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The Ostomy Files: A One- or Two-Piece Pouching System?
Clinicians in virtually every setting are charged with the task of selecting and recommending appropriate pouching systems for ostomy patients.
This task often seems overwhelming because of the variety of ostomy supplies and pouching systems available. Ostomy rehabilitation and mastery of self-care requires individualized patient teaching and support from a credible authority.1 Clinicians must have a working knowledge of the appropriate use and types of ostomy supplies if: 1) the clinician is to be viewed as credible by the patient; 2) the pouching system is effective and pleasing to the patient; and 3) the patient's rehabilitation is to progress. What it really comes down to is a process of matching the specific features and benefits of a particular pouching system to an individual patient's clinical needs, mental and physical capabilities, and personal preferences, as well as the patient's current venue (ie, hospital, nursing home, or home).
Ostomy pouching systems can be divided into two main categories: one-piece systems and two-piece systems. Subcategories within these two classifications include:
* type of pouch (ie, closed-end, drainable, or urinary; transparent or opaque)
* type of skin barrier (ie, standard, extended-wear)
* stomal opening (ie, pre-cut or cut-to-fit)
* depth of convexity (ie, flat, convex)
* method in which the convexity is provided (ie, integral or supplemental).
Two-piece Ostomy Pouching Systems
A two-piece pouching system is manufactured as two distinct and separate units intended to be fastened together. A detachable pouch with an integral ring or flange attaches to a body-side skin barrier wafer with a compatible flange. The attachment mechanism can vary relative to the amount of pressure necessary to snap the two together to a lock-ring mechanism.
Two-piece systems afford lifestyle choices - they permit patients to change the style of pouch they wear according to their activity or the amount and character of stomal output. For example, patients might prefer a smaller, closed-end pouch during sexual activity, swimming, or during periods of minimal stomal output following colostomy irrigation. Another patient may choose a drainable pouching system for use only at night or at work to increase capacity or to provide a sense of security away from home. Others prefer two-piece systems because the pouch can be removed without disturbing the skin barrier wafer, cleaned, and reattached each time it is emptied. Others prefer to merely discard the soiled pouch and reattach a clean one.
Two-piece systems often are used during the postoperative period because they facilitate stomal access without changing the entire system. The use of a two-piece pouching system requiring lighter pressure for pouch attachment or a lock-ring mechanism on a sensitive or postoperative abdomen also may help reduce discomfort. If discomfort or pain is associated with ostomy care, patients may be reluctant to participate in self-care. Therefore, making a pouch change as pain-free as possible is a goal of postoperative care and may even encourage earlier participation in self-care and expand the opportunities for patient teaching.
Two-piece pouching systems also have been helpful in fostering independence in a variety of situations. Patients with limited mobility, for example, may have difficulty getting into a bathroom to empty a pouch, but can function independently by removing a full pouch from the flange and replacing it with a clean one without having to be in the bathroom.2 Successful teaching also has been reported using a tactile approach and a two-piece system in patients with limited vision.3,4
One-piece Ostomy Pouching Systems
One-piece systems are manufactured so that the skin barrier and pouch are one unit that requires no assembly for application. These systems are usually lightweight and flexible. Patients with dexterity problems or cognitive impairment may benefit from a one-piece system because it requires the fewest number of steps to assemble, apply, empty, and change.5 Patients preferring a totally disposable system may select a one-piece pouching system due to its ease of use. Because of the one-piece system's inherent flexibility, some clinicians use it on patients with round and hard "watermelon" abdomens to improve leak-proof wear time.
The "Right" Pouching System
Regardless of a patient's clinical condition or preference, any pouching system, whether it is one- or two-piece, should protect the peristomal skin, control odor and effluent, maintain a seal for a sustained and predictable wear time,6 and promote self-care to the patient's maximum physical and mental potential. The "right" pouch for a patient is the pouch that satisfies the patient and the one the patient says is right.7 However, what constitutes the "right" pouch varies among individuals. What a clinician confidently recommends as a clinically appropriate pouching system may not be the "right" system for the wearer.
The Role of the Clinician
It is, therefore, imperative that clinicians in all healthcare settings view a working familiarity with a variety of pouching systems as a way of compressing the time required to find the "right" system and streamlining the rehabilitation process. In a world of healthcare cost containment, this belief can easily translate into a cost-effective means of accelerating ostomy rehabilitation and reducing resource utilization in nursing time, ostomy supply costs, and their related issues.
The Ostomy Files is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ.
1. Righter BM. Uncertainty and the role of the credible authority during an ostomy experience. J WOCN. 1995;22:100-104.
2. Erickson PJ. The art of ostomy pouching. Progressions. 1990;2(1):14-19.
3. Lemiska L, Watterworth B. Case study: teaching ostomy self care to a legally blind patient. Ostomy/Wound Management. 1994;40:52-54.
4. Jeffres C, MacKay AT. Improving stoma management in the low-vision patient. J WOCN. 1997;24:302-310.
5. Erwin-Toth P, Doughty D. Principles and procedures of stomal management. In: Hampton B, Bryant R, eds. Ostomies and Continent Diversions: Nursing Management. St. Louis, Mo.: Mosby; 1992:29-103.
6. Rolstad BS. Principles and techniques in the use of convexity. Ostomy/Wound Management. 1996;42(1):24-32.
7. Turnbull GB. The ostomy assessment inventory: a data-gathering process to enhance appropriate pouching system selection. Ostomy/Wound Management. 1998;44(2):28-37.
