Most fresh post op patients are now visited in the hospital by a nurse specialist, a WOCN (Wound Ostomy and Continence Nurse) to determine the appropriate equipment for them. They follow up periodically to make sure the equipment remains appropriate for the patient. So by time you get to them, most of the decision-making has been done for you.
There are one piece bags and two piece bags.
This is the flange that sticks to the skin in a two piece set up. Notice the white ring in the center. That is like a tupperware top. The ring on the bag snaps on to that.
This is a colostomy bag for a two piece setup. The ring on the bag snaps on to the flange. The little tabs with holes are to attach a belt to the bag that goes around the waist for additional support if needed.
This bag does not open at the bottom, so when it fills up it is usually taken off and replaced by a new bag.
This is an adjustable ostomy belt that hooks onto the bag to secure it more to the abdomen. Not everyone needs one.
There are flanges shaped convex to push down into the surrounding skin for those stomas that are not raised up above the level of the skin.
There is either a colostomy bag that is completely closed or a bag that you can unwrap the end to empty it without removing from the body. Some of the bags with the open ends use Velcro to close the bottom others have a plastic clip. A box of bags usually comes with only 2 clips for 10 or 15 bags so wash and reuse, DON’T throw them out until they no longer work.
Some bags have a small filter opening on the top of the bag to allow gas to escape so the bags don’t expand.
You will notice in the following video that the stool is liquid. That is because it is probably coming from the small intestines and would be called an ileostomy (vs colostomy which is from the colon). Note: remember, -ostomy is a permanent opening, -otomy is a temporary opening)
There are many times a bowel resection (surgical removal of a portion of the bowel) is performed, a colostomy created for a few months to let the bowel “rest” and then a second surgery for a “colostomy take-down” or re-anastomosis. This is where the stoma and remaining portion of the colon are reconnected.
The patient then returns to normal without any permanent colostomy.
For some reason, the term “colotomy” is never used for this temporary situation. Go figure….
As the stool travels through the colon it changes from liquid, to soft unformed, to formed stool the further along the intestines that the stoma is placed.
Sometimes, unfortunately, the colostomy bag is placed right at the waistline, so every time the patient sits, it bends the flange and bag. This makes it easier for the flange to become unstuck from the skin.
I prefer to have the patient either standing or lying down so that the skin on the abdomen is as stretched as much as possible. That way when it won’t pop off when the patient moves.
Some patients have been taught to use just the flange (the sticky part of the system) and a colostomy bag.
Some use adhesive remover when taking off the bag. If they use the remover they have to remember to wash off any residual or the new flange will not adhere well. It’s also important to remember not to use any moist wipes that have lanolin or other moisturizers as that will also make the skin slippery and the flange won’t stick to the skin well.
Others have been taught to use a skin protectant such as “Skin Prep” applied to the surrounding skin which also helps adhesion. This is a small square wipe the same size as alcohol wipes you have used. The patient just wipes the skin where the bag will be placed, let it dry, then proceed.
Leaving the colostomy bag on for too long and allowing stool to seep under the flange and sit there for days will excoriate the skin and cause breakdown.
In the beginning, the bag may have to be changed every 2-3 days. The WOCN will tell the patient the plan. As the patient and the colostomy progress, the patient may find that the bag and flange stay intact for up to a week.
A good close fit around the stoma keeps the stool from seeping under the flange but too close and it can rub against the stoma and cause bleeding. The stoma is literally the inside of the intestines rolled out like an inside out cuff. It is very friable (fragile, easy to bleed). A little blood is nothing to be concerned about but please be gentle.
If you have an irregular shaped stoma that doesn’t fit the circle templates that come in the box of flanges, you can cut any shape you need in the flange and then save the plastic covering that you remove before applying. That way you have an exact template to pre-cut before taking off the bag the next time.
The size of the stoma can change as it ages, so the template may change from time to time. There is also the possibility of a prolapsed stoma that may need a larger bag to accommodate it. Depending on the situation, there may be a surgical revision of the stoma to reduce the size.
To complicate application of the colostomy bag, there may be a surgical incision or open abdominal wound nearby.
If there is stool on the stoma, you can gently wipe it off but don’t worry about getting it totally clean. Unlike the surrounding skin, the stoma produces mucus to keep it moist and protected.
It is difficult to fit the bag on the body if the bag is opaque so folding the flange in halves as shown in the video is a good idea. Also, the soft “gasket” that the nurse applied to the new opening is the same material as the flange itself. Another option is to use stomahesive paste. It comes in a tube and you squeeze it out like toothpaste. It is placed around the cut out and any deep creases in the skin near the stoma to conform to the body and create a good seal.
If you do use stomahesive paste, when you remove the old bag, wash as much of the paste that comes off easily. Don’t rub and scrub to try to get it all off. Just reapply more over the top.
Should the surrounding skin become excoriated and weepy, the flange won’t stick as well, so you can use a third variation of the stomahesive…. Powder form. Dust on the weepy skin and gently brush off the excess. It will absorb the weepy drainage a little more than just the flange, protect the skin and hopefully let the bag stay on longer.
The prime job of the nurse is to teach the patient to become independent in this procedure. It is difficult for many to first become involved as it is a major body image change. It is also difficult for some because they need to use a mirror and working “backwards” can be tough.
Have patience with your patient. It eventually becomes part of the normal daily hygiene routine.