Appliance Wear-Times
Question:
I have just come home from the hospital with an ostomy. My ET in the hospital said I should change the appliance twice a week, but my HomeCare Nurse says I only need to do it once a week. What should I do?
Answer:
While you may hear that wearing an appliance for seven days is the goal for all patients with ostomies, there is no standard wear-time for ostomy appliances. Several variables must be taken into consideration when determining a wear-time that best suits your needs:
- the type of stoma you have,
- the “age” of the stoma,
- the characteristics of your stool,
- the construction of your stoma and the surrounding skin contours,
- the type of barrier/product that you are using,
- and social norms.
Stoma Type
The type of stoma you have (ileostomy or colostomy) provides general information about your stool: ileostomies tend to have liquid to pasty stool and typically function about 4-6 times daily, while colostomies tend to have thicker, more formed stool and function less often. More liquid stools and more frequent stoma function contribute to “melt-out” of the barrier (the gradual erosion of the barrier component of your appliance), necessitating more frequent changes or alternate products. When the barrier melts, it no longer provides skin protection, potentially leading to skin irritation. An Enterostomal Therapy Nurse (ET) can show you how to assess the degree of melt-out you have with your appliances, and determine an appropriate wear-time.
Stoma Age
The “age” of your stoma may also temporarily influence how often you must change your appliance. Newly constructed stomas are initially edematous, or swollen. It generally takes 6 weeks for the swelling to resolve, during which time the stoma will gradually decrease in size. As the opening of the flange should always be 1/8 inch (3-4mm) larger than the base of your stoma, you will need to adjust the flange opening as the swelling decreases. For this reason, an ET will often recommend that you change the flange twice weekly for the first 6 weeks after surgery, to ensure that your peristomal skin is well protected from the stool. After 6 weeks, the frequency of appliance changes can be re-evaluated.
Stool Characteristics
As mentioned above, the characteristics of your stool can affect the wear-time of your appliance. While most people with ileostomies will function 4-6 times a day for liquid/pasty stool, and those with colostomies will function much less frequently for formed stool, there can be individual variations based on the amount of bowel resected during surgery, underlying disease states, or treatments such as radiation and chemotherapy. All of these either may temporarily or permanently change the consistency of your stool: again, more liquid stool with more frequent bowel functioning will cause your barrier to melt and wash away faster than stool that is formed and functions less. More rapid melt-out generally means more frequent appliance changes.
Stoma Construction
Ideally, well-constructed stomas protrude and have flat surrounding body contours, allowing for simple pouching products and techniques. Quite often, however, stomas may not protrude, or there may be peristomal creases and skin curves that make pouching more challenging. In these situations, wear-times may be less than expected. Achieving predictable wear-times of 1, 2, or 3 days may be more reasonable than trying to make a leaking pouch last for a longer period of time.
Type of Product
The types of products you are using can also impact on your wear-times. Most ostomy suppliers carry 2 types of barriers: regular and extended wear. Regular wear barriers have specific characteristics: the barriers are less resistant to melt-out, have less initial adhesion and enduring tack, and tend to be slightly cheaper in cost. Regular wear barriers work well for patients who have colostomies with formed stool. Depending upon the degree of stomal protrusion and peristomal skin contours, these flanges can be worn for up to a week. Regular wear barriers can be used for ileostomies, but the consistency of the stool and the frequency of outputs mean the barrier will melt-out more quickly, and changes of the flange should be considered after 3-4 days.
Extended wear barriers, on the other hand, have different characteristics: these barriers are more resistant to melt-out, have greater initial adhesion and enduring tack, and tend to cost slightly more. People with ileostomies more commonly use these types of barriers, as it takes longer for the barrier to erode than a regular wear-barrier; consequently, these barriers can also be worn for up to 7 days without compromising peristomal skin.
Some people use special barrier rings such as ConvaTec’s Eakin® Seals, Hollister’s Adapt® Rings, and Coloplast’s Skin Barrier Rings®, in addition to the barrier on the flange. These products can also extend the wear-time of an appliance. If you are unsure how long you can extend the wear-time of your appliance with the use of these barrier seals, you should check with your ET. Some people with colostomies (and formed stool) use a 1-piece closed end pouch that is intended to be changed when ⅓ to ½ full of stool. Depending upon stool volume, this can be 1-2 times a day, or up to once every other day. The barriers on these appliances have been specially formulated to have less tack, minimizing skin damage with frequent removal.
Social Norms
Lastly, social norms can also be a determinant of wear-times. In North America, it is commonly believed across the healthcare system that ostomy appliances should be worn for at least a week (in most cases). There is varied and limited financial support from provincial and federal government sources, as well as varied coverage from third-party payers (insurance companies). Manufacturers have responded to this “norm” by producing barriers that are more resistant to stool and have greater adhesion.
The financial cost of supplies may be burdensome for some people, causing them to extend the wear-time of their appliances beyond recommendations. In contrast, some European standards are very different: wear-time expectations for appliances can be quite short, no more than 2-3 days, and there is substantial support from government agencies, alleviating the financial impact on patients with ostomies. Because appliances are not intended to be worn for long periods of time, product formulations differ and reflect the need for less enduring adhesion and less resistance to erosion.
Determining the ideal wear-time for your appliance should be done in conjunction with your ET, giving consideration to the points mentioned above.