Purpose:

The need for convexity is based on patient assessment and knowledge of product features. Thisposter will explore the variety of options for achieving convexity and provide clinical applications that demonstrate best practice. Although different products are available globally, the goal is to examine commonalities of clinical approaches. Both novice and advanced practitioners may benefitfrom product terminology clarification and guidelines related to convexity product use.

Filling in the Gaps: Using Convexity to Meet Patient Needs

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CASE STUDY A:

Four weeks postoperative end ileostomy with obese flaccid abdomen, stoma lumen pointing downward, with retracted peristomal skin. A firm integrated convex product and barrier ring were used to create an adequate skin seal. Tape bordered skin barrier assisted with irregular skin contours.

• Bonnie Sue Rolstad, RN, MS, CWOCN, webWOC Nursing Education Program, Minneapolis, MN, USA • Jo Hoeflok, RN, BSN, MA, CETN(C), CGN(C), St. Michael's Hospital, Toronto, Canada

• Julia Kittscha, RN, BHSc (Nursing), Post Grad Cert STN, Wollongong Hospital, New South Wales, Australia

Conclusion:

Globally, ostomy care nurses work with multiple manufacturers without standardized terminologyor descriptions related to convex features. Standardization of terms, decision-making frameworks,and clarification of product descriptions and characteristics would provide helpful clinical guidance and enhance patient outcomes. This standardization will also provide the opportunity for comparative analysis.

CASE B:

Loop ileostomy with leakage and skin damage; multiple pouch changes in a 24-hour period.Abdomen flaccid with irregular contours and a retracted stoma. Required customized convexity toachieve wear time of four days. Skin barrier sheet, deep firm integrated convexity was customizedfurther with two stacked convex barrier rings.

Patient Assessment

Assessment of the patient, abdomen, stoma, and peristomal field occurs immediately postoperativelyand over the long-term. Prevention of complications related to peristomal skin breakdown is key.Therefore, ongoing assessment for the patient without complications is also prudent. Questions tobe considered during assessment include:

Subjective Assessments

• What is the presenting problem (e.g., leakage, skin irritation, poor wear time, duration, routine follow-up)?

• Any discomfort when wearing the pouching system?

• What is the wear time of the pouching system? Has the wear time decreased?

• Is the pouching system being applied correctly?

• Other comments around difficulty of stoma care?

Abdominal Assessment in supine (Photo 1) and standing (Photo 2) positions. Note the peristomal skin retraction on the right.

Photo 1 Photo 2

Background

Ostomy patients require a secure pouching system with predictable wear time in order to decreasecomplications and live comfortably. Characteristics of the stoma, peristomal skin, and abdominalmuscle tone create clinical situations where achieving this goal requires the use of convexity in the pouching system. Convexity is the outward curving of the pouching system that adheres to the peristomal skin. It can enhance skin protection, wear time, and comfort by filling in retractedareas and supporting tissue in the peristomal field. Convexity is not new and has evolved overmany years. However, with the introduction of different convex forms, the decision-making processis now less straight forward.

Both the large number of convex product solutions available today and their associated descriptionshave simultaneously helped and confused some clinicians. Internationally, products differ fromcountry to country. In the US and globally, a lack of standardization related to convexity productdescriptions is problematic. Globally, there are more manufacturers; some are located in only one country.

Understanding the Types of Convexity available and indications for use is key to effectively managing patients with both routine and challenging abdomens and stomas. Convex product terminology and classifications include: depth, profile, flexibility, pressure, and construction. (See Table 1) Appropriate utilization of convex products is based upon ongoing stomal, abdominalplane, and peristomal skin assessments coupled with best practices.

CASE C:

Four weeks S/P colectomy and ileostomy. Stoma lumen off center, and peristomal skin creases andslight retraction; stoma was not easily visible by patient. The patient had leakage under the skinbarrier. A deeper, firm integrated convex product and skin barrier ring with an ostomy belt wasused to accentuate convexity and ensure a secure skin seal. The barrier ring was rolled throughthe skin barrier prior to application.

References Bourke R, Davis E, Dunne S, George S, Kittscha J, Stott C, Purnell P. Making Sense of Convexity, 2006.

Hoeflok J. A Guide to Ostomy Assessment and Barrier Selection, October 2010.

Rolstad BS, Boarini JH. Principles and Techniques in the Use of Convexity. Ostomy/Wound Management. 42(1): 24-32, 1996.

Rolstad, B.S., Ermer-Seltun, J, Bryant, R.A. (2011) Relating knowledge of anatomy and physiology to peristomal skin care. Gastrointestinal Nursing, 9:9 (suppl) 3-9.

Rolstad, B. S. & Erwin-Toth, P. L. (2004) Peristomal skin complications: prevention and management.Ostomy/Wound Management, 50(9): 68-77.

Rolstad, B. S. & Beaves, C. 2006 Update: Principles and Techniques in the Use of Convexity. Scientific poster presentation WOCN Annual Conference.

WOCN. Convex Pouching Systems: Best Practice for Clinicians, 2007.

Table 1: Convex Product Terminology and Classification Presented at the Wound, Ostomy, Continence Nurses Society, 2012

Physical Assessment (in sitting, standing, and supine positions)

• Peristomal Skin: What is the condition of the peristomal skin? What are the contours of the peristomal skin? Does the skin retract so that there is a defect to be filled at the base of the stoma in order to make a flat pouching surface?

• Stoma: Is the opening at the apex or skin level? Is the stoma round or irregular in shape? What is the protrusion (height) of the stoma or retraction?

• Abdominal Muscle Tone: When palpated, is the abdominal muscle tone soft or firm?

• Movement Induced Changes: Are there observable peristomal skin topography changes? Are there stoma length changes with movement (does the peristomal skin or stoma retract during abdominal movement)?

ConstructionFlexibilityProfileDepth

IntegratedLocationAmountSoft

Firm Low

High

Gradient

Slope

Shallow

Moderate

Deep

CustomizedInnerAperture

PeripheralBarrier

Pressure

ConvexProducts

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