A 70-year-old gentleman with cancer had a nephrectomy, cystectomy and a nephrostomy tube placed. The patient was a large man and was premarked for stoma placement. However, the stoma ended up in between two abdominal folds and was barely budded. The nephrostomy tube was removed one day prior to discharge, at which time leakage started to occur.

Home care nursing was initiated for assessment and teaching. The patient was getting only a few hours to twelve hours wear time from any appliance tried. The patient understood the reason for difficult pouching so he remained very good natured and optimistic.

CLINICAL PROBLEM: His position changes revealed that when he reclined, the stoma was in a small fold and slightly budded. Upon sitting, the stoma was retracted and not visible as it was in a deep abdominal fold. When the patient stood, the stoma was partially visible but a large fold obstructed the top of the stoma.

PAST MANAGEMENT: Two piece appliances were discarded due to folds and need for flexibility. One-piece appliances were not giving the patient good wear time either. Attempts to make a flatter surface with caulking, strip paste, rings, convex rings only gave pt up to 36 hours wear time. The most flexible samples were tried without success. The goal was to find a system that held at least 48 hours and gave the patient a sense of security.

CURRENT CLINICAL APPROACH: An appliance was found that was most flexible and gave the patient a 7-day wear time. A polyurethane film appliance was extremely successful. A device for self-application was tried but due to deep abdominal folds pt was unable to apply independently.

OUTCOME: Surgical revision was not needed and the patient developed a sense of security with the new appliance.