Retracted stoma, bag repeatedly coming off

[rDsport]

Hello!

My elderly mother (94) has had a colostomy for almost 4 years now. The stoma has pretty much been retracted since the original surgery. Due to her age and risk of complications, her doctor has discouraged a re-sitting. We agree!

Mom lives in Assisted Living, so we rely on the staff to change the flange and bag. Unfortunately the flange is prone to popping off regularly (since there isn't an 'external' stoma for the flange 'hole' to wrap around) and she uses her 20 flanges (supplied by Medicare) usually halfway through the month. We've just buy more out of pocket and make the best of it. The perception is the stool is pushing on the backside of the flange and pushes it "off."

Mom is also little overweight and unfortunately with her age and mild dementia she doesn't like wearing supportive undergarments. We believe that aggravates the situation creating a pushing down effect on the flange/bag as well. She's also of that generation that doesn't want to be a bother, so she'll wait until it's popping off and exploding onto her before asking for help or for someone to check. The staff checks the bag once in the morning and once in the evening (we'd prefer it be more frequently, but like most facilities, they seem to often run short-staff unless someone calls for help, no-one is roaming looking for problems. Mom is also now the only one with an ostomy).

Her situation has been reviewed by the wound care nurse at our pouching supply twice. She's great but unfortunately doesn't make on-site calls (we even offered to pay for the visit). Her flange has been changed to a convex, and those semi-circular tape reinforcements have been used on the edge of the flange to the skin. Instructions were given to use no cleaning toilettes or wipes (only warm water, as the flange won't stick properly once other residues on on the skin). Finally, the facility now only lets the nurses change the flange; not the assistants. None of this has reduced the frequency of it popping off.

The head nurse suggested more stool softener. I told her I didn't object to trying, but observed mom's stool was already soft, the consistency of loose pudding, so I worried if it became even looser, would that really help?

Her flange 'hole' is 1" pre-cut. I also wondered if making it wider, since her stoma is retracted, might help? (The theory is less for the stool to push on the back-side)?

Based on all this, we're resigned to the fact what we be at the best we may be able to achieve, considering mom's age, mild dementia, retracted stoma, etc...

Any thoughts? We're open to other's experiences and suggestions!

[ot dave]

Hello!
Sorry to hear that your mom is struggling with her ostomy. You are on the right path with what you have been doing. A convex flange sounds like the appropriate flange for her. In addition to the flange, you might consider trying a seal. Some common names are Eakin Seals, Adapt Barrier Rings, etc. They are a moldable material that you can place either on the skin or on the flange prior to flange placement. These kind of act like an O-ring in a garden hose, and they keep output from creeping behind the flange.

Applying a flange to a dry clean surface is definitely the way to go. Wipes and other cleaners do leave behind oils and residues that compromise flange adhesion. Soap and water is best, making sure to dry the skin well prior to applying the flange.

You want the cut edges of the flange to be about 1/8"-1"4" away from the edge of the stoma. You are correct in that it gives the output a little more room to slide into the pouch and keep it from going behind the flange. If you have to, you can definitely cut the holes bigger.

I would really recommend that she be placed on an at least every 4 hour checks of the ostomy. Everyone voids differently, but twice a day doesn't seem adequate to me, especially if she is having these issues. I don't know what kind of pouch she has, but I would recommend drainable pouches, that way she wouldn't need to go through them so quickly, at least if you've got a good seal on the flange.

Stool softeners are for constipation issues. If she isn't having constipation issues, I wouldn't recommend a softener. They may make the output more loose, which would make it easier for the output to leak behind the flange. More thick, formed stool, would be preferred...in my opinion.

Hope some of that helped.

David

[cdogtom]

i agree with everything David said ,get some samples of a larger two piece ...good luck solving these issues

[rDsport]

Appreciate the responses...

I failed to mention we already use a wax ring... Maybe... I'm starting to take an inventory of supplies each time I go, and so far we don't seem to be going through wax ringes as quickly as the flanges... Hmmm.

When I change the flange, I attach the wax ring to the back-side of the convex flange bottom, around the hole opening. At least that's what we were taught. However, I've also found them on the inside of the flange hole side as well (I guess someone goofed). Another thing I noticed when mom had a brief visit to the hospital, was that wound care nurse put his hand on the flange after applying it to the skin, and held it there for at least a minute. Seems like he was trying to mildly heat the wax ring? and make sure the flange had better adhesion to the skin. The big difference there was mom was lying down in a hospital bed, and normally in Assisted Living she's sitting up in her wheelchair. Regardless, we need to try to remember to try that. Also, I wonder if we may need to try additional paste or wax to fill in areas where the skin around the retracted stoma has a valley. Along with possibly cutting a slightly bigger hole into the flange.

We agree on an increased frequency of checks. Hopefully the staff will cooperate and/or remember.

We also recently switched from emptyable bags to tossable ones. With Medicare you get fewer emptyable bags per month and we always ran out. With the close-end tossable ones, we always wind up with extra. Don't know why...

More trial and error I suppose! Thanks all!

[ot dave]

Yes, the seals go between the skin and the flange. If you found one between the flange and the pouch, then that was a mistake. I caution against the use of paste. It's name is deceiving in that it does NOT possess any adhesive properties. Think of it more as a putty. There are only a few folks who find that stuff useful. It usually causes more issues than it is worth and people quickly find it to be the cause of leaks in their systems.

Applying the flange while seated is probably not ideal either. I would recommend changing it while supine on the bed or in standing. When you sit, your abdomen "wrinkles" , causing dips and valleys in the skin. Ideally, you want a flat surface to attach the flange too. They are flexible, but if you put it on with the skin "wrinkled", and then stand up, the skin is going to pull away from the flange causing potential leaking areas.

The flanges do stick better once they are heated up to body temperature. When I'm in a hurry, I will use a hair dryer for a few seconds to warm up the flange before placement. When I'm in no hurry, I like to lay on my bed and let the skin around the stoma get some air for awhile, and I will lay on the flange to get it up to body temperature. Then, after application, I will lay on my stomach to promote better adhesion as well.

If you are ending up with more closed pouches than drainable pouches at the end of each month, then the ALF is either not draining the pouches with enough frequency, or they are simply not draining them, and throwing them away with each change. I can make a drainable pouch last for days. There's really no typical reason, except for neglect, that would explain why 20 drainable pouches wouldn't last for a month.

Hope that answers some more questions.

David

[Jimbob]

David is spot on in what he is suggesting, The adhesives on the flange is formulated to work at body temperature. I always heat mine with a hairdryer to get it to temperature.

Also the skin must be perfectly clean and dry for the flange to work best. Ensure that if they are using a cleaning agent such as a wet wipe that it contains no lotions or fragrances. Best to just use soap and water like Dial or Ivory that do not have the fancy stuff added. Make sure there is no soap residue left. Using the hairdryer on a warm, NOT HOT, setting will help dry the skin.

[derryairre]

We have had an ordeal with my moms since Feb this year.we finally went with the 2pc Hollister and her stoma is flat and wouldn't stay on for the longest time.her opening size is 2 3\4 we have to get the one where u cut it urself, its been an ordeal hope it gets better for your mom

[To Dream a Dream]

Excellent advice from the above. Just to add that some facilities may have access to a WOCN's help. Thank you for supporting your mother during a difficult time.

[Bklynbabe]

Is she using an ostomy belt? Or does that fit in the realm of supportive undergarments for her? It might help and it doesn’t really feel very restrictive.