Stoma appliance change

A stoma is a surgical opening on the abdominal wall with a piece of bowel brought through and stitched to the abdomen. There are two faecal output stomas; a colostomy formed from the colon and an ileostomy formed from the ileum and a urinary output stoma termed an ileal conduit or more commonly a urostomy.

The output from a colostomy is formed faeces and flatus and is passed on average once a day. The usual appliance for a colostomy is closed and it is replaced when dirty, commonly once a day but this can be between three times a day to three times a week.

The output from an ileostomy is loose faeces and flatus and it is passed several times a day. The loose faeces are emptied several times a day into the toilet, often four to six empties are required during the day and for some people also

The purpose of a stoma appliance is to collect and contain the stomal output and maintain intact peristomal skin (O’Flynn, 2019). The purpose of an appliance change is to remove the old stoma appliance, often called a bag or pouch, and replace it with a new one.

It is necessary to assess the need for an appliance change as well as the peristomal skin during the appliance change. The assessment to determine the need for an appliance change includes checking: are there any visible leaks?, Is the patient reporting any issues such as discomfort around the stoma?, Is the patient being taught how to care for their stoma and is the appliance in situ for three days?

An appliance should not be left in situ until it leaks as skin damage is likely. A leaking appliance will also reduce the quality of life of the person with a stoma.

Assessment during the appliance change needs to include examination of the stoma, the stomal output and the peristomal skin. Assessment of the stoma will include colour, temperature and appearance. The stomal output assessment includes colour, consistency as well as what is being passed. It is never normal to

When undertaking an appliance change it is important to collect all the necessary equipment. Equipment includes:

• clean appliance
• rubbish disposal bag
• warm tap water
• cleaning and drying cloths (kitchen roll can be useful)

For people with a new stoma the necessary equipment will additionally include:

• scissors
• measuring guide
• pen

For people with a stoma that requires products in addition to the stoma appliance that have been assessed as necessary, there may be additional products. For example, these products can include barrier film to protect skin or adhesive paste that can increase adhesion.

When undertaking an appliance change the procedure may need to be revised per individual but is essentially as follows, and should involve the patient as much as possible.

1. If the appliance is drainable, empty this prior to changing to reduce the risk of spillage.
2. Collect all the necessary equipment as detailed above.
3. Gently remove the appliance from the abdominal wall, being careful not to damage the peristomal skin.
4. Place into the rubbish bag.
5. Using the cleaning cloths and warm tap water clean the peristomal skin, gently but thoroughly.
6. Once all the faeces or urine is removed from the peristomal skin it should be carefully but well dried.
7. The appliance aperture should be the same shape and 2-3mm larger than the stoma.
8. The aperture may be pre-cut for people with an existing stoma or for people with a new stoma the size should be determined using the measuring guide, marked and

There are more risks such as skin damage associated with not changing appliances than during an appliance change. It is very unusual to have an allergic reaction (Stelton 2019), but skin can be sensitive and when the appliance is initially removed transient erythema may be noted for a short period of time. However, with darker skin tones this may not be as obvious as for patients with paler skin tones. If skin damage is noted this needs to be assessed for cause and addressed appropriately (Metcalf 2018). If uncertain, make a referral to the specialist stoma care nurse for assessment and a treatment plan. Regular assessment is required depending on the time since surgery and if a problem occurs, but with a minimum of a yearly review.

Appliance changes should be planned so that the skin remains healthy and intact. This may alter between patients depending on activity. For example,  swimming and exercise might mean that more frequent appliance change is necessary. For people with a high output ileostomy there is an increased risk of skin damage, the cause of the high output needs to be treated and referral to the specialist stoma care nurse can be useful.

References

Burch J, Black P. Essential stoma care. St Mark’s Academic Institute: London; 2017.  

Lloyd Jones M. Fundamentals of peristomal skin care. Wound Essentials. 2016; 11(1): 51-54.

Metcalf C. Managing moisture-associated skin damage in stoma care. British journal of nursing. 2018; 27(22): S6-S14.

O’Flynn SK. Peristomal skin damage: assessment, prevention and treatment. Br J Nurs. 2019; 28(5): S6-S12.

Stelton S. Stoma and peristomal skin care: a clinical review. AJN. 2019;119(6) 38-43.