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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!
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