Hernia / Ostomy Belt Worksheet By Nu-Hope
Laboratories, Inc.
1)
Belt Style: (select one)
□ Nu-Form™ Style for support of
non-reducible hernia
□ Original Flat Panel for pouch
support/hernia prevention and small bulge flattening
2) Belt
Fabric: (select one) □ Regular Solid Elastic
or □ Ventilated Cool
Comfort®
3) Belt Width: For hernia
prevention, pouch support, prolapsed stoma and small bulge flattening, a narrow
belt (3” or 4”) is normally sufficient.
For hernia support, first, measure the hernia or area you want to
support from bottom of the hernia to the top and then take that size and round
up to the next whole inch size. It’s typical that only 2/3 to 3/4 of the hernia
needs to be captured by the belt.
Original
Flat Panel 3” 4” 5” 6” 7” 8” 9” Other______”
Nu-Form™ 3” 4” 5” 6” 7” 8” 9” Other______”
4) Belt Size: Measure horizontally around the body in line
with the stoma. If herniated, the
measurement should be made while lying on the back (supine position) after 5-10
minutes. If the measurement falls between sizes, go the next larger size.
Girth measurement:
Standing: _______” or Lying
(supine):_______”
(circle one) Small (28”-31”) Medium (32”-35”) Large
(36”-40”) X-Large (41”-46”) XXLarge
(47”-52’)
5) Stoma Location: (circle one) Left Size Right
Side
6) Belt Opening: For two piece
systems, usually ½” is added to the flange size. One piece systems, adhesive
couplings, and tabs please contact Nu-Hope customer service.
Belt
Opening___________” or Pouch Manufacturer________
Product #__________
(if already known) □One Piece □Two Piece Flange
Size:________”
7) Opening Placement: To find the hole
placement (other than standard), measure from the bottom of the hernia or where
you would like the belt to start, up to the center of the stoma. Next, divide the required hole size by two
and subtract it from the measurement taken between the bottom of the hernia and
the center of the stoma. This will tell you the distance between the bottom
edge of the belt and inside edge of the hole.
Nu-Form™: 3” through 6” have a
centered opening
7”
through 9” have the opening 1” from the bottom
Original
Flat Panel:
3” & 4” have a centered
opening
6”
and 9” have the opening 1” from the bottom
Or
Custom Placement
__________” Opening
Placed__________ “ from top □
or
bottom □
(check
one)
8)
Additional Requirements: Prolapse strap (-P), Auxilliary Belt, etc:
Hole Size Chart
(Standard Placement Only), 2-3/8” = Standard
|
2” =
E
|
2-3/4”
= A
|
3-3/4”
= M*
|
Medium
Oval = H
|
|
2-1/8”
= L*
|
2-7/8”
= DC
|
4” =
O*
|
Large
Oval = J
|
|
2-1/4”
= F
|
3” =
B
|
4-1/2”
= R*
|
XLarge
Oval = K
|
|
2-1/2”
= G*
|
3-1/4”
= C
|
2-7/8”x3-3/8”
= Q*
|
Custom
= SP
|
|
2-5/8”
= I(i)*
|
3-1/8”
= U*
|
3-1/2”
= T*
|
No
Hole = NH
|
*Nu-Form™ Only
