Protocol for the Ostomized Person in the Trans-Hospital and Outpatient Period : Integrative Review

tlng=t 2. Sonobe HM, Barichello E, Zago MMF. A visão do colostomizado sobre o uso da bolsa de colostomia. Rev Bras Cancerol 2002 JulAgo -Set; 48(3):341-8. 3. Mendes JOS, Leite MMAM, Batista MRFF. Sentimentos vivenciados pelo homem adulto colostomizado. R. Interd. 2014;


Introduction
The person with ostomy is the one who underwent to a surgery, which is an opening of the abdominal wall and an intestinal or urinary segment, with the purpose of diverting the faecal or urinary transit to the outside.[1] This procedure is performed to maintain the elimination function and causes several changes that can negatively affect physical, psychological, social and sexual health of the person who needs to live with this condition.[2] These changes require different resources and specific types of care.
Ostomy is defined as a surgical procedure whose objective is to create an artificial opening between the hollow internal organs with the external environment, to preserve life in a situation in which it is not possible to use the anus to physiological eliminations.The exit opening is called "stoma", a Greek word that means mouth, used to indicate exteriorization of any hollow viscus through the body.The elimination stomas may be ileostomy, colostomy and urostomy.[3] The colostomy is a surgical creation of an artificial opening (stoma) in the colon that is a part of the large intestine, causing a part of the intestine to be exposed in the abdomen.This opening will be place be the place where faecal materials will come from, which will be stored in a collection bag.The stoma localization determines the faeces consistency.An ileostomy is an intestinal shunt, made at the level of the small intestine (ileum), in which the ileum is exteriorized through the abdominal wall, forming a new path and an opening for the effluents outlet.Consequently, the faeces are of the liquid.The same happens to an ascending colon colostomy.A colostomy of the transverse colon usually results in more solid and formed faeces.A sigmoid colostomy eliminates almost normal faeces.The colostomy location is usually determined by the patient's health problem and by their general condition.[4] About the urostomy, it is the surgical creation of an artificial opening of the urinary ducts in the abdominal wall.The urine will flow through this opening in the abdominal wall and will be stored in the collection bag.[5] The intestine stomata may be temporary or definitive, and the causes that lead to a stoma are several.Among the most often ones are diseases like colon and rectum cancer, diverticular disease, inflammatory bowel disease, anal incontinence, familial adenomatous polyposis, trauma, megacolon, severe perineal infections, congenital diseases, CD and the presence of sharp objects.[6] In Brazil, according to Brazilian Society of Stomatherapy (SOBEST) there are about 50,000 stomized people.Of these, 80% of ostomized people are colostomized, 10% are ileostomized and 10% are urostomized.[7] Among the main diseases, which determine indications for ostomy, colorectal cancer (CRC) is highlighted because it is the third more frequent neoplasm in the world in both genders and the second cause in developed countries.Mortality persists continuously over the past 50 years, even with advances in diagnosis and treatment.[8] The CRC includes tumors that affect a segment of the large intestine (the colon) and the rectum.Great part of these tumors starts from polyps, benign lesions that can grow on the inner wall of the large intestine.[9] In Brazil, in the South, Southeast and Midwest regions the cancer of colon and rectum is known as the fourth more frequent one in men and the third in women.[10] The ostomized patients, although with common characteristics that unite them in a special group, are people with their own needs and reactions to their identity and subjectivity.Thus, the response to the trouble caused by the stoma opening keeps relation to personal conditions of each one, as well with external variations, such as quality of the family, financial and healthcare support received in all phases of the surgical treatment which generate the stoma.[10] Although the stoma causes changes in the life of who has it, it is possible to learn how to live with this condition.For this, it is essential to find support from family, health professionals and public health actions both for the development of self-care and psycho-emotional support.[11] This new condition new condition generates not only physical changes, but also psychological related specially to the involuntary elimination of faeces or urine due to loss of sphincter control, which expose the patient to the experience of social constraints.Hence, when dealing with the presence of the stoma the patient may suffer numerous changes in his biopsychosocial state.[12] Due to the high complexity of care for these patients, it is necessary that the healthcare professional offer guidance regard the procedure that will be performed and the possible complications, besides the psychological and emotional support to the individual and their family.[13] The presence of a team capable of performing quality care with the objective of avoiding complications, giving emotional support, stimulating selfcare and offering resources and guidelines for care becomes essential.[13] For this reason, it is proposed that the human resources team of the Specialized Ostomized Care Service has a doctor, nurse, psychologist, nutritionist and social worker.[14] In light of the above-mentioned, it was reflected on the importance of a systematized nursing service at the outpatient level, specifically aimed at the humanized care of patients in the preoperative phase, candidates to the intestinal stoma, in order to guide them about the surgical process that involves hospitalization, preparation for surgery, recovery and the care they will need to adopt in the postoperative period.Thus, it was decided to set up a systematized itinerary for nursing consultation in the different stages that the patient would be submitted.
The assumption is based on actions that minimize complications, reduce stress and stimulate self-care, to facilitate postoperative rehabilitation and better quality of life.
The Nursing Consultation, composed of the stages of the nursing process is the strategy for the clinical assessment and interventions proposition, it allows to measure the results and to have the decision making, based on scientific knowledge.[15] A national health resolution about nursing consultation brings in its article 1 that the nursing consultation must be developed during the nursing care in all levels of health care, in public or private institution, aiming the health promotion, prevention, recovery and rehabilitation.[16] The objective of the Nursing Consultation is to identify the health and care needs, to plan and implement assistance, being these actions based on the best available scientific evidence, described in protocol and institutional norms.[15] In order to set up a protocol it is necessary an integrative review of literature on this subject, allowing the establishment of existing evidence histories.It consists of providing primary information (written by the person who originated the study) and secondary information (summarizes and cites contents from primary sources).[17] The use of the protocol tends to improve care, emphasizing scientifically sustained practices, minimizing the doubts about the information and conducts between the members of the nursing team, it establishes limits of actions and cooperation between the professional teams and they are also legal instruments.[15] In the light of the complexity of the ostomized person care the in-hospital phase and outpatient care, it is questioned: How is knowledge production configured in national and international journals on evidence-based protocol for assessment and intervention in nursing consultation?
The objective of this paper is to review the literature about the evidence-based protocol concept application for clinical assessment and interventions in nursing consultation to ostomized people in the transoperative and outpatient period.

Method
It is a review of national and international literature about the evidence-based protocol to the assessment and intervention in the nursing consultation for ostomized patients in trans-hospital period and outpatient care.The reference period was from 2011 to 2015.The integrative review is defined as an instrument to obtain, identify, analyse and synthesize the literature directed to a specific theme.It also allows the construction of a broad analysis of the literature, including discussions on methods and results of publications.[17] The integrative review comprehends five steps: 1) establishment of the problem, that is, definition of the theme of the review as a question or primary hypothesis; sample selection (after defining the inclusion criteria); 3) characterization of the studies where the characteristics or information to be collected from the studies are defined, by means of clear criteria, guided by instrument; 4) analysis of the results identifying similarities and conflicts; and 5) presentation and discussion of the findings.[17] The selection of the sample was established by online access to the health database available at the web portals Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior: CAPES (www.capes.gov.br) and Bireme -Biblioteca Virtual em Saúde (BVS).At CAPES portal, we have found the following database: Cumulative Index for Nursing and Allied Health Literature (CINAHL), SCOPUS, WEB OF SCIENCE and PUBMED.On the BIREME portal -Virtual Library in Health (BVS), we found the following database: Medical Literature Analysis and Retrieval System Online (MEDLINE), Latin-American and Caribbean Literature in Health Science (LI-LACS), Scientific Electronic Library Online (SCIELO) and Indice Bibliografico Español de Ciencias (IBECS).
In order to assure broad search of primary studies, the controlled descriptors (search terms) were combined in different ways, using Boolean Operators OR and AND, according to Descriptors in Health Scienc (DeCs) and Medical Subject Headings (MeSH): Ostomy OR Colostomy OR Colonic Pouches OR Surgical Stomata OR Colorectal Neoplasms OR Colorectal Cancer AND Protocols.
A total of 338 articles were located in the eight databases, nine were excluded because they were repeated at SciELO, LILACS and MEDLINE, from these 233 were excluded because of the title, 75 were excluded due to its abstract using the inclusion criteria and the sample to perform this study was constituted of 21 scientific papers according what Figure 1.
After the scientific papers selection, a careful reading of the 21 scientific papers in full was conducted, with the application of the data collection instrument to categorize themes.

Results
In order to characterize the sample, from the total of 2 (100%) of studies, these were made by two or more authors.When considering the first authorship according to their profession it was obtained 10 (47.6%) nurses, 8 (38.1%) physicians, 2 (9.5%) psychologist and 1 (4.8%) nutritionist.A total of 13 (61.9%)work in universities, 5 (23.8%) in hospital institution and 3 (14.28%)did not mention their workplace.
From these 21 (100%) studies included in the integrative review, 11 (52.4%) of the scientific papers were categorized in Quality of Life, 4 (19%) in Nursing Care, 4 (19%) in Protocol, 2 (9.5%) in Complications and 1 (4.7%) in Surgery.In the themes category Quality of Life papers that approached the feelings lived by the ostomized patients, their difficulties in social and sexual life and the change in the body image were included, they also referred to the importance of the professional and family support, the benefit of the self-care and the adaptations that the patient will have in the course of their life.
The studies categorized as Nursing Care referred to nursing care in the preoperative, hospital and post-hospital period, encouraging the importance of planning care for the intestinal stoma, teaching technical concepts under the perspective of the patient, family and professional to the care development.
In the category Protocol the studies revealed the efficiency that this instrument brings to the patient care, preventing major complications.
In the theme Complications the studies addressed aspects of prevention and treatment of the intestinal stoma complications.
And finally in the category of Surgery it has been reported the procedure itself, the demarcations and various types of stomas.

Discussion
According to data from Cancer National Institute, the colorectal cancer is the second most prevalent type in the world.In Brazil, it is the second most common among women and the third among men.In Europe it is the most frequent type of cancer.[9, [18][19] In the USA it is the third type of cancer that most affects the population.[20] The colorectal cancer incidence is more prevalent in western countries where we found high consumption of fats and red meats, poor in fiber, vegetables and fruits.[21][22] Studies shows that the westernization of diet among Japanese is directly related to the increased incidence of colorectal cancer in Japan.[21] Besides colorectal cancer, there are other colonrelated diseases, such as the inflammatory bowel disease, which are considered chronic, of unknown etiology, but capable of developing an inflammatory reaction in the digestive mucosa of immunological nature.[4,23] They are represented by three diseases: nonspecific ulcerative colitis, CD and undetermined colitis.[4,6] Among all these diseases, the main forms of treatment are surgeries, chemotherapy, radiotherapy and the performance of stomas.
In relation to the stoma, several other authors report about changes that occur in the life of patients who have undergone to this procedure.As well as the change in the body image, causing low self-esteem, behaviour changes causing the social isolation.[23][24] With regard to quality of life, the health professionals have the great task of carrying out strategies, planning and incentives in the reintegration of the ostomized individual in society.One of the main orientations to the patient and their family/care giver is about the realization of self-care effectively and safely at home.[6,8,20,[25][26] The use of the WHOQOL-bref scale shows that the patients' quality of life improves after the second year of living with the stoma.[6,8] The teaching and guidance to the self-care must start right after the decision about the therapeutic procedure to be performed.[27] The preoperative period is highlighted, due to its importance for teaching the patient about his future life condition, and the care that, from then on, will be necessary.In the hospitalization phase in the immediate and late postoperative period, the patient must clarify their doubts, present their skills and show to be able to perform the home care, in case it is necessary a family member/care giver, the training will be guided to them too.A discharge, the patient will be directed to the Ostomized People Program, where they will receive specialized care and information on where to purchase the necessary equipment for their new lifestyle.[28][29] Regarding to the nursing care, the performance of nursing is always seen as of great importance, because besides giving support in the preoperative period, it is a learning action in which the nurse and the patient interact in an empirical relation, seeking to solve the objections, through the nursing diagnosis.[24] It is evidenced that the rehabilitation process must be initiated with the patient and the family already in the diagnostic phase, planning to restore their social life and improve their quality of life in face of the stoma impact.[28] With regard to protocols, the articles analysis revealed that there are few research and publications about the instructions to the ostomized patient, as well as, the lack of preparation of the nursing professionals.It is highly reported the importance of strategies that facilitate the care of patients, however we have not yet found an instrument model in this area.
It is necessary to propose tools and strategies to improve and obtain more effectiveness in the care, but not to forget about the singularity and subjectivity of each patient, involving their habits, culture, religion, physical, cognitive and psychological aspects.
In nursing consultation it is possible to periodically follow up the patient, preventing complications and giving support in coping with the difficulties due to changes caused by the stoma.[24] The family involvement it is always considered important, because it is through these people that we know the habits, culture, the preferences and life style of the patient, that is, they own significant information which may help in the rehabilitation planning.[29] Health education is indispensable and fundamental in the nursing action for the care.Thus nursing orientations to both patients and their families are extremely important.[24] As for complications, global incidence rates range from 21% to 60%.They may be classified as early or late.The most frequent early complications are ischemia, haemorrhage, retraction, edema and dermatitis.The most present late complications in the literature are hernias, stenosis, obstructions, prolapse and fistulas.[11,30] And finally, considering surgeries, it is mentioned the importance of the specialist physician with surgical experience in this area, taking into account that it is not just to make the stoma, but also to plan ways to prevent complications.[30]

Conclusion
This paper development enabled the broadening of the knowledge about the nursing care for ostomized patients.
In a general view it is possible to state that ostomized patients are mostly derived from CRC, not disregarding the other causes.With regard to the quality of life, we see the importance of subjectivity, since each individual has its own characteristics and lifestyle and we must respect them in what is allowed.Care and teaching strategies in care should be considered and explained as the patient understands, with easily understandable language considering their culture and social class, It is the duty of the professional to seek to understand the feelings and the reaction of the patient in this new style of life.
Thus, the nursing care is extremely important to this subject, even the non-specialized nurses must be attentive to improve in this way, because it is common the contact with patients with stomas in this profession.To work with an ostomized patient requires specific knowledge, available in the scientific literature based on already lived experiences.
The patients with stomas are people with special needs and it is extremely important that their care has specific knowledge inherent to the patients' needs.In this way, the need to construct a systematized instrument, a protocol, that directs the professionals to exercise such care with the ostomized patients in their different periods, is observed in the preoperative, postoperative and outpatient visits.
Through the integrative review it was observed that the clinical protocols make it easier and more efficient to care for patients with stoma, but this type of instrument is not found on the literary bases.
The research themes analysis made it possible to identify the need for future research on specific aspects in the nursing care and teaching strategies in all stages of care, being they in the preoperati-ve stoma, postoperative/hospital period and in the outpatient phase in the nursing consultations.
Hence, we conclude that the integrative review contributed to achievement of the objectives proposed in this paper, contributing to the innovation and improvement in the ostomized patient care, providing new ideas for the planning of a protocol that guides the professionals when faced with care related to the stoma.

Figure 1 :
Figure 1: Flowchart of articles selection to the integrative review of literature, São Paulo-2015.