06. Management of the Ostomy Patient - General Principles Postop Care - Stoma Assessment and Pouching

In this class, we're going to talk about general principles and guidelines for post-operative management of the ostomy patient. We're going to focus specifically on assessment and then pouch selection. We'll describe management principles for the patient with the new ostomy, parameters to be included in the initial assessment of the stoma, we'll spend a good bit of time on pouching system options and considerations, and I'll introduce a decision pathway for selecting an appropriate pouching system for an individual patient. So your patients back from surgery, this is your first visit to see this patient. In this visit and throughout the initial post-operative phase, you'll be assessing stoma viability and function that will be an ongoing assessment. You'll be working to establish an effective pouching system. You'll be assessing the patient's emotional status and providing ongoing support. And you'll be working to teach that patient the basics of self-care and ostomy management. This is our focus in the hospital following ostomy surgery and also in the home health setting for a new ostomy patient. So looking at stoma assessment, we're assessing both viability and function. We look at color, we look at turgor, we look at hydration. A normal stoma is the end of the bowel or a loop of bowel, so it should always be pink or red, it should be moist, it should have good turgor. Indicators of ischemia include a grey, brown or black color like you see on the bottom right and the bottom left. Now one thing to be aware of, you can definitely see a dark maroon color kind of a dark red purple color, that doesn't necessarily mean ischemia, it can just reflect congestion because there is edema in the stoma during the initial days and weeks post-operatively. So if you see bright red, moist, good turgor, great, that's what you will. If you see dark black, dry, you've got to do further assessment of the proximal bowel. If you see kind of a purple red color, kind of a swollen stoma, you're going to continue to monitor. Usually you'll find that that resolves within the first few days post-operatively as edema subsides, I think I went the wrong direction, I apologize, see if I can get this right. So now let's talk, what if you do see indicators of necrosis? What if you go and you find that the stoma is 100% brown black or 50% brown black? Then you want to know, what's going on with the proximal bowel? Because you can have two different situations. The best scenario if the stoma itself does not look good, if the stoma itself looks brown or black and dry, is that the proximal bowel is viable. Because remember the stoma typically represents kind of the end of the bowel. If the proximal bowel is viable, then that means there's no risk of intra-abdominal perforation. It means that the dead portion of the stoma is going to sluff off. It will alter the contours of the stoma, you might end up with a skin level stoma. That might modify your pouching system, but the patient will not require surgery. So if the necrosis is limited to the stoma itself, that's a relatively good sign. We're going to continue to monitor. We're going to allow the necrotic portion of the stoma to sluff. We're going to modify the pouching system as indicated. A more concerning scenario is when the evidence is that the necrosis involves not only the stoma, but also the proximal bowel. If the proximal bowel is necrotic, now we have to worry about intra-abdominal perforation and sepsis. In this case, we need to notify the surgical team because they might need to take the patient back to surgery. So obviously, it's very important to differentiate between the necrosis confined to the stoma itself and the necrosis that also involves the proximal bowel. How do you do that? We do that through what we call the test tube assessment, or some people call this a mini endoscopy. What you're going to do is you're going to take a test tube. You're going to lubricate the blunt end. You're going to place the blunt end into the stoma, and then you're going to shine a flashlight while looking through the test tube so that you can actually see the mucosa of the proximal bowel. If the mucosa of the proximal bowel is bright red and healthy, great. That means that necrosis is limited to the stoma. You'll continue to monitor. You'll modify your pouching system as indicated. But if you put that test tube in and you shine your flashlight and you look, and all you see is brown black, that's a very different situation. Now you have necrosis involving the proximal bowel. Now you have to let the surgical team know very likely that the patient will have to go back to surgery. So we assess viability and that's an ongoing assessment for the first few weeks post-operatively. You also assess stoma function. Now what you expect from a fecal stoma and what you expect from a urinary stoma is very different. We know that in Ilias is a normal post-operative occurrence for a patient with a fecal stoma. The time frame for a resumption of stool output depends on where is the stoma. Is it a small bowel stoma? Is it a large bowel stoma? You probably all know that small bowel Ilias resolves fairly quickly. Typically we see output from an Iliostomy within 48 to 72 hours. Ilias involving the colon takes longer to resolve so it's very common for a patient with a colostomy to have no gas, no stool, for three to four days. So typically by the end of day two with an Iliostomy you have output with a colostomy it might be the end of day four, occasionally day five. But look at normal findings for a U-rostomy. As soon as they connect the ureters to that section of bowel your instinct should start flowing through the stoma into the pouch. So you should have immediate output of urine. If you do not have normal output of urine you would immediately notify the surgical team. So if you had either a very low volume output or no output. Now what about hematuria? Well hematuria is common because after all we just did surgery, we moved the ureters from the bladder to the segment of bowel. So yes very common to have hematuria but you should have normal volumes of urine output. And the urine should be mixed with any blood so that you have urine that is transparent not opaque. If there's enough blood to make the urine opaque now you have an actively. So your concerns with an u-rostomy, no output, very limited output or significant bleeding as evidenced by opaque urine. So goal number one, monitor the stoma in terms of viability and function. Go number two is to establish an effective pouching system. You've already talked about how important that is, that it's foundational to patient rehab. What we're trying to accomplish, effective containment of stool or urine and odor, consistent protection of the peristoma skin, prevention, burning and itching of the peristoma skin. stemless skin and predictable wear time. So we want a good seal. We won't help the peristomal skin and we won't predictable wear time. Now when you look at the world of pouches and pouching systems it's a pretty big world. There are three major companies and a number of other companies and each company has a number of product lines. So how do you bring order out of that chaos? Well this is one way to look at it. All pouches are either urinary or fecal. That's a very good starting point. Within the world of fecal pouches you have drainable pouches. You have high output pouches and you have closed-end pouches. We'll talk more about that. Pouches are either one piece or two piece. Some patients do better with one piece. Others prefer two piece. You can categorize pouches by the type of barrier used to protect the skin and prevent leakage. Barriers are either standard or extended wear or infused and we'll talk about each of those. You can separate pouches based on the shape of the barrier. Is the barrier that goes next to the skin? Is it flat or is it convex? That helps you make an appropriate decision. How stiff is this pouching system? Is it completely flexible? It will bend into a deep crease. Is it semi-flexible? So the edges bend but the center is fairly rigid or is the entire system rigid. And finally do you need any accessory products? Do you need rings? Do you need straps? Do you need paste? Do you need added adhesive? Might you need to add about? So we're gonna walk through all of those decision points. So when do you use a urinary pouch? When do you use a fecal pouch? Well I know you're laughing and saying well duh you use a urinary pouch for urinary stoma and a fecal pouch for a fecal stoma and you're absolutely right. But do you know how many times ostomy nurses go in and find urinary pouches on fecal stomas and fecal pouches on urinary stomas? So our point is not only do you need to understand this, your staff needs to understand it as well. So you see the urinary pouch on top? I also have a urinary pouch right here. So unique features to urinary pouches are the spout system. So this is designed to drain urine. It's also designed to connect to a night drainage system. That spout is exactly what you need when you're emptying urine, but it does not work well for stool. Even if the output is fairly liquid, it doesn't drain well through this very narrow spout. Now the other thing that you get with a urinary pouch and I wanted to explain this. So I hope you can see this. It's something called an anti-reflux valve. It's not a valve. It's an extra layer of pouch material. So I hope you can see that the outer layer of the pouches out here and I've pulled the inner layer of the pouch through so you can see it. This is the anti-reflux valve. What does it do? It essentially folds down over the stoma and prevents urine from pooling on the skin. So the anti-reflux valve in a urinary pouch is designed to protect the peristomal skin. When I'm wearing this pouch, the urine is trapped in the outer chamber away from the skin. That's the role of the anti-reflux valve. So not really a valve, an extra layer of pouch material designed to prevent massuration of the peristomal skin. So unique features for a urinary pouch are the spout and the anti-reflux valve. Great for urine, not good for stilts. Fatal pouches, as you see on the bottom of this slide, actually come in three versions. Most of your pouches are what we call drainable. So if you look on the left, look at the illustration on the left. You see drainable pouches. Drainable pouches have a fairly wide spout that facilitates the emptying of stool and that works for the vast majority of patients with a fecal ostomy. But you also had the option to use a high output pouch which you see in the middle of the screen. So it looks like a fecal pouch but it does have a modified spout that can be connected to a drainage system. That's very helpful for patients who have very high volume output, like a high volume eleostomy. And finally look to the far right on the bottom. Fecal pouches also come enclosed in. Those pouches cannot be emptied. They have to be removed and replaced. But they're a good option for patients with form stool, especially if there's any kind of barrier to emptying, which we'll talk more about. So let's talk a little bit more about this drainable high output closed in. So drainable or high output pouches. Again you see them at the top in the middle of the screen. These are standard care. You should empty these pouches when they're one-third to one-half full. In general they're changed every three to seven days. So once or twice a week. Drainable is considered kind of standard of care for the vast majority of patients. They work really well for patients who have moderate volume output. High output pouches as we've just said should be limited to the patients who have liquid high volume stool. So it's a high volume eleostomy, a high volume geogenostomy. Closed in pouches have to be removed and replaced when one-third to half full. So they're not indicated for patients with high volume output. They're very good for patients with form stool low volume output because you would only need to remove and replace the pouch once or twice a day. It's a great choice for patients who have limited dexterity, compromised eye hand coordination and they have difficulty manipulating the spout of a drainable pouch. You could teach them instead just peel the old pouch off or snap it off. Put the new one on. Closed in pouches are also a great choice for patients who hate emptying. There are patients who will tell you I don't mind changing it. I absolutely hate emptying it. It feels nasty to me. I have a hard time not getting it on my fingers, even with gloves. It still just grossed to me. I hate it. Okay, well let's talk about closed in pouches. That might be much more comfortable for you. So think about that as an option. When you have a patient who hates emptying or who has a very difficult time with emptying, most insurance companies will cover 62 closed-in pouches a month. So they basically will cover two pouches a day. If your patient would be going through more closed-in pouches than that. If they're having to empty three times a day and they want to switch to closed-in, you've got to have a discussion about the calls factor. We've said it's a good choice for patients who are having output once or twice a day and you should be aware that closed-in pouches come both in one piece and two piece. So if you're using a closed-in pouch, you could either take one off, clean your skin, put another one on, or you could snap it off of the two-piece wafer, clean around the stoma, snap a new pouch on. What about one-piece versus two-piece? Probably a lot of you have been asked by your patients which is better, one-piece or two-piece. I was asked that very question last week which is better, one-piece or two-piece. It's not which is better, it's which is a better choice for this patient. They work equally well. They use the same kind of barriers. So one is not going to give you a better seal than the other. Here are the things to think about. With a one-piece, one piece. When you change the pouch, there are fewer steps involved because the system is molded together, is welded together. So once you put the pouch down, you're done. Whereas with the two piece, you put down the barrier wafer and then have to snap on the pouch. So it's fewer steps. Frequently a good choice for patients with poor dexterity or limited hand strength because you don't have to snap anything together. But you do not have the option to change the pouch and leave the barrier wafer in position because it all goes on and comes off together. And the other thing I didn't put it on here but I should have is that some people find a one piece pouch more difficult to center. So look at the two piece. Look at the bottom illustration on your slide. So you can see that with the two piece system is very easy to center the barrier wafer around the stomach. You can see exactly where you're going. You can tell, did I get it lined up exactly right? Yes, it's right where I want it. So that is very helpful to a number of patients early post-op being able to visualize that they center the pouch correctly. You do have the option to snap off a pouch and throw it away and snap a new pouch on. That can be beneficial for people who might want to use a closed-em pouch during the day, a drainable pouch at night. I've had some patients who wanted to use drainable during the day, high output at night. So if you have a patient who needs to move back and forth between either a drainable and closed end or a drainable and high output, they would be better off with a two piece system. But they have to have enough hand strength. They have to have enough dexterity to snap the pouch onto the wafer. So sometimes I'll take a one piece pouch and a two piece pouch to the patient's bedside and say, "Let's figure out which one of these is better for you." So let's go through what you would do to put this pouch on. Let's go through what you would do to put this pouch on. Let's see how difficult it is for you to snap the pouch onto the barrier wafer. And then you can make a choice. Now, barrier formulation is usually a fairly straightforward decision point. In the past we frequently used corioreng barriers. And that's what you see on top. You see a corioreng attached to a pouch. It was the very first barrier we had. It works pretty well for solid stool and is very conformable. But it does not provide any active adhesion. So you always have to have a tape border or a belt. It's very soft. Melt's rapidly with heat. Melt's rapidly with liquid stool. Melt's instantly with urine. So you will see corioreng use very infrequently. I mention it because you might still have patients who use it and who do well with it. But it definitely has many limitations. No adhesion, minimal resistance to liquid stool, no resistance to urine. Most of the pouches on the market today use either a standard wear hydrocholoid barrier or an extended wear hydrocholoid barrier. Your standard wear contains pectin but primarily gelatin and a little bit of carboxy methylcellulose. It is very moldable. It's adhesive. It's designed to absorb small amounts of moisture so light perspiration without loss of the seal. It's intended primarily for patients with soft to form stool. It's a good option for patients who want to change their pouches more frequently because the level of adhesion is not as aggressive. So standard wear frequently used for clostomy. Frequently used for patients who are using closed-end pouches and want to change the pouch 2-3 times a day. In contrast, extended wear has more pectin, less gelatin, again has some carboxy methylcellulose. The formula was modified to provide greater absorption. These barriers actually swell with moisture and form soft total necks around the stoma that provides a very secure seal for a prolonged period of time. These products are indicated for high volume, more liquid output and less frequent pouch changes. The way it usually works out is Iliostomy patients are managed with high output. U-rostomy patients are managed with high output. A high volume clostomy is managed with high output. A clostomy with soft to form stool is frequently managed with standard wear, especially if the patient wants to change the pouch more frequently if they're using, for example, a closed-end system. Now, we have a new type of barrier on the market and these are infused barriers. When they came out with infused barriers, the goal was to come out with a barrier that would not only provide secure adhesion and good wear time, but that would also promote peristomal skin health. Now, there are several on the market. The only one on the market in the United States is a hydrocholoid barrier infused with ceramides. Now, a lot of you know about ceramides. They are naturally occurring skin lipids, and I want you to look at the illustration on the top left. So on the far left, you see normal skin. And you can see that the normal skin is loaded with ceramides. There's lots of ceramides. Ceramides attract and hold moisture, so they keep the skin plump, well hydrated. And then the illustration on the right shows depleted ceramides, which we frequently see in patients with different kinds of dermatitis. So when ceramides are depleted, we frequently have patients who are complaining of itching, who are complaining of dry skin, and who have varying levels of dermatitis. So ceramide infused barriers can be really helpful for patients who have dry skin, who complain of peristomal itching, who have minor peristomal irritation that we can't tend to resolve. We can't seem to resolve. Try the ceramide infused barrier. Now there are hydrocholoid barriers that are infused with either manuka honey or aloe. And as many of you know, these are products that are widely used in wound care to promote healing. And that's the concept behind incorporating them into ostomy barriers, is that if they promote healing, maybe they'll promote skin health. At this point we do not have manuka infused barriers or aloe infused barriers in the US. They are available in the UK and Australia, but not here yet. The next consideration is the shape and the contour of the barrier. Now one of the things we're always thinking about is what does it take to get a really good seal? What does it take to get really good adhesion between the pouch and the skin? So you think, okay, what are the abdominal contours? Are they flat? Are there deep creases? Is there a bowl shape defect? Then I've got to pick a pouching system that matches. So if I have a barrier that's flat but has rigid components, then that's a great option if I have a protruding stoma on a flat surface. So all of your two piece pouches are almost all of your two piece pouches fall into this category. They're flat. Most of them are flat. They have that barrier ring that adds a rigid component. They're a great choice when the stoma protrudes a little bit and when the stoma is on the flat surface. You'll also have one piece pouches that have a belt ring that belt ring. add some rigidity. So if there's anything within this pouching system that adds rigidity you need a relatively flat surface and it's very helpful if the stoma protrudes a little bit. When would a flat completely flexible pouch be a good option? That is the only option when you have a stoma located in or a adjacent to deep creases. Then you have to have a pouch that will fold and bend into that deep crease. Most of the time these pouches are one piece and there's no belt ring. They're just completely flexible. You can fold them into, tuck them into a deep crease. What about the increasing number of convex pouching systems? Now we have convex pouching systems with shallow convexity, moderately deep convexity and deep convexity. So when you look at the back of the pouching system you see differences in the curve. Is it a shallow curve? Is it a deep curve? When do you need that you need convexity when the stoma empties at skin level. Remember we're always looking for the os, the opening. Where's the opening? Where does it empty? If it empties at skin level the drainage tends to undermine to run under the pouching system. So it's critically important to use convexity and to force the drainage to come up and over. It's also the best option for a stoma located in a concave defect. You're always trying to match and marry the back of the pouch to the surface of the abdomen. The better the match, the better the adhesion, the better the seal. Then other things to consider. A lot of your fecal pouches, I'm going to show you this, have integrated or add-on flatus filter. So here's a flatus filter. What it is is little holes in the surface of the pouch. There's a charcoal disc placed over those little holes and then little holes through the charcoal disc. It's always at the top of the pouch because gas rises so it allows the gas to escape out of the pouch. It forces the gas through the charcoal filter so it's deodorized and then allows it to escape into the environment. So what flatus filters do is they help keep the pouch flat, but they prevent odor. That can be very helpful for a patient with a colostomy or aneliosomy. Now tell you this, flatus filters are an ongoing challenge for manufacturers. They're constantly working on improving them and proving their wear time and their effectiveness. So sometimes the patient will tell you will that filter. It's pretty good the first couple of days and then it gets less and less effective, meaning the pouch starts to fill with gas again. It no longer filters and deodorizes. So are filters a good thing? Yes for most patients. Are they perfect? We're not there yet. And then we have a lot of accessory products that are designed to improve the pouch seal. So we have rings. We'll bury your rings like you see on the top left that can fit right around the stoma. You can either put it right around the stoma or on the back of the pouch and then around the stoma. You can use paste strips. You can use tube paste. All of those are designed to help protect the skin to provide caulking between the stoma and the pouch to prevent leakage and to improve pouch seal duration. So do you need accessory products? It depends, depends partially on what's going on with the basic pouching system. Are you getting a good seal? It's lasting four days. You're not having any issues. The skin looks great. You probably don't need any accessory products. Do you have a very high output stoma? And every time you take the pouch off you notice that the barrier next to the stoma is soft and macerated and breaking down. Then a barrier ring might provide you with increased resistance and increased wear time. Do you have a very irregular surface right next to the stoma? Then paste or a barrier ring is going to give you a much better seal. In general you're solid forms of accessories like your rings and your paste strips are more resistant than the soft tube paste. The other thing is you have to remember paste melts with urine. So if you need more protection around a urinary stoma you're going to need to use a barrier ring or a barrier strip not paste. We also have adhesive products that make the back of the pouch stickier. Give you better initial adhesion. So it improves the bond between the pouch and the skin especially initially. And many patients improve their outcomes by adding a belt or a binder that provides mechanical support and helps to hold the pouch securely against the skin. So now we're going to try to put it all together. We're going to introduce a decision pathway you can use when you're selecting a pouching system for a patient. Remember your goals are to match the back of the pouching system to the patient's abdominal contours. So you get a secure seal you get great adhesion you prevent leakage. And you want to select products that promote an advanced peristomal skin health. You don't want your patient itching complaining of dry skin. Okay so step number one you always start with the patient and with your assessment of the patient. So what are the critical assessment parameters? What kind of stoma do you have? Is it fecal? Is it urinary? If it's fecal do you have low volume thick output? Do you have high volume liquid output? Next look at the stoma itself. Where does the stoma empty? Where is the oss? Sometimes you'll have a stoma that protrudes nicely and you wonder why I'm having problems with leakage but when you look carefully you find that the stoma empties at skin level. Even though the stoma protrudes the oss is at skin level. So you're not as concerned with stoma height as you are with location of the oss. Then you look at the peristomal contours. Are they flat or relatively flat? Maybe slightly rounded like you see on the bottom. Do you have concave defect? Do you have creases? And then finally you think about the patient's dexterity and coordination and their concerns and preferences. So now you're ready to start making decisions about the pouch. So if it's a urinary diversion you pick a urinary pouch. If it's a fecal diversion you're like well am I just gonna do a drainable pouch? Should I think about high output? Should I think about closed end? But in general we start with a drainable pouch because everyone needs to learn how to manage a drainable pouch. It's the best pouch for a patient with moderate to high volume output. So they're emptying at say two to four times a day. That's well managed with a drainable pouch. If the patient can manipulate the spout empty it effectively, clean it effectively. We want them to learn that procedure. Because even if they say I hate emptying I want to use that closed end pouch. They still usually need to know how to manage a drainable pouch. What are they going to do when they have diarrhea or they require a bowel prep. So typically we start with a drainable pouch. We teach them to manage a drainable pouch. even if most of the time they're going to use closed in. So I think we've covered most of the things about fecal closed in. We've said it's best for low volume output depending on patient preference. If you have a patient with higher volume output but maybe they're managing one handed because they had a stroke and they have paralysis on one side or we had one patient who had had amputation of one arm. So if they cannot manipulate the spout then they need to go to closed end and they would have to use closed end with a two-piece system. Okay, so you've picked fecal or urinary. You have within the realm of fecal stomas you've picked drainable which is standard versus high output which is indicated for anybody with more than one and a half liters of output a day. And you've considered that your patient might want to use closed end long term. They still need to learn drainable. Then you've got to talk to the patient, show the patient the difference between a one-piece and a two-piece and determine which is better for them. It's almost always up to the patient. So when is one-piece better just to reiterate? Patient who needs a very simple procedure, patient who lacks the hand strength to snap the pouch onto the barrier. One piece is also better for a patient who has a stoma and a deep crease. Because if my stoma is in a deep crease I need an all flexible. That's going to be a one-piece. Two-piece can be extremely helpful for a patient who has a urinary stoma with stints. It's much easier to get that two-piece wafers centered around the stints. So it's better for our stints, better for a support bridge until removed. It's also better for the patient who wants to change the pouch without changing the barrier, better for a patient who wants to be sure they have everything centered correctly. Then you select barrier formulation. This is a pretty straightforward point. So if you have a patient with soft to form stool, low volume output you can use a standard barrier. If you have high volume output, either a urinary stoma or a high volume ilostomy, you want to use your extended wear barrier. And if you have a patient with dry skin, sensitive skin, itchy skin, or damaged skin, think about a seramide-based barrier. Now this is a very important consideration. The others have been fairly straightforward. Select the barrier shape and contour. And this is going to be affected by the location of the osc. Does it empty at skin level or does it empty higher? And the peristomal contours, are they flat? Are they concave? Is there a crease? If the osc empties above skin level and you have a flat pouching surface you're like, that is the best I could have hoped for. That's perfect. So you see here, look at the illustration on top. When you see a stoma like that, you're so encouraged because you feel confident that you can get this patient into a secure system and that they're going to have good outcomes. Because the stoma protrudes, the osc is centrally located and you have flat contours. You want to go find that surgeon and tell them, thank you. If you look at the illustration in the middle, again, even though this stoma only protrudes a little bit, you see that the osc is located centrally so the drainage is going to project into the pouch and the peristomal contours are flat. That means that you can use almost any pouching system. You can use a one piece flat or a two piece flat. Or you could use an olflex if you chose to or a flat with rigid components. Bottom line, if you get that scenario that I just showed you, you can use almost anything you have and give that patient really good outcomes. But of course, we're not always so lucky. What if we have a stoma located in a concave defect? That's what you see on top. That's also what you see in the middle. And what if the osc empties at skin level? That's what you see in the middle. So in the middle, you have a concave defect and you have an osc that empties at skin level. Now you need a pouching system with convexity because the pouch, the back of the pouch, needs to match the abdominal contours. So you can see that to match a concave contour, you need a convex pouch. And frequently, when you use a convex system, you find that it's very helpful to add a belt because it now adds support and holds that pouching system firmly against the abdomen to minimize the risk of leakage. What if you have a stoma located in a deep crease? Look at the one on top. You can't even see the stoma. But you know that any pouch you put on that patient has to be completely flexible because it has to fold into that crease. So that's going to be a one piece, all flexible pouch, no belt ring. If you have a stoma located in a shallow crease, and that's what we have on the bottom, this was my patient. She had a very soft abdomen. She had an ileostomy located in a shallow crease. I could see the stoma, but I could also see the crease. So I knew we had two options. One option would be an all flexible system. But I thought she might do well with a pouch that had shallow convexity because it would give support right around the stoma. And since she had a very soft abdomen, I was thinking, well maybe if I put her in a convex system, it will support the creases around the abdomen, flatten them out, I can add a belt. So we put her in convexity with a belt, and she went from one day pouch seal to one week pouch seal. So think about that. If you have a stoma in a shallow crease, you have two options, all flexible versus shallow convexity. And then you're going to select accessory products that you might need to get us at your seal. And a lot of times this is trial and error. So you might try a barrier ring. Barrier rings come flat. They also come convex. So if you've got a convex, you've got to, excuse me, if you have a concave defect, maybe you need a convex barrier ring. If you have a relatively flat surface, but a lot of irregularity right around the stoma, you could use your flat barrier ring. So you use some combination of barrier rings, paste strips, tube paste to create the flatest surface possible, to caulk right around the stoma to prevent undermining. We also have adhesive products that we can use to improve the seal between the barrier and the skin. And as we've said, we can use belts to provide mechanical support. So then I put it all together, I put it on the patient. And what do I say to the patient? I say to the patient, we're going to try this, we're going to see how well it works. We're going to see how well it stays on. We're going to see what problems we have with it. And we're going to continue to tweak the system and to make modifications until we come up with a secure system that you can totally trust to get you through from Tuesday to Friday or Friday to Tuesday. And I'm going to be here and I'm going to keep working with you until we get this problem solved. Because if we are frustrated with pouching problems, difficulty, obtaining and maintaining a good seal, what's it like for the patient? So we never want to lose sight of what it's like for the patient. We want to reassure them, we want to tell them we're here, we're going to keep working with you until we find the best system. the best seal. So in summary, a secure pouching system is you've only heard ten times at this point. It's absolutely foundational to the ostomy patient's quality of life and it's a critical responsibility for us as ostomy nurses. So to establish an effective pouching system, we have to assess the output. We have to identify the location of the ost. We have to assess peristomal contours, line and sitting. We have to consider the patient's dexterity and take into consideration their preferences whenever possible. We're going to decide, do I need a fecal pouch or a urinary? I'm going to talk to the patient to determine, do you want one piece or two piece? I'm going to select the barrier formulation based on outputs. So formed outputs, soft to formed outputs, standard liquid output, extended wear, dry itchy skin, infused barrier with ceramides. I'm going to pick the contours of my barrier based on the location of the ost and the peristomal contours. If the ost is centrally located in above skin level and I have flat pouching surface, I can use anything. If the ost is at skin level or the peristomal contours or concave, I need convexity. If I have a stoma in a deep crease, I need a very flexible pouch to fit into those deep creases. I'm going to select accessory products to give me the flatest surface, the best adhesion, the lowest risk of undermining, and then I'm going to keep tweaking until I get the best outcomes possible. And that's the end of this lesson. Thank you very much.