Volume 39 Number 3

Causes attributed to stoma or peristomal skin complications in northeast Brazil

Yterfania Soares Feitosa, Luis Rafael Leite Sampaio, Déborah Albuquerque Alves Moreira,
Francisco Antonio da Cruz Mendonça, Tatyelle Bezerra Carvalho, Juliano Teixeira Moraes,
Maria Euridéa de Castro and Eliziane Ribeiro Barros

For referencing Feitosa YS et al. Causes attributed to stoma or peristomal skin complications in northeast Brazil. WCET® Journal 2019; 39(3):15–19

DOI https://doi.org/10.33235/wcet.39.3.15-19

PDF

Author(s)

References

中文

Abstract

Problem statement To identify the causes attributed by people with stomas or by their caregivers to complications arising in the stoma and peristomal skin.

Method A qualitative study performed in the period March–June 2018 on a group of 19 people with intestinal stomas. The data were collected through the process of structured interviews and were analysed by applying a content analysis technique.

Results It was possible to perceive that the causes attributed to complications of the stoma and peristomal skin were alterations associated with or related to: the use of the ostomy appliance; personal conditions; knowledge about self-care; and the condition of the stoma or surgical technique.

Conclusions People who live with a stoma can identify the possible causes for the complications to which they are predisposed. These are described by: the use of the ostomy appliance used; personal conditions; knowledge of the person on self-care of their stoma; condition of the stoma and peristomal skin; and the surgical technique employed.

Introduction

A stoma consists of an opening created by surgical techniques that allows visceral shunting through the skin at a point other than the natural insertion site in order to promote breathing, feeding or elimination1.

Stomas are identified according to the section of the body where the stoma is placed and associated tissue that is segmented or averted to form the stoma and are known as tracheostomy (respiratory), gastrostomy and jejunostomies (feeding) and urinary or intestinal (elimination). With regard to the period the stoma may be required, they can also be classed as temporary or permanent according to the possibility, or not, of re-establishment of the habitual route of elimination2.

Among the different types of ostomies, intestinal (ileostomy and colostomies) deserve a special mention, given that several situations can lead to the necessity for intestinal tract diversion such as inflammatory bowel disease, trauma, diverticulitis, cancer and congenital diseases3. In Brazil, the main causes for intestinal stomas in the adult and elderly population are colorectal neoplasias4. The Instituto Nacional do Câncer (National Cancer Institute, INCA), estimates for each year of the 2018–2019 biennium over 17,380 new cases of colon and rectum cancer in men and 18,980 in women will occur5.

There are many clinical contexts which contribute to the occurrence of complications in the stoma and / or peristomal skin, among which the most frequent are prolapse, retraction, ischaemia, parastomal hernias and peristomal dermatitis6. It is worth highlighting that these complications negatively influence the general quality of life of the person with a stoma, causing sexual problems, depressive feelings, flatulence, constipation, dissatisfaction with appearance, frequent change of clothes or style of clothes, difficult gait, fatigue, and concern with noise. Thus these factors can adversely affect personal and professional relationships as well as lead to withdrawal from the social environment7.

In view of these problems, the stomal therapy nurse is an essential health professional in order for the assessment and appropriate plans of management for the individual and their stoma to be implemented in an effective way. Therefore, from the time of the creation of the stoma to the ambulatory and domiciliary care phases of the patients’ rehabilitation, the stomal therapy nurses’ goals and actions are to assist the patient with the stoma to prevent or facilitate early identification of complications related to the ostomy8.

Considering this context, this study aimed to identify the causes attributed by people who live with a stoma or by their caregivers in the northeast of Brazil as to the complications related to the ostomy and /or peristomal skin. Comprehending these issues from this perspective and the causes attributed to these complications can assist the stomal therapy nurse to provide individualised plans of care. Such specialist nursing assistance can help people with stomas to better adapt to the modifications required and experienced by them as a result of their new health condition.

Method

This descriptive study with a qualitative approach was performed March–June 2018 in a rehabilitation centre located in a state in the northeast region of Brazil.

In the Serviço de Atenção à Saúde da Pessoa Estomizada (Service of Healthcare of the Stoma Person, SASPO) of the Secretaria Estadual de Saúde do Estado do Ceará (State Department of Health of the State of Ceará, SESA) 57 people are registered with a stoma. Among these, 26 people did not accept an invitation to participate in the survey, which resulted in a total of 31 people in the study cohort. However, by the criterion of theoretical saturation – where no new information is being extracted from participants’ responses, duplication or repetition of responses is observed and the study aims have been met9 – 19 participants were interviewed, 11 with an intestinal stoma and eight caregivers.

The data collection was performed through interviews with a structured script which included questions related to complications of the stoma and peristomal skin. The interviews were recorded in audio, while the answers were later transcribed in full and coded by the letter ‘E’ for patients with intestinal stomas and ‘C’ for caregivers followed by Arabic numerals.

The data analysis was performed using Bardin’s Content Analysis technique following the stages of pre-analysis, material exploration and treatment of results, inference and interpretation. Content analysis corresponds to a set of methodological tools that aims to analyse different ways of communication, verbal or non-verbal, obtained through interviews or through direct observation, whose material, extracted after complete and exhaustive analysis, is classified / separated into themes or categories10.

Ethical considerations

Consent to participate in the study was voluntary, through the signing of the Term of Free and Informed Consent paying respect to the national and international ethical precepts for research involving human beings. In this sense, the participants were guaranteed in their anonymity, as well as their privacy and the right of autonomy regarding the freedom to participate or not in the research project. The research was appraised and approved by a Research Ethics Committee regulated in Brazil, under opinion no. 2,542,686 and CAAE registration no. 83103518.4.0000.5052.

Results and discussion

Participant demographics

Nineteen participants aged 22–75 registered to take part in the study. Of these, 11 participants were employed with companies and eight were managers with an average wage of 950 reais. All were living in cohabitation with others. Of the participants with stomas, four of them were females and seven were males In this group, nine of them had completed elementary education and one had completed higher education, the other were unknown. Among the caregivers, six were female and two were male, all of whom hold elementary education.

In regard to the clinical characteristics of participants’ stomas, 10 participants had a permanent stoma and nine had a temporary stoma. Among them, 15 had colostomies and four ileostomies. Regarding the cause of the stoma, 10 participants had colorectal cancer, seven were the result of trauma, and two had an acute abdomen.

Participants’ perceptions of the causes of stomal or peristomal skin complications

After transcription and analysis of the audio-taped interviews, it was possible to group participants’ perceptions of how they attributed the development of complications of the stoma and / or peristomal skin into four categories:

• Alterations relating to ostomy appliance usage.

• Alterations relating to personal conditions.

• Alterations relating to knowledge about self-care.

• Alterations relating to the ostomy condition or to the surgical technique.

Alterations relating to ostomy appliance usage

Regarding the ostomy appliance, the participants pointed out that the development of the complications identified are related to the type of equipment available in the service, the quality of the material in the appliances received, the adhesiveness of the appliances and, consequently, the period of adhesion. Comments from participants to substantiate this perceptions were:

When I removed the bag, her skin was very white, very sensitive, I noticed that the skin became red / What caused this problem was the type of bag [C1, C2, C3, C4, C6, C7, C5, C8].

I think what they use to stick to the skin is not at all efficient. Because it is easy degreasing, it burns the skin of the person. They are supposed to do something that would stick more and that would not hurt so much the skin of the person. I think it’s totally related to the bag [E19].

There is no ideal type of ostomy appliance which adapts to all people, all stomas, and all situations. However, there are several types of products that can be used to meet the individual needs of patients with stomas due to the different types and structural changes that occur in the stoma as the stoma matures after surgery and the patient resumes their normal activities of daily living. These factors imply a change of conduct in relation to the selection of equipment and the prescription of specific care according to the individual needs of each person11,12.

Furthermore, regarding the ostomy appliance, it must be noted that if this equipment is used permanently on the abdomen of the individual, it may affect their body image. In these circumstances, the prescription of equipment becomes a complex task. The stomal therapy nurse needs to know with clarity the products available as well as their indications, advantages and disadvantages. Integral to the ostomy appliance selection process is an evaluation of the individual who requires the appliance – this should take into account the physical, emotional and social dimensions of the individual as well as considering other factors such as their manual dexterity, visual acuity, clothing, family support, lifestyle, personality, cognitive ability and user preferences13.

The Política Nacional de Saúde da Pessoa com Deficiência (National Health Policy of the Person with Disabilities), instituted by directive no. 400/09 of the Brazilian Ministry of Health, determines the criteria and provision of ostomy equipment for stomas and adjuvant materials for peristomal skin conditions based on an evaluation of the characteristic of the stoma and peristomal skin14. A diverse range of equipment and adjuvant materials are available. However, around the world there are wide variations in relation to the care provided and to the quantity and quality of materials distributed to people with an ostomy, despite there being specific recommendations for this audience. It is noteworthy that in Brazil these differences are present in several regions, directly interfering in the satisfaction of the person with ostomies regarding the supply of collecting and adjuvant equipment12.

Alterations relating to personal conditions

People with stomas frequently report that issues related to their stoma and skin are related to changes in their personal condition. Regarding this aspect, study participants report the non-acceptance of the skin to the constituent materials of the ostomy appliances:

... At times, it is itchy ... so I think it’s due to the skin, which doesn’t fit on bags that gets red, scratching, but it’s just a matter of adaptation, but I think that the problem is my skin itself [E9, E11, E10, E12].

The removal of any body part is considered an experience that provokes a sense of vulnerability and lack of mastery over its existence. For this reason, it is necessary to actively listen to fortify the link between the health professional and patient in order to identify their concerns, and then to develop intervention strategies that help people with stomas and/or the caregiver to self-care15.

In another study, which evaluated the perception of patients who suffer from intestinal stoma, it was reported that people experienced changes in their lives during the ostomy rehabilitation process ranging from uncertainty of feelings, fear of lack of awareness, to lack of information, which makes it difficult to return these individuals to their usual activities of daily routine16.

Therefore, the introduction of strategies that will lessen their vulnerabilities and fortify their self-belief is important. Educational technologies such as video lessons, interactive programmes through the internet, telephone support and group therapy can assist with this. These activities are of fundamental importance in facilitating processes of rehabilitation and adaptation of people who live with a stoma. Such strategies also aid in the early recognition and notifications of complications which results in a better quality of life17.

Alterations relating to knowledge about self-care

The interviewees’ responses indicated a lack of knowledge regarding their condition, suggesting that this situation is one of the factors responsible for triggering stomal and peristomal complications. One of the major concerns expressed was the difficulty in managing the ostomy appliance, especially in relation to the cutting of the adhesive portion of the appliance to the size and shape of the stoma.

... the skin was very irritated, hurt, painful and irritated around, I wanted a medicine to heal it, but I have no idea that it took that bleeding and that red skin around [E16, E15, E13, E14].

Effective counselling and teaching across the continuum of care is therefore a necessity to effectively satisfy the holistic needs of individual patients, their families and the community. Thus, the stomal therapy nurse needs to also promote educational and counselling practices so that the family and the patient are heard, involved, and reassured for their new life situation18.

According to the Brazilian Ministry of Health legislation, the healthcare of people who suffer from ostomies must be composed of actions developed from the context of basic healthcare at the hospital, passing through the specialised services (for example Health Care Service of Ostomized People: Attention to Ostomized People I and Attention to Ostomized People II) in a framework of collaborative multidisciplinary practice14. Nursing is represented in all health services; however, it is preferable that a stomal therapy nurse with the requisite skills will guide the self-care of the patient with a stoma, assist in the prevention of complications, and advise on the provision of ostomy equipment and adjuvants for safe peristomal skin protection. In addition, the stomal therapy nurse should train other health professionals so they understand the criteria for and can dispense ostomy equipment more effectively14.

However, in reality, within the entire territory of Brazil, there are insufficient stomal therapy nurses to meet the needs of patients with stomas, which implies difficulties in the implementation of the ostomy guidelines for self-care and the management of the stoma and peristomal skin and, consequently, can lead to complications19. Complications related to stoma and peristomal skin are decreased when the stomal therapy nurse can interact with the patient preoperatively. Preoperative care includes marking the stoma site, determining the ostomy appliances to be used in the immediate postoperative period, and discussing lifestyle changes as the result of having a stoma. Postoperatively, the stomal therapy nurse continues to guide the patient and caregiver on how to care for the stoma and peristomal skin and apply the ostomy pouch. The patient and/or care-giver are advised how to recognise stomal or skin complications and to seek assistance from the stomal therapy nurse in how to resolve these complications20.

Alterations relating to the ostomy condition or to the surgical technique

Some of the participants described that the cause of the complication was in relation to how the stoma was constructed, which was a reason for the low duration of wear time of the ostomy bags and, consequently, the development of complications:

... because the stoma is that withdrawn. It is that convex bag that makes you exposed. We were using the other one, and it was when we suffered more because it was not suitable and it used to leak a lot. It did not stimulate the gut to get out. And until we noticed that, we had to buy a lot of bags. After it has been evaluated, and the convex was indicated. And when we just we stick the bag on the gut comes out [E18, E13, E17, E16, E14].

Ostomy surgery can cause significant morbidity or mortality when the factors related to the underlying disease, as well as whether the indication for surgery was an elective or emergency procedure, are taken into consideration. Clinically, the fashioning, appearance and location of the stoma may be influenced by the patient’s abdomen in terms of abdominal scarring, contours or obesity and location of the stoma. Surgical issues relate to the complexity of the surgery, the degree of difficulty in creating and extruding the stoma through the abdominal wall without undue tension, and the skill of the surgeon. One or more of these factors may trigger the development of stomal or peristomal complications in an early or late form7. For example, the following comment from a participant points to the surgical procedure as the cause of their stomal complication:

Man, I cannot tell you the reason why. I do not know if it was a well done or poorly done surgery, but I know it was not good because the colostomy mouth closed on its own [E17].

The most common immediate postoperative ostomy complications are bleeding, ischaemia, necrosis, oedema, retraction, mucocutaneous detachment, and peristomal sepsis. Later complications are retractions, stenosis, prolapse and herniation21. The surgical technique chosen influences the emergence of these complications – several techniques are described for the opening of the stoma, and all have a set of complications. However, laparoscopic colostomy is safe and effective, with faster return of bowel function, shorter hospital stay and decreased pain, therefore avoiding wound and stoma-related complications.

Surgical intervention therefore requires preventive guidance from a variety of health professionals. In this context, the stomal therapy nursing consultation presents an excellent opportunity for the development of care in a systematic and individualised manner, as well as support for the promotion of actions and direct monitoring of the person, preventing stoma-related complications and helping them to cope with the difficulties caused by changes after surgery21,22.

Limitations

It is important to state that this study was limited by the difficulty of the stoma patients’ access to SASPO as access to public transportation was not provided. Additionally, the healthcare professionals had difficulty in accessing the self-care and development guidelines of an individualised and personalised care plan.

Conclusions

People post-ostomy surgery who participated in this study were are able to identify the possible causes for the ostomy complications they were experiencing. Further, they attributed these complications to the type of ostomy appliances being used, personal conditions, their knowledge of and their ability to self-care for their stoma, the condition and/or appearance of the stoma, and the surgical technique used to create the stoma that may have contributed to the complications being experienced.

In view of these causative factors as indicated by the users of a specialised stomal therapy nursing service within health services in northeastern Brazil, it may be concluded that the presence of any stomal and/or peristomal skin complications arising from surgical techniques or from a poorly fitting or an incorrect ostomy appliance may affect a person’s ability to manage the stoma. Self-management and self-adjustment to living with the stoma may also be compromised by lack of advice or failure of the person with the stoma or the carer to adhere to the advice provided. Another important factor is having access to quality ostomy appliances and accessories that can assist with the management of ostomy complications. In addition, the appliances must be reliable in terms of their ability to mould and adhere to the skin and prevent leakage.

Thus, we suggest that the correct choice of the ostomy appliance should be based on an evaluation of the individual’s needs, the adoption of educational technologies such as video lessons or interactive programmes on the internet as well as telephone monitoring and group therapies to enhance teaching strategies to improve self-management of the stoma. Further, compliance with the Brazilian legislation that recommends the services of either a stomal therapy nurse or staff well trained in all aspects of ostomy care is vital to facilitate optimal ostomy care pre and postoperatively. In this way, potential or actual stomal and peristomal skin complications can be detected earlier. The correct preventative and rehabilitation measures can then be initiated and evaluated in conjunction with the patient and/or carer. This approach, it is hoped, will reduce the incidence of intraoperative and postoperative ostomy surgery complications.

Conflict of Interest

The authors have declared that there are no political and / or financial conflicts of interest associated with the provision of materials that were used in the study, nor any type of funding for their realisation.

Funding

The authors received no funding for this study.


巴西东北部地区患者出现造口或造口周围皮肤并发症的原因

Yterfania Soares Feitosa, Luis Rafael Leite Sampaio, Déborah Albuquerque Alves Moreira,
Francisco Antonio da Cruz Mendonça, Tatyelle Bezerra Carvalho, Juliano Teixeira Moraes,
Maria Euridéa de Castro and Eliziane Ribeiro Barros

DOI: https://doi.org/10.33235/wcet.39.3.15-19

Author(s)

References

PDF

摘要

问题声明 确定造口者或其护理者认为导致造口或造口周围皮肤发生并发症的原因。

方法 2018年3月至6月,对19例肠造口患者人群进行定性研究。通过结构性访谈收集数据,然后采用内容分析技术分析数据。

结果 可以注意到,导致造口或造口周围皮肤并发症的原因是以下因素相关的变化:造口器具的使用;个人情况;自我护理知识;造口条件或手术技术。

结论 造口者可以指出其易感并发症的可能原因。他们描述的原因有:造口器具的使用;个人情况;有关其造口自我护理的个人知识;造口条件及造口周围皮肤;使用的手术技术。

前言

造口是通过手术技术制造的一个开口,其可使内脏器官通过皮肤上非自然插入部位的某一个部位分流,从而改善呼吸、进食或排泄1

根据造口所处的身体部位以及为形成造口而分割或避开的相关组织,造口可分为气管造口术(呼吸)、胃造口术和空肠造口术(进食)及尿道或肠造口术(排泄)。对于可能需要造口的时长,根据是否能够重建习惯排泄途径,造口可分为临时性或永久性造口2

在各类造口术中,需要特别提到肠造口(回肠造口术和结肠造口术),因为有几种情况可能导致必须进行肠道改道 , 如炎症性肠病、外伤 、憩室炎 、癌症和先天性疾病 。在巴西,成人和老年人群接受肠造口的主要原因是结直肠肿瘤4。Instituto Nacional do Câncer(国家癌症研究所,INCA)估计,在2018–2019两年期的每年间,将会出现17380例新增男性结肠和直肠癌患者,以及18980例女性结肠和直肠癌患者5

许多临床环境可能导致造口和/或造口周围皮肤并发症的发生,其中频率最高的是脱垂、回缩、缺血、造口旁疝和造口周围皮炎6。值得强调的是,这些并发症对造口者的整体生活质量造成负面影响,导致性问题、抑郁情绪、胀气、便秘、对外观不满、频繁更换服饰或服饰风格、步态困难、疲乏和噪音困扰。因此,这些因素可能对人际关系和职业关系产生不利影响,并导致回避社会环境7

考虑到这些问题,在对造口者及其造口进行评估和实施适当的管理计划时,造口治疗护士是不可或缺的医务人员。因此,从制造造口之时到患者康复的非卧床护理和居家护理阶段,造口治疗护士的目标和行动是协助造口患者避免或及早发现造口相关并发症8

在此背景下,本研究旨在确定巴西东北部地区的造口者及其护理者认为导致造口和/或造口周围皮肤相关并发症的原因。从这个角度理解这些问题以及造成这些并发症的原因,可以帮助造口治疗护士制定个性化护理方案。这类专业护理能够帮助造口者更好地适应因其新健康状况而需要和体验的改变。

方法

2018年3月至6月,在位于巴西东北部地区一个州的一所康复中心进行了采用定性方法的本描述性研究。

在Secretaria Estadual de Saúde do Estado do Ceará(塞阿拉州卫生部,SESA)的Serviço de Atenção à Saúde da Pessoa Estomizada(造口者医疗服务,SASPO)中,57人登记为造口者。其中,26人没有接受参与本调查的邀请,因此本研究队列总计为31人。但是,根据理论饱和标准(不能从患者回应中提取到新的信息,观察到回应重复或反复,或已满足研究目标9),只对19例参与者进行访谈,其中11人为肠造口者,8人为护理者。

使用结构性脚本进行访谈,从而收集数据,脚本中包括有关造口及造口周围皮肤并发症的问题。通过音频记录访谈 ,然后将回答全文誊写 ,肠造口患者编码为“E”,护理者编码为“C”,其后带有阿拉伯数字。

经分析前、材料探索和结果处理、推断和解释阶段后,使用Bardin内容分析法分析数据。内容分析涉及一组方法学工具,旨在分析通过访谈或直接观察得到的不同交流方式(语言或非语言),然后把完全、详尽分析后提取的材料按主题或类别分类/分组10

伦理事宜

本研究为自愿参加,通过签署自由知情同意条款(已考虑涉及人类研究的国家和国际伦理学规范)获取同意。在这个意义上,保证了参与者的匿名性、隐私,以及有关自由参与或不参与研究项目的自主权。本研究得到巴西监管的研究伦理委员会的评估和批准,意见书编号2,542,686,CAAE登记号83103518.4.0000.5052。

结果和讨论

参与者人口统计学数据

19例年龄为22–75岁的参与者登记参与本研究。其中11例参与者为公司雇员,8例为管理人员,平均薪资950雷亚尔。所有人均与其他人同居。造口参与者中包含4例女性和7例男性。其中9例完成初等教育,1例完成高等教育,另1例未知。护理者中包含6例女性和2例男性,均完成初等教育。

至于参与者造口的临床特征,10例参与者为永久性造口,9例为临时性造口。其中15例为结肠造口,4例为回肠造口。至于造口原因,10例参与者为结直肠癌,7例为外伤所致,2例为急腹症。

参与者对造口或造口周围皮肤并发症发生原因的认识

誊写和分析音频记录的访谈后,可将参与者认为导致其患造口和/或造口周围皮肤并发症的原因分为4类:

  • 造口器具使用相关的变化。
  • 个人情况相关的变化。
  • 自我护理知识相关的变化。
  • 造口条件或手术技术相关的变化。
造口器具使用相关的变化

关于造口器具,参与者指出,已识别并发症的发生与服务中可使用的设备类型、收到的器具的材料质量、器具的粘合度及由此导致的粘合时间相关。以下是参与者的评论,可证实这个观点:

她的皮肤非常白,很敏感,我取下造口袋后,发现她皮肤发红/造成这个问题的原因是造口袋的类型[C1、C2、 C3、C4、C6、C7、C5、C8]。

我认为他们用来粘附皮肤的产品完全没有效果。因为太容易脱脂了,灼伤了人的皮肤。他们应该改进一下,应该粘得更牢,而且不应对人的皮肤造成这么大的伤害。我认为完全是造口袋的原因[E19]。

现在尚无能够适用于所有人、所有造口和所有情况的理想造口器具类型。但是,有几种产品可以用来满足造口患者的个体需求,这些需求取决于不同造口类型,以及随着造口的术后成熟及患者恢复其正常日常生活活动而在造口中发生的结构变化。这些因素意味着在根据每个人的个性化需求选择设备和开处具体护理方法时,应采取不同的做法11,12

另外,有关造口器具,必须指出,如果是腹部永久使用的设备,那么它可能影响患者的体像。这种情况下,设备的开处将变得复杂。造口治疗护士需要明确了解产品可用性及其适应症和优缺点。在选择造口器具时,还必须评估需要使用该器具的个人,包括考虑个人的身体、情绪和社会维度,以及其动手能力、视觉敏锐度、服装、家庭支持、生活方式、个性、认知能力及用户偏好等其他因素13

依巴西卫生部第400/09号指令制定的Política Nacional de Saúde da Pessoa com Deficiência(国家残障人士健康政策)规定了造口设备和造口周围皮肤病用辅助材料(根据对造口和造口周围皮肤的特征评估)的标准和供应14。可用的设备和辅助材料类型繁多。但是,尽管对这些人群提出了具体的推荐,但在全世界范围内,对于向造口者提供的护理和所分发材料的质量和数量,仍然存在巨大差异。值得注意的是,在巴西,若干地区中存在这种差异,并直接影响了造口者对收集和辅助设备供应的满意度12

个人情况相关的变化

造口者频繁报告称,其造口和皮肤的相关问题与其个人情况的变化有关。在这方面,本研究的参与者报告称其皮肤不适应造口器具的组成材料应:

……有时,很痒……所以我认为是皮肤原因,皮肤不适应造口袋,发红,但这只是适应的问题,我觉得问题出在我的皮肤本身[E9、E11、E10、E12]。

去除身体的任何部分都可看作一种引起脆弱感和无力掌控其存在的体验。因此,必须主动聆听,加强医务人员与患者之间的联系,以发现他们的顾虑,然后制定干预策略,帮助造口者和/或护理者进行自我护理15

另一项评估肠造口患者感受的研究报告称,患者在造口术康复过程中体验到了生活上的一些变化,包括感觉的不确定性、害怕缺乏认识,以及缺乏信息,使得这些人难以恢复他们日常生活的常规活动16

因此,实施缓解其脆弱感和加强自信心的策略非常重要。视频课程、互联网互动程序、电话支持和集体治疗等教育技术能有所帮助。这些活动对促进造口者的康复和适应极其重要。此类策略还可以帮助及早发现和报告并发症,提高生活质量17

自我护理知识相关的变化

受访者的回应表明他们对于自身情况缺乏了解,说明这也是引发造口及造口周围皮肤并发症的因素之一。他们谈到的一个主要顾虑是难以管理造口器具,尤其是按照造口的大小和形状切割器具粘胶的部分。

……皮肤受到很大刺激,又疼又痛,周围也受到刺激,我想用药治好皮肤,但我不知道这会引起周围皮肤出血发红[E16、E15、E13、E14]。

因此,为了有效满足个体患者、其家属和社区的整体需求,必须在持续的护理工作中提供有效的咨询和教育。造口治疗护士还需要推广教育和咨询实践,以便听取家属和患者的心声,让他们参与进来,使他们对新的生活状况感到放心18

根据巴西卫生部的法律,造口者的医疗保健必须包括在多学科合作实践的框架中,从医院基本医疗保健环境出发,经由专业服务(如《造口者医疗健康服务:造口者须知I和造口者须知II》(Health Care Service of Ostomized People: Attention to Ostomized People I and Attention to Ostomized People II))而制定的措施14。所有卫生服务中都包含护理工作;但是首选具备必要技能的造口治疗护士,他们能够引导造口患者的自我护理,帮助预防并发症,推荐造口设备和可安全保护造口周围皮肤的辅助材料。另外,造口治疗护士应该培训其他医务人员,让他们理解造口设备的标准,进而能够更有效地分配造口设备14

但是实际上,整个巴西境内都没有足够的造口治疗护士来满足造口患者的需求,这意味着难以实施针对造口和造口周围皮肤自我护理和管理的造口指南,因此可能导致并发症19。当造口治疗护士能与患者进行术前互动时,造口及造口周围皮肤相关的并发症有所减少。术前护理包括标记造口部位,确定造口术后即期使用的造口器具,以及讨论因造口导致的生活方式的变化。术后,造口治疗护士继续引导患者和护理者了解如何护理造口及造口周围皮肤,以及如何使用造口袋。患者和/或护理者接受指导,了解如何识别造口或皮肤并发症,并从造口治疗护士处寻求解决这些并发症的帮助20

造口条件或手术技术相关的变化

有些参与者描述,并发症的原因与建立造口的方式有关,这是造口袋佩戴时间较短、从而引起并发症的原因之一:

……因为造口,所以不想出门。凸面造口袋让我感觉自己暴露了。我们以前使用的是另一种,但那时我们更痛苦,因为它不合适而且经常大量渗漏。这让我们不敢出门。在我们注意到这一点之前,我们不得不买很多造口袋。后来经过评估,换成了凸面造口袋。我们坚持使用这种造口袋才让我们敢出门[E18、E13、E17、E16、E14]。

当考虑到基础疾病相关因素,以及手术指征是择期手术还是紧急手术等因素时,造口手术可能导致较高的发病率或死亡率。临床上,造口的方式、外观和部位可能受到患者腹部疤痕、轮廓或肥胖等患者腹部状况及造口部位的影响。外科手术问题包括手术复杂度、穿过腹壁制造并穿出造口而不引起过大张力的困难程度,以及外科医生的技术。以上单个因素或多个因素都可能触发造口或造口周围皮肤的早期或晚期并发症7。例如,一例参与者的以下评论指出手术操作是其造口并发症的发生原因:

唉,我没办法告诉你原因。我不知道手术做的成功还是失败,但我知道肯定不算好,因为结肠造口开口自己关闭了[E17]。

最常见的造口术术后即期并发症包括出血、缺血、坏死、水肿、回缩、粘膜皮肤分离和造口周围败血症。晚期并发症包括造口回缩、狭窄、脱垂和造口疝21。选择的手术技术会影响这些并发症的发生率,文献描述了制造造口开口的一些技术,但都会带来一系列并发症。但是,腹腔镜结肠造口术是安全有效的,可以更快恢复肠道功能,缩短住院时间,减少疼痛,从而避免伤口和造口相关的并发症。

因此,手术干预需要多方医务人员的预防性指导。在这种背景下,造口治疗护士的咨询就为开发系统性和个性化的护理提供了绝好的机会,并为推动各项措施及对个人的直接监测提供了支持,从而预防造口相关的并发症,帮助他们应对术后变化带来的困难。21,22

局限性

必须说明,本研究的局限性在于造口患者很难进入SASPO,因为没有提供公共交通。另外,专业医护人员也很难获取个人化和个性化护理方案的自我护理和制定指南。

结论

参与本研究的造口术后患者能够指出他们发生造口并发症的可能原因。另外,他们将这些并发症归因于:使用的造口器具的类型、个人情况、对自身造口的自我护理知识和能力、造口的条件和/或外观,以及用于制造造口的手术技术。

鉴于巴西东北部地区医疗服务中心的专业造口治疗护理服务用户指出的上述原因,可以得出结论,任何造口和/或造口周围皮肤并发症的存在,无论是由手术技术还是由造口器具适合性差或选用不当造成,都可能影响个人管理造口的能力。造口者或其护理者缺乏指导或未遵守提供的建议,也可能影响造口者对造口的自我管理和对生活的自我调节。另一个重要因素是,可使用能够帮助管理造口并发症的优质造口器具和附件。另外,造口器具必须具有可靠的皮肤吻合/贴合性,以及防渗漏能力。

因此,我们建议,应该根据对个人需求的评估正确选择造口器具,并采用视频课程或互联网互动程序、电话监测及集体治疗等教育技术加强教育策略,以提高对造口的自我管理。另外,巴西法律建议由造口治疗护士或在造口护理各方面均受过良好培训的人员提供服务,遵守该法律是促进术前、术后最佳造口护理的关键。这有利于尽早发现造口或造口周围皮肤的潜在或实际并发症。然后可以与患者和/或护理者共同采取和评估正确的预防和康复措施。如此有望降低术中和术后造口术并发症的发生率。

利益冲突

作者声明,就本研究中使用的材料,其供应不存在任何相关的政治和/或经济利益冲突,其实现也不存在任何类型的资助。

资助

作者未因该项研究收到任何资助。


Author(s)

Yterfania Soares Feitosa
Stomatherapy Nurse, Regional Hospital of Cariri, Ceará, Brazil

Luis Rafael Leite Sampaio*
Stomatherapy Nurse, Teacher, Regional University of Cariri, Ceará, Brazil
Email rafael.sampaio@urca.br

Déborah Albuquerque Alves Moreira
Emergency Nurse, Regional Hospital of Cariri, Ceará, Brazil

Francisco Antonio da Cruz Mendonça
Nurse, Teacher, Center Universitary Estácio of Ceará, Ceará, Brazil

Tatyelle Bezerra Carvalho
Nurse, Ceará, Brazil

Juliano Teixeira Moraes
Nurse, Teacher, Federal University of São João Del-Rei, Minas Gerais, Brazil

Maria Euridéa de Castro
Nurse, Teacher, Ceara State University, Ceará, Brazil

Eliziane Ribeiro Barros
Nurse, North Regional Hospital, Ceará, Brazil

* Corresponding author

References

  1. Figueiredo PA, Alvim NAT. Diretrizes para um programa de atenção integral a pacientes e famílias ostomizadas: uma proposta de enfermagem. Rev Latino-Am Enfermagem, Ribeirão Preto 2016;24(1):2694.
  2. Dantas FG, Souza AJG, Melo GSM, Freitas LS, Lucena SKP, Costa IKF. Prevalência de complicações em pessoas com estomias urinárias e intestinais. Revista Enfermagem Atual. Cidade 2017;1(1):55–82.
  3. Steinhagen E, Colwell J, Cannon LM. Stomas intestinais: cuidados de estoma pós-operatório e complicações de pele peristomal. Clínicas em Cólon e Cirurgia Retal 2017;30(3):184–192.
  4. Miranda SM, Luz MHBA, Sonobe HM, Andrade EMLR, Moura ECC. Caracterização sociodemográfica e clínica de pessoas com estomias em teresina. Estima 2016;14:29–35.
  5. Instituto Nacional de Câncer José Alencar Gomes da Silva. Coordenação de prevenção e vigilância. Rio de Janeiro: INCA; 2017.
  6. Krishnamurty D, Blatnik J, Mutch M. Stoma complications. Clin Colon Rectal Surg 2017; 30(3):193–200.
  7. Vonk-Klaassen SM, Vocht HM, Ouden ME, Eddes EH, Schuurmans MJ. Ostomy-related problems and their impact on quality of life of colorectal cancer ostomates: a systematic review. Qual Life Res 2016;25(1):125–133.
  8. Jayarajah U, Samarasekara AMP, Samarasekera DN. A study of long-term complications associated with enteral ostomy and their contributory factors. BMC Res Notes 2016;9(1):2–6.
  9. Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DG. Amostragem em pesquisas qualitativas: proposta de procedimentos para constatar saturação teórica. Cad Saúde Pública 2011;27(2):389–94.
  10. Marconi MA, Lakatos EM. Fundamentos de metodologia científica. 8th ed. São Paulo: Atlas; 2017.
  11. Lage EMI, Paula MAB, Cesaretti IUR. Equipamentos coletores e adjuvantes usados no cuidado das estomias. São Caetano do Sul, SP: Yendis Editora; 2014.
  12. Hey AP, Nascimento LA. A pessoa com estomia e o fornecimento de equipantos coletores e adjuvantes pelo sistema único de saúde. Estima 2017; 5(2):92–99.
  13. Sena RMC, Nascimento EGC, Sousa WPS, Oliveira MAM, Maia EMC. Aspectos emocionais do indivíduo no enfrentamento da condição de estomizado. Estima 2017;15(1):43–49.
  14. Brasil: Secretaria de Atenção à Saúde. Portaria n. 400 de 16 de novembro de 2009. Estabelece as diretrizes nacionais para a atenção à saúde das pessoas ostomizadas. Brasília, DF: Diário Oficial da União; 2009.
  15. Marques ADB, Amorim RF, Landim FLP, Moreira TMM, Branco JGO, Morais PB, et al. Consciência corpórea de pessoas com estomia intestinal: estudo fenomenológico. Rev Bras Enferm Brasília 2018;71(2):391–397.
  16. Nieves CB, Díaz CC, Celdrán-Mañas M, Morales-Asencio JM, Hernández-Zambrano SM, Hueso-Montoro C. Ostomy patients’ perception of the health care received. Rev Latino-Am Enfermagem 2017;25:e2961.
  17. Medeiros LP, Silva IP, Lucena SKP, Sena JF, Mesquita EKS, Oliveira DMS, et al. Atividades da intervenção de enfermagem “cuidados com a ostomia”. Rev Enferm Ufpe On Line 2017;11(12):5417–5426.
  18. Gomes B, Martins SS. A pessoa estomizada: analise das práticas educativas de enfermagem. Estima 2016;14(3):146–153.
  19. Moura RRA1, Guimarães EAA, Moraes JT. Análise da implantação dos serviços e atenção à saúde da pessoa estomizada: estudo de casos múltiplos em Minas Gerais, Brazil. Divinópolis: Universidade Federal São João del-Rei; 2017. Dissertação de mestrado.
  20. Mota MS, Gomes GC, Petuco VM, Heck RM, Barros EJL, Gomes VLO. Facilitadores do processo de transição para o autocuidado da pessoa com estoma: subsídios para enfermagem. Rev Escola Enferm USP 2015;49(1):82–88.
  21. Mota MS, Gomes GC, Petuco VM. Repercussões no processo de viver da pessoa com estoma. Texto Contexto Enferm 2016;25(1):e1260014.
  22. Caetano CM, Beuter M, Jacobi CS, Mistura C, Rosa BVC, Seiffert MA. O cuidado à saúde de indivíduos com estomias. Rev Brasil Ciências  Saúde 2014;12(39).
  23. Saxena S, Gibbons M, Chatoorgoon K, Villalona GA. Laparoscopic-assisted divided colostomy for anorectal malformation case series: a description of technique, clinical outcomes and a review of the literature. Pediatr Surg Int 2018;34(8):861–871.