WOC nurses have to deliberate on how to pouch a challenging ostomy or fistula. The clinical problem is how to contain bowel effluent and maintain skin integrity in an individual with a stoma and prolapsed bowel and a person with an ileostomy next to a high output fistula. The first case study involved a 73-year old male with severe COPD, morbidly obese and vascular disease who underwent an emergency right upper quadrant loop transverse colostomy due to significant ischemic bowel post-colonoscopy. This patient’s loop of bowel was stabilized with fascia and skin sutured underneath. There was no rod. On the distal side of the loop, 3 inches of prolapsed bowel was secured to the skin circumferentially with sutures. The post-operative stoma management included Vaseline gauze dressings wrapped around the bowel and a colostomy pouch loosely in place over the loop of exposed bowel. The challenge of management developed five days after surgery when peristalsis returned and effluent started leaking from the ill-fitting appliance. The clinical approach to pouching 5 ½ by 3 ¾ inches of bowel included modifying 2-flat wafers with one adhesive coupling pouch. The wafers cut to create a secure pouching surface resulted in a wear time of 4 days. The second case involved a 50-year old female with a 27-year history of colitis and Crohn’s Disease. She had nine bowel surgeries and relocation of stoma with an uneven abdominal plane. Her last surgery resulted in a high output fistula at the distal-end of the wound base adjacent to her ileostomy. After multiple pouching attempts to contain effluent and maintain skin integrity, a wound manager modified as a pouching system gave her a 4-day wear time. The patient and staff nurses believed the pouching systems were successful. The WOC nurse needs to be innovated to mange pouching challenges.