most commonly, baseplate. There is also a collection apparatus that will contain the output from the stoma. For faecal output stomas, there is also an incorporated filter that will release flatus but keep the odour within the appliance. An appliance can come with both of these parts (adhesive and collection) combined, which is called ‘one-piece’, or separate, termed a ‘two-piece’ appliance. Stoma appliances are usually replaced every day or two (see Table 1).

Products

There are many UK-based or international manufacturers that produce stoma products. Table 2 contains website details for several of these. The choice of stoma appliances are discussed with the specialist stoma care nurse in hospital, and patients are sent home with appropriate products. However, over time, needs can change, for a number of reasons. As a person ages or their weight changes, for example, it may be necessary to alter the stoma products used. The community nurse may be seeing patients for reasons unrelated to their stoma, but the patient may bring up their concerns or problems experienced with their stoma. The huge variety and accessibility of the many stoma products available can result in difficulty in understanding the many factors that must be considered when choosing a suitable option. The specialist stoma care nurse is a good source of information on this topic.

One-piece appliances

A one-piece is the most common type of appliance used in the UK. Traditionally, a one-piece appliance was considered to be thinner, more flexible and more discreet than a two-piece appliance. A one-piece appliance can be more simple to change. However, with a one-piece, it can also be more difficult to carefully see the stoma to ensure that it is positioned within the aperture of the flange during application.

Two-piece appliances

Two-piece appliances are more commonly used in the US. The way in which two-piece appliances are joined depends upon the manufacturer. The two more common ways of joining the flange and the pouch parts together is either with plastic rings, which clip together, or with adhesive rings, which stick together. The advantages of a two-piece appliance include the fact that, when applying the flange, it is easier to see the stoma and ensure that it is situated in the centre of the aperture. There is also the ability to change the pouch part without removing the adhesive, which can protect the skin from the trauma of frequent appliance changes (Ratliff et al, 2021). However, one disadvantage of a two-piece appliance is that it can be difficult to clip the rings together if a patient has arthritis in their hands, as an example.

Pre-cut appliances

When patients are discharged home from hospital, they are advised to monitor the size of the stoma for roughly the first 2 months and cut the appliances themselves. This is because the postoperative oedema takes about 8 weeks to resolve. Once the swelling has subsided, it is possible to obtain pre-cut appliances. These are circular shapes that are already cut into the adhesive flange. The ideal aperture in an appliance flange should be the same shape and about 2–3 mm larger than the stoma. Thus, for people who do not have a round stoma shape, a pre-cut appliance will not be appropriate. With that being said, some companies will hand-cut and deliver appliances for patients who are unable to do it themselves.

Stoma complications

There are a number of stoma complications that can occur. The most common is skin damage in the peristomal area. The reasons for skin damage are usually related to the output from the stoma touching the skin and causing it to break down. Therefore, it is important to keep the faeces or urine away from the peristomal skin. One way to do this is to ensure that the aperture is the correct size. An aperture that is too large will allow the stomal output to be in contact with the skin. An aperture that is too small will result in the adhesive sticking to the moist stoma and not adhering effectively, causing faeces to leak under the stoma adhesive.

It might be that the stoma is not well formed and that there is no spout on an ileostomy, for example. This can be resolved using a convex appliance.

Convexity

A convex appliance features a domed flange. The dome pushes into the abdominal wall around the stoma. This pressure means that the stomal output is pushed further away from the skin, reducing the risk of skin damage. Convexity can also be used if the skin around the stoma is slightly uneven. It has been demonstrated that about a quarter of people with a stoma require a convex appliance (Redmond et al, 2009).

However, there are potential risks associated with using a convex appliance. The pressure exerted on the peristomal skin can result in bruising or ulceration. Therefore, patients need to be advised to inspect the skin at every appliance change and report its status to the specialist stoma care nurse. It is advisable for the use of convexity to be guided by the specialist stoma care nurse, as they have more experience of its use (Perrin et al, 2021).

Accessories

There are many accessories that can be used in conjunction with a stoma appliance, including those that can help protect the skin from stomal output, such as skin barrier films, and those that help to improve adhesion between the peristomal skin and the stoma appliance, such as adhesive paste or stoma seals (which are also called washers). There are also accessories to prevent damage to skin, such as adhesive removers.

Barrier films

A barrier film adds a thin, physical barrier between the peristomal skin and the output from the stoma to prevent skin damage. A barrier film is available as a spray, wipe or wand. A barrier film is used on the peristomal skin after it has been carefully cleaned and dried.

People who are more at risk of skin damage are usually those with an ileostomy or urostomy, as the output is loose or liquid and is more likely to seep under the flange, when compared to a colostomy. For people with an ileostomy, there are also the proteolytic enzymes (digestive enzymes) that can break down the skin if in prolonged contact with it (Stelton, 2019). These populations can benefit from barrier films.

Adhesive pastes

An adhesive paste is similar to the adhesive flange, but it is more flexible. Adhesive paste may contain alcohol, which can sting if there is broken skin present. Adhesive paste is used to improve adherence between the skin and the flange if the skin is uneven, for example. The paste can be added into a slight skin dip or crease, or used around the flange aperture. As the paste needs to dry, it should be used sparingly to ensure good adhesion. Adhesive paste can be difficult to remove from the peristomal skin; an adhesive remover might be necessary.

Seals

A seal has a round shape and is often designed to be malleable and can be stretched and shaped. A seal is used around the stoma for a number of reasons. The seal can add adhesion, to prevent leakage of faeces under the stoma flange. Alternatively, the seal can smooth out a slightly uneven skin surface. For deep creases in the skin, a small section of seal can be rolled into a sausage-like shape and placed into the space, often with a small amount of adhesive paste. For complicated skin surfaces, it is useful for a specialist stoma care nurse to review usage.

Adhesive remover

An adhesive remover is used to remove a stoma appliance while reducing the risk of skin trauma. For fragile skin, skin that is prone to breakdown or when an appliance needs to be removed more than once a day, this can be useful. An adhesive remover should be used between the skin and the flange. It is not necessary for all patients to use adhesive remover, but it can be more comfortable.

Cost versus quality of life

It is known that stoma products are expensive, and there are always resource constraints within the NHS to consider (Dufton, 2017). Therefore, careful nursing assessment prior to the addition or removal of stoma products is necessary (O'Flynn, 2016). Additional products might be necessary to resolve or prevent complications, while products that are no longer needed or only periodically required should not be prescribed each month.

Conclusion

Community nurses are not experts in stoma care but, with an increased knowledge about stoma products, they can help ensure that patients are using the equipment that is best suited to their needs. People with an ‘ideal’ stoma are able to use a variety of stoma appliances, whereas people with complicated stomas or those experiencing issues such as appliance leakage may need to use convex appliances or additional accessories. The specialist stoma care nurse is a good source of information if clarification or additional advice is necessary.

Key points

• A colostomy appliance is closed and usually changed daily
• Ileostomy appliances are designed to be emptied multiple times a day
• A urostomy appliance is usually attached to night drainage to drain urine when asleep
• Additional stoma products might be needed to prevent or resolve stoma-related problems.

CPD reflective questions

• How can you ensure that patients in your community area are accessing and using the appropriate stoma products for their needs?
• If a patient reports needing more products than usual, consider whether they might be experiencing appliance leaks. What do you need to include in your nursing assessment if this is the case?
• Reflecting on your clinical practice, what measures can you take to ensure that resources dedicated to stoma products are being effectively utilised?