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HELP with Cutting the wafer to fit around my stoma

Posted by tudibird, on Mon Oct 28, 2013 8:48 pm
Hi there.  I seem to be having a terrible time getting the right fit around my stoma.  Twice now when I have cut the wafer thinking it was perfect my home health nurse has said it was too snug and cut it larger.  Problem I have with this is I then see stool pooling around my stoma and it seems to be to large of a gap.  I am currently fighting a problem with skin breakdown around my stoma.  Here's my question - how snug of a fit should the wafer be??  Home health nurse said to me if its too snug I could harm the stoma.  Is this true?  Seems like I'm doing more harm by having it too loose.  She did apply some paste this time around so hoping it helps some but again I see the stool just sitting around the gap between the wafer and my stoma.  Any advice is appreciated!!
Reply by Juuust_Jim, on Tue Oct 29, 2013 12:37 am
is you stoma of an irregular size or oval? I only used cut-to-fit wafers for a few months while recovering from sugery. once the swelling had gone down and my stoma was it finished size, i then used pre-cut. I found the the cut to fit barriers didnt last me half as long. the reason why nurses will tell you to not cut it to too tight of a fit is one, to allow you stoma to expand when passing food, and two cut to fit barriers can leave sharp edges that can cut your stoma and cause bleeding -which is very had to get to stop. I have to pay for my supplies 100% out of the pocket, so I nee to get as much wear-time out of them I can. so I'm thankful I average 7 days on a  barrier. so I order mine a really snug fit so to get that great wear time and not have any skin around the stoma which as you know gets very red and irratated from the high acidic nature of our output. One possible alternative is cut tham a little larger as your WOC nurse says, and use and moldable ring or barrier on you skin thats fit snug around your stoma ( Eakin seals are a popular one) and place the ostomy flange on over the top
Reply by tudibird, on Tue Oct 29, 2013 11:59 am
I'm told my stoma is a "lovely oval".  It is definitely still shrinking.  I started out at 1-1/2" and now am at 1-1/8" even though when I use the template I measure 1" exactly.   But this is where the nurse says I need to go a little bigger.  I have heard a lot of people talk about the Eakin seals so perhaps I should look into that.  My skin is definitely having a hard time right now and looks bad around the stoma (raw, raw, raw).  She did apply a paste so I hope it helps some.  I did receive a free sample of the moldable ring so I guess I could also ask to try that.  She suggested I start changing my appliance every other day right now while my skin is so bad.  Dreading this.  I look forward to the day when I can order the pre-cut wafers.  Thanks so much for the input.  I am so lost in this whole process and struggling to come to terms with it.
Past Member
Reply by Past Member, on Tue Oct 29, 2013 4:44 pm
It is a lot of practice.
You Should have a size guide with your stoma products. get a rough measurement maybe a few miller meters bigger and  use the paste around the wafer and that seemed to work for me.
keep the template and you should be ok
Reply by Ewesful, on Tue Oct 29, 2013 7:19 pm
I was told the same thing and I suddenly decided this is crazy - if the skin is breaking down because the digestive acids whatever are eating the skin, then it is time to rethnk the size -- so I did one not a smidgeon bigger than the stoma - the skin was immediately better but it took a couple times to be 100%.  I absolutely do not let the bag stay over 3 days and if anything feels itchy, it means the skin is being compromised so get it off as soon as you can - obviously if you are at work or wherever you can wait awhile, but I learned that was an immediate clue.   I am  wishing you the best of luck.  Also the stoma will change over time - I am nearly 7 mos out with FAP and have had 3 size changes already - smaller as it "heals"  The stoma does not "hurt" as there are no pain cells  there but all the tissue sure is sensitive to pain.
Reply by tudibird, on Tue Oct 29, 2013 8:05 pm
Thanks guys for the feedback.  My appliance was changed yesterday and already my skin is itching under the wafer.  I have my first post-op apt tomorrow and will see my ostomy nurse from the hospital at this appt.  I am anxious for her to see how my wafer cut out looks and get her input.   I almost wanted to change the bag today but really wanted to know if the hole for my stoma has been cut too big so I can say something to my home health nurse who keeps insisting on cutting it bigger than the measurement.  Hopefully I return home tomorrow better informed and better instructed on cutting the wafer so I can get my poor skin to heal.  It's upsetting that I'm only 3 weeks into this and my skin looks as bad as it does around the stoma.  Sigh.
Nurse
Reply by ahavvah, on Tue Oct 29, 2013 8:59 pm
Hi there,

Sounds like you must have an ileostomy? I always instruct my patients to cut the wafer approximately 1/8" larger than their stoma. This allows for it to expand and contract, as well as prevents the moisture from the stoma itself from wearing away the wafer. The caveat is though that if you have an ileostomy, its very important to cover that exposed skin with a paste product, like others have said either paste ring or tube paste.

You didn't mention what you were using for your irritated skin, but prior to applying the wafer, you could dust ostomy powder. It will stick to the wet irritated skin. Then coat over top that with a NON-STING barrier wipe or spray. Depending on the severity of the irritation, I do anywhere from 1-3 layers. Then put your wafer/paste on. This will coat the skin so it can heal. But your nurse is probably right that changing more frequently will be better because the powder/wipe mixture will cause the wafer to not last as long.

Best of luck in your journey!
Ashley

_________________
Certified Wound and Ostomy Nurse
Reply by iMacG5, on Tue Oct 29, 2013 9:32 pm
I think I'm correct in thinking any stoma output will damage bare skin.  If we cut the wafer 1/8" larger than the stoma, that 1/8" of bare skin will get damaged unless it's protected by some other means.  Stomahesive paste might be OK but, for me, Eaken seals work better.  That's after a skin prep like Cavilon barrier wipes or spray or Smith & Nephews protective spray.  There CANNOT be any unprotected skin next to the stoma.  That's my thought.  If I'm wrong I apologize and thanks in advance for the education.
Respectfully,
Mike
Nurse
Reply by ahavvah, on Tue Oct 29, 2013 9:47 pm
Hi Mike,

The amount of damage ostomy output creates really depends on how enzymatic the drainage is. Typically the higher up the bowel the ostomy is made-the more enzymes will be in the output. And more enzymes equal more damage. For instance a sigmoid colostomy (down near the rectum) won't have the enzymes that a high ileostomy (made from the small bowel) has. The lower in the gut the stoma is made, the more "normal" the stool should be, and the less costic to the skin (but there are always exceptions). So I think that is why Eakins work for some people and others are able to get away with just paste. Good thoughts! And I personally love the Cavilon wipes. Another one that I've found interesting is the Marathon skin protectant (I think Medline makes it). I just tested some on my hand and it stayed on for like 3 days! And that was through washing frequently of course.

Ashley

_________________
Certified Wound and Ostomy Nurse
Reply by anyark, on Tue Oct 29, 2013 9:52 pm
Have you tried putting an Adapt ring snugly around your stoma before putting the wafer on?  I put it on and then press it up against the stoma & down against my skin, put the wafer on, press more around the stoma to be sure the ring stays snug and that should take care of any gaps.  Then I put my hands over the wafer for about 5 min. to help the adhesive firmly attach to my skin.  Hope this helps.
Past Member
Reply by Past Member, on Wed Oct 30, 2013 3:05 am
Hi,
I highly recommend the ConvaTec Moldable Technology 2 piece system available in flat or convex.  I was having all the same problems that you have described. I heard about this system and ordered a trial packet directly from the company.  I tryed it out for 2 weeks and had virtually no problems with skin rashs, blow-outs, pancaking, leaks and odors. It was easy because there was no cutting or guesswork and it molds to your skin for a custom fit.   You don't have to worry about adding any other skin barriors such as the Adapt rings because it is built into the system.
You have to see it to believe it and really understand what I am talking about. If you are ready for better,  call ConvaTec and order a sample packet. YOU WILL NOT REGRET IT!!
Reply by iMacG5, on Wed Oct 30, 2013 10:04 am
Hey Ashley, I think we all learned something from your offering.  Thank you.  Also, like Suesong, I use the Convatec Moldable 2- piece stuff with Cavillon wipes.  If I didn't have that flexibility near the soma I would worry about the stoma getting squeezed.  Sometimes I use an Eaken seal but that's probably an overkill.
I think we'll all find what's best from sharing our thoughts and experiences.
Sincerely,
Mike
Reply by ostomyvisitor, on Wed Oct 30, 2013 11:01 am
Tudibird,

I'm enclosing an info sheet I give to all the new ostomates I visit in hospitals.

Please pay close attention to the "1/8 inch leeway" mentioned.

If you have the opening too close to the wafer there is the chance the wafer could cut your
stoma. On the other hand too large of a hole leaves your stoma prone to leakage. An 1/8
inch around the stoma is recommended by most manufacturers.

Here's that info sheet I give out:


Steps For Changing Your Pouch


Wash your hands well and have all equipment available.

***Gently*** remove the pouch. ***Push the skin away from the seal.***
***Do not pull the ostomy wafer away from your skin.***

Wash your stoma and the skin around it carefully with soapy water.
    * Do not use a soap that has perfume or lotion added to it.
    * Use mild soap, such as Ivory, Safeguard, or Dial.


Look carefully at your stoma and the skin around it for any changes.
***Allow your stoma area to dry completely***  
before connecting the new pouch.

Trace the shape of your stoma onto the back of the new pouch and
barrier or wafer (wafers are part of a 2-piece pouch system).

    * Use a stoma guide with different sizes and shapes, if you have one.  
Or, draw the shape of your stoma on a piece of paper. You may want to cut
out your drawing and hold it up to your stoma to make sure it is the right
size and shape. The edges of the opening should be close to the stoma,
but they should not touch the stoma itself.

*** (leave 1/8" leeway).***

Trace this shape onto the back of your new pouch or wafer. Then cut the
wafer to the shape.

    * The skin around your stoma should be completely dry and smooth.
There should be no wrinkles in the skin around the stoma.
(I use a hair dryer, on low setting, to completely dry)

Remove the backing from the pouch. Make sure the opening of the new
pouch is centered over the stoma and pressed firmly onto your skin.

    * Hold your hand over the pouch and barrier for about 30 seconds after
you have placed it. This will help seal it better. Warming the skin also helps.
(Again, I use a hair dryer on low setting)


I hope this helps!
Reply by Penguins7, on Wed Oct 30, 2013 11:04 am
I have had similar problems and yes any exposed skin around the stoma can cause problems. My ostomy nurse said if I can thicken my output this will also be a big help to the watery acid output penetrating around the stoma.  I cut mine very close to the stoma and I purchased a piece of pvc plastic cap from hardware store that fits inside the wafer and I use this to apply pressure when installing the wafer.  It is difficult to get your fingers close enough to stoma while pressing down the wafer.  Good luck I know it can be frustrating.  Rod
Reply by ostomyvisitor, on Wed Oct 30, 2013 11:09 am
Hey Rod,

That's a good idea. Her's a cheaper one... The ladies in my support group use the plastic top of a "hair spray" can.  I tried it with the top of my shaving creme cas and it works perfect!
Reply by Penguins7, on Wed Oct 30, 2013 11:18 am
The pvc caps are less then $2.00 at any hardward store.  The hairspray cap is a good one to but the pvc cap will catch any output while you are pressing the wafer on.  The cap is open on the bottom and closed on top.  I am very excited as I just finished my prototype for a stoma flow-guard that will help with seat belt pressure, pant/belt waist line pressure.  This device allows continuous flow into the pouch.  I tried a few that are on the market but they did not work very well.  Rod
Reply by soapy, on Wed Oct 30, 2013 5:34 pm
Hi, obtain some adhesive washers from your supplier, lay bag cut to size on flat surface, peel protective plastic nearly off, fold underneath bag, take washer out of its protection, stretch it to approx. size, place on bag adhesive, shiny side down, fold plastic backing back over bag/washer make sure all glue is covered. Put it on the floor cover it with plastic disposal bag and stand on it 4/5 times, place under arm to keep warm till needed, spray on skin protector when dry, put finger in hole and mold washer to bag hole, spin finger in around hole where stoma will enter to make sure it is smooth, remove plastic backing and fit to stoma, press washer from outside so it molds and fills in gap between stoma and bag still keeping warm with flat hand till done.

Best of luck...Les.
Reply by iMacG5, on Wed Oct 30, 2013 8:20 pm
Hi ostomyvisitor, kudos to you for your volunteering.  Now, I need to pursue the 1/8" thing.  With all due respect to you and Ashley, the bare skin surrounding the stoma is subject to damage.  Since you (OV) are not differentiating between illeostomies and colostomies and maybe even urostomies, I need to wonder about the enzyme levels relative to damage.  Suesong and I do the same thing and it works for us.  
I'm sticking with NO UNPROTECTED SKIN anywhere near the stoma regardless of where the stoma is.
Now Penguin, I'm with you on the PVC stuff except my stoma is a little too long for a cap.  Instead I use a 1/2" and 3/4" PVC coupling.  Their inside diameters are about 15/16"" and 1-1/8" respectively.  I slide the smaller one over the stoma and apply a slight pressure for about a minute.  Sometimes, I slide the larger one over and hold it for about a half minute.  I don't know why.  I guess it's just to better seal more of the wafer to my skin.  I never had a leak and don't ever want one.  BTW I heat my wafer with a hair dryer before applying it.
And Penguin, we're both from New Jersey but I'm older so I must be right.
Respectfully,
Mike
Reply by tudibird, on Wed Oct 30, 2013 9:55 pm
Thank you everyone for the helpful tips.  I had my two week follow-up today at Hopkins and my ostomy nurse stopped in to check on me.  She did measure my stoma at 1" with a small amount of room to spare so said the wafer I had on was too big.  She was not happy at how my skin looked and also said one of my problems is my stoma is sinking in some so she switched me to a convex 2 piece system with a 1" stoma opening.   She said this should help me considerably.  I hope she is right.
Reply by stomafart, on Thu Oct 31, 2013 4:42 am
Hi Tudibird,
I am assuming you are in the USA? Here in the UK the company I get my supplies from cut the hole to my stoma. I have it slightly larger than the stump but not too much. Around the ileostomy stump I have a special aloe vera powder which I first put on and then just take the excess with a tissue, I then spray cavelon onto the powder. Coloplast make extension strips for the outside of the bag but I cut one in half and then apply this to the raw site which I have just put the powder on. The I use a cavelon stick all around my skin where my bag will go and then make sure the stump is in the middle when applying. One secret is to make sure that you have a small amount of air in the bag when you close it or it will suck itself to the stoma and that is when you get pancaking and leakage. I then fit 2 extension strips on the edge of the bag and heyho! I have not had a leak for a long time, the skin around the stoma is a little raw but not sore. I work in the operating theatre as an assistant to the colorectal surgeons and this was such a nightmare as I would always leak during surgery and I had to leave the operation and could not finish sutering the patient and had to leave this to the surgeon. They were very understanding as they had done the surgery for me but it has really been trial and error with the bag and now I am happy. I am very lucky as in the UK all the products including disposable bags, wet and dry wipes etc are all free and I have been able to try various products until I got it right but try and leave some air in the bag on closure.
Good luck and I know how you feel but things will be alright in the end.

Regards
Stomafart
Reply by Penguins7, on Thu Oct 31, 2013 6:28 pm
Mike,  I am from Michigan but since you are older then I will give you the wiser part.  Penguin
Reply by VeganOstomy, on Fri Nov 01, 2013 9:51 am
                                 
Penguins7 wrote:
The pvc caps are less then $2.00 at any hardward store.  The hairspray cap is a good one to but the pvc cap will catch any output while you are pressing the wafer on.  The cap is open on the bottom and closed on top.  I am very excited as I just finished my prototype for a stoma flow-guard that will help with seat belt pressure, pant/belt waist line pressure.  This device allows continuous flow into the pouch.  I tried a few that are on the market but they did not work very well.  Rod



That's a great tip about the PVC cap! I've got to check that out the next time I'm at the hardware store!

We'd love to hear more about your stoma flow-guard.  New products are always exciting Smile
Reply by iMacG5, on Fri Nov 01, 2013 11:54 am
Sorry, Penguin.  Obviously, my "wisdom" took a detour.  Thanks for the free pass.  Special thanks for sharing your research.

Mike
Reply by tudibird, on Fri Nov 01, 2013 1:31 pm
Follow-up to my post about switching to convex wafer.  Wow, what a difference 2 days made.  Home health nurse came today to replace appliance.  My skin has already improved by 50%.  I was amazed and so happy.  My stoma, however, is taking on an entirely new shape and one side has sunk considerably (almost down to my belly level) and this is where my opening is so don't know how things will play out.  But for now very happy my skin is healing with the convex wafer.  To Stomafart, must say love the username and lucky you to have free supplies to try.  It's definitely been trail and error with me.  The fold and lock bags seem to give me a heck of a time getting the opening open even though it says just squeeze the sides.  I must be clumsy because half the time I can't get the dang thing to open.  To all others, I love all the feedback.  So many good ideas.  This site has been so helpful to me as I begin my journey with an ileostomy.  I'm now 3 weeks post-op and coming to terms better with all of this.
Reply by bmeup, on Mon Nov 11, 2013 11:37 am
Hi Tudibird,

It sounds like your stoma and mine could be twins.  I had a heck of time learning to cut the wafer correctly to fit over my oval stoma.  I use the Coloplast Assura 2-piece system and having tried many different products I find this to be the one which works best for me.  I do have to get a little creative sometimes with the stencil for the wafer.  I place one guide over the upper part and mark either side where the stoma starts to go oval.  I tape this to my body and then I use another guide and place on the stoma at the bottom, then tape to the other guide.  When I remove it I have an oval guide which I use to cut the wafer.  I save the plastic backing so that I don't have to go through all of that again until my stoma decides to change shape slightly.  I always cut it as close to my stoma as possible without causing pain.  You can smooth any rough edges just by rubbing or cutting them away.  I use skin barrier wipes and that's all unless I start having problems then I might layer on the spray or the Nystop powder if my skin gets irritated.  Also I've suggested this in the past to another ostomate on this site but if you are having problems with stinging or irritation under the wafer, when removing I use the wax removing oil that I find at Sally's in the waxing/hair removal section.  It works great and doesn't sting and is good for your skin.  You just have to be sure to rinse all of it off before applying your wafer or it won't stick.   Remember it takes a while for your stoma to finally find it's true shape and even then it can decide to change on you. Lol! You just gotta roll with it.  Good luck and I help this helps.
Reply by ostomyvisitor, on Mon Nov 11, 2013 3:27 pm
There is an ostomy company that has oval stencils to use when measuring your stoma.
Its called Nu-Hope Laboratories in California. their website is:
www.nu-hope.com

****     or you can call  1-800-899-5017

Incidently there should be a 1/8 inch lee way around your wafer.
Don't cut the wafer/flange too close leave a one inch lee way.

It seems you have excorriated skin from feces laying on it... Here are directions for changing ones pouch



Steps For Changing Your Pouch
Wash your hands well and have all equipment available.

***Gently*** remove the pouch. ***Push the skin away from the seal.***                 
***Do not pull the ostomy wafer away from your skin.***

Wash your stoma and the skin around it carefully with soapy water.
   * Do not use a soap that has perfume or lotion added to it.
    * Use mild soap, such as Ivory, Safeguard, or Dial.
Look carefully at your stoma and the skin around it for any changes. ***Allow your stoma area to dry completely***  before connecting the new pouch.

Trace the shape of your stoma onto the back of the new pouch and barrier or wafer (wafers are part of a 2-piece pouch system).

    * Use a stoma guide with different sizes and shapes, if you have one.  Or, draw the shape of your stoma on a piece of paper. You may want to cut out your drawing and hold it up to your stoma to make sure it is the right size and shape. The edges of the opening should be close to the stoma, but they should not touch the stoma itself. *** (leave 1/8" leeway).***

Trace this shape onto the back of your new pouch or wafer. Then cut the wafer to the shape.


    * The skin around your stoma should be completely dry and smooth. There should be no wrinkles in the skin around the stoma. (I use a hair dryer, on low setting, to completely dry)

Remove the backing from the pouch. Make sure the opening of the new pouch is centered over the stoma and pressed firmly onto your skin.

    * Hold your hand over the pouch and barrier for about 30 seconds after you have placed it. This will help seal it better. Warming the skin also helps.  (Again, use a hair dryer on low setting).





CARING FOR EXCORIATED SKIN
If after removing your wafer you find your skin to be red, denuded of skin, painful or sensitive, you have “Excoriated Skin.”

Excoriated skin is often caused by pulling at your wafer too vigorously, along with moisture under the wafer. Use the 'Push Pull' method below.

When removing your wafer use a non-alcohol adhesive remover. Simply hold down your skin with the adhesive remover pad and going from side to side, gently pull your wafer down and away from your skin.

After gently washing the stoma and surrounding skin with warm water, dry the skin thoroughly. Sprinkle the skin with stomahesive powder, dust off the excess and seal the powder in with a non-alcohol containing skin prep, i.e. Cavilon spray.

Wipe the skin with the skin prep until you can’t see any more powder. Then instead of placing your wafer squarely on your skin put it on “diamond” shape. The next wafer change put it on your skin squarely [ ] and rotate every other change.

This gives at least part of your “excoriated” skin a good chance to heal. Remember be gentle with your skin and it will be good to you!


A quick fix (as long as it's not fungal in origin) is to get some Maalox (not the mint kind!). Don't shake the bottle, skim the watery bit off the top and dab the thicker mixture onto your irritated skin. Wait for it to dry and put your wafer on over the top (it will still stick!). It helps soothe and heal the sore irritated skin.
(If you have trouble locating Maalox, it may have been discontinued, use the generic brand).


I Hope This Helps


Copyright  2007  Larry Pilarski  All rights reserved
Reply by tudibird, on Mon Nov 11, 2013 10:10 pm
To bmeup - I just received some samples from Coloplast and I spoke to a rep about applying the wafer and can't remember if she said to heat it up before applying or not.  Do you heat yours up and how do you do it?  Thanksl
Reply by ostomyvisitor, on Tue Nov 12, 2013 11:37 am
You can use a hair dryer set on low to warm the wafer up... Slowly go around the wafer.  You can also warm the skin around your stoma this way...  BUT be sure to have the hair dryer on low.

Another way if no hair dryer is present... After centering and placing the wafer over the stoma, just hold your hand over the wafer and apply gentle pressure for about a minute ~~ the heat from your hand will also bring heat through the wafer to the skin.

I chose the hair dryer because I can aim where I want the heat.

One more thing, if you have gained or lost weight you may have some "Nooks & Crannies" (little crevices in/on your skin).  If you have this problem it is best to use a wafer that is very thin. The pliability of this type of wafer will work itself into crevices -- I use wafers that seem like a band-aide (That's how thin they are).

Most of the people in my support group use this type of wafer when running into leakage problems.


I hope this helps. . .

Good Luck,

Lawrence (Larry) Pilarski
     The Ostomy Visitor
Reply by hometown, on Thu Nov 21, 2013 4:42 am
Don't feel to bad as I have the same problem and it is four years and I still don't get it right,  My biggest problem is I can't touch the stoma as it makes me sick and I start gagging, so I have to judge.  I get it ok most of the time now  My other problem is the colostomy was misplaced and I can;t see it with out holding a hand mirrow close.  Do you have and ill feeling touching the stoma?   Well keep at it you will get it right most of the time    Joyce
Reply by Penguins7, on Thu Nov 21, 2013 9:34 am
Hi VO,  The PVC caps works great for applying pressure plus the cap catches any output so it doesn't get around stoma and ruin new wafer before it is properly adhered.  I got my first prototype for the stoma flow guard and it works great.  I drive a lot for my job and it really keeps seat belt pressure off stoma.  Plus it allows flow into the pouch from restricting waist bands and belts.  I tried a few products on the market and did not like the results.  Take care.  Penguin
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