cancer Self-care of elderly people with ostomy bycolorectal Coloproctology Journal of

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w w w . j c o l . o r g . b r

Journal of

Coloproctology

Review Article

Self-care of elderly people with ostomy by colorectal cancer

Raul de Paiva Santos

^∗

, Silvana Maria Coelho Leite Fava , Eliza Maria Rezende Dázio

UniversidadeFederaldeAlfenas(UNIFAL-MG),FaculdadedeEnfermagem,ProgramadePós-graduac¸ãoemEnfermagem,MinasGerais, MG,Brazil

a r t i c l e i n f o

Articlehistory:

Received29October2018 Accepted7January2019 Availableonline1March2019

Keywords:

Self-care Elderlypeople Ostomy

Gerontologicalnursing

a bs t r a c t

Objective:Toidentifyinliteraturethescientiﬁcproductionaboutself-careinelderlypeople withostomiesbycolorectalcancer.

Method:Integrative review, performed with the descriptors “self-care”, “ostomy” and

“elderly/aged”withtheBooleanoperatorANDinthefollowingdatabases:SCOPUS,CINAHL, MEDLINE,LILACSandCOCHRANE.Forthetheoreticalbasis,Orem’sSelf-CareDeﬁcitTheory wasused.

Results:Atotalof533paperswerefound,however,afterapplyingtheeligibilitycriteria,16 studiescomposedtheﬁnalsampleofthereview.

Conclusion: Thenurseisoneoftheprofessionalsclosesttothepersonwiththestomaand hisfamily,andshouldactasalinkbetweentheelderlyperson,thefamilyandthemulti- professionalhealthteam.Inthissense,healthprofessionals,especiallynurses,shouldbe trainedandcompetentinassistingthediversedemandsofcareofthisspeciﬁcpopulation,so thatitiseffective,resolutive,integraland,aboveall,humanized,aimingattheimprovement ofqualityoflife.

licenses/by-nc-nd/4.0/).

Autocuidadodepessoasidosascomestomiaporcâncercolorretal

Palavras-chave:

Autocuidado Pessoaidosa Estomia

Enfermagemgerontológica

r e su m o

Objetivo:Identificar naliteraturaa produçãocientíficasobreoautocuidadoem pessoas idosascomestomiaporcâncercolorretal.

Método:Revisãointegrativadeliteratura,realizadacomosdescritores“autocuidado/self- care”, “estomia/ostomy”e “pessoaidosa/idoso/aged”comooperador Booleanoandnas BasesdeDadosSCOPUS,CINAHL,MEDLINE,LILACSeCOCHRANE.Paraoembasamento teóricoempregou-seaTeoriadoDéﬁcitdeAutocuidadodeOrem.

∗ Correspondingauthor.

E-mail:raulpaivasantos@hotmail.com(R.P.Santos).

https://doi.org/10.1016/j.jcol.2019.01.001

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jcoloproctol(rioj).2019;39(3):265–273

Resultados: Encontrou-seumtotalde533artigos,noentanto,apósaaplicac¸ãodoscritérios deelegibilidade16estudoscompuseramaamostraﬁnaldarevisão.

Conclusão: Oenfermeiroéumdosprofissionaismaispróximosdapessoacomestomia edesuafamília,devendoatuarcomoumeloentreapessoaidosa,afamíliaeaequipe multiprofissionaldesaúde.Nessesentido,profissionaisdaáreadasaúde,especialmenteo enfermeiro,devemestarcapacitadosesercompetentesnaassistênciaàsdiversasdeman- dasdecuidadodessapopulaçãoespecífica,paraqueelasejaefetiva,resolutiva,integrale, sobretudo,humanizada,visandoàmelhoradaqualidadedevida.

´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

Integrativereviewcenteredonself-careofelderlypeoplewith ostomybycolorectalcancer.Seeingthatinthisagerangemay occur sensory-motorsmodiﬁcations, obesityor overweight, anemia,physicalandmentaldeteriorationthat,along with thepresenceofanostomy,cancompromiseevenmorethe self-care.¹

Hence,inthepopulationagingcontext,somediseasesare commonsintheagingprocess,amongthemcancergainsvis- ibility.AccordingtoWorld Health Organization,cancer isa genericname giventoavastgroupofdiseases,whichcan invadeadjacentbodypartsanddisseminatethoughtheorgan- ism.Itisconsideredthesecondcauseofdeath,with8.8million ofdeathin2015.²InBrazil,estimatesfromtheCancerNational Instituteto2017pointtotheoccurrenceof600thousandnew cases;beingcolorectalcancerresponsiblefor7.8%ofthecases;

yet,assumesthirdandsecondplacesregardingincidence,in menandwomen,respectively.^3,4

Colorectalcancerisapathologywithmultiplelocalizations and clinical–pathologicalaspects,besides, it doesnot have pathognomonicsigns,inotherwords,donotpresentspeciﬁc signsandsymptoms.⁴Duetothediagnosismightbemade,in anadvancedstaging,somedrastictherapeuticdecisionsmay beadopted,suchasasurgicalconstructionofanostomy;thus, abdominalresectionwithacreationofanostomycontinuesto bethemainapproach.⁵Furthermore,thesurgicalprocedure maybeaccompaniedbychemoorradiotherapy,implying,in agreaterself-caredemandtotheelderlypeople.

Ostomyreferstoasurgical-createdopeninginthebody, aimingtoeliminatecorporalefﬂuentsordietadministration, itcanbepermanentortemporary.⁶Thereby,thepresenceof newcondition,ofhaveanostomy,affectsnotonlythebiolog- icaldimensionofthesubject,aswellasitspsych-emotional, generatingademandofeffectiveandintegralcare;so,health professionalsmust be capacitatedinattendance ofelderly peoplewithanostomy.

Thenurse,asapartofthemulti-professionalhealthteam, has the duty ofmanaging the care ofelderly people with anintestinal ostomy,in anylevels ofassistance, sincethe diagnosisprocesstothehomemonitoring. Inprimarylevel ofassistance,itspracticecentersitselfinthe preventionof cancer-riskbehaviors,inreferenceandcounter-referenceof patients with ostomies; making partnerships between the Healthand Educationsectorsand the Government, aiming

toguaranteetherighttonecessarysupplements.Inthesec- ondary level, its assistance beginsinthe preparing forthe treatment(chemo,radio,surgicalormixed),helpinginthese and,beforethehospitaldischarge,hasthepotentialtodevelop the health education,guiding theelderly people about the performanceofthe self-careathome.Inthis scenario,the nursewiththemulti-professionalhealthteam,mustprovide quality careforpeople goingthroughanostomy surgery,a life-changingexperience.⁷

Notwithstanding, in care planning of the elderly with ostomy and intheadaptation process,theFamily mustbe involved.Itisindispensablethesurveyofneeds,takinginto consideration the elderly with ostomy, multi-professional healthteamandfamilysingularities.Thus,healthprofessionals that work in caremanagement must assess individual needs, patient attitudes, willingness to learn and be com- fortablemanipulatingtheostomyandthecollectordeviceof efﬂuent,theabilitiestousualostomycare,capacitytoidentify possible problems,carewith peristomeskin and tounder- standhowtopreventandmanagepotentialcomplications,⁸ havingasagoalthereturntodailylifeactivities,thepreven- tion ofsocialisolationand improvementsinthequalityof life.

Inthisscenario,theintegrativereviewaimedto:investigate self-careofelderlypeoplewithostomybycolorectalcancer andtoanswertheresearchquestion:howistheself-careof elderlypeoplewithostomybycolorectalcancer?

Method

AnIntegrativeReviewwaselaborated,thatprovidesabroad search andinterpretation ofinvestigativemethodologiesin asinglestudy,consistinginﬁvestages;whichareexplained below.⁹

Stepone:researchproblemidentiﬁcation

Althoughitswell-knownbeneﬁts,anostomydemandsacom- plexhealth-relatedassistanceandisalsoneededdomiciliary care,performedbytheownelderly,inotherwords,self-care.

Thiscareincludesprocedures relatedtodeflation,changes andfixationofthecollectordevice,amongothers.Inthisper- spective,self-carehasgreatimportance,withdirectinfluence inpatient’squalityoflife,comfortandwell-being.Fromthe needtoadapt toanewcondition,the followingresearches

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Records identified through database searching

(n = 533)

ScreeningIncludedEligibilityIdentification

Additional records identified through other sources

(n = 3)

Records after duplicates removed (n = 464)

Records screened (title and abstract reading)

(n = 464)

Records excluded (n = 409)

Full-text articles assessed for eligibility

(n = 55)

Full-text articles excluded, due to not being available for free, researches that approach elderly people

without ostomies, or urostomies, child, teenagers and young adults with ostomies, and

others.

(n = 42) Studies included in

qualitative synthesis (n = 13)

Fig.1–PRISMAﬂowdiagram*–literaturesearchprocess.*Adaptedbytheauthorsfrom:Moheretal.¹⁰

questions emerged: “Howself-care isperformed byelderly peoplewithostomies?Howhavethesepeoplebeenoriented inrelationtoself-care?Whatistheroleofthenurseinthe self-careoftheelderlywithostomies?”

Steptwo:literatureresearch

The exploration process was conducted in 2017 July, on ﬁvedatabases bythe authors (RPS and EMRD). Thesearch strategies,HealthSciencesDescriptors,MeSHTermsandthe Boolean operator AND were applied. On SCOPUS database was used the search strategy “self-care”, “ostomy” and

“aged”[keywords],resultinginatotalof23publications.In the next database, CINAHL, “self-care” and “ostomy” [MW Wordinsubjectheading] strategywasapplied,resulting in 193 studies. On MEDLINE, was appliedthe “self-care” and

“ostomy” [MeSH terms] strategy, ﬁnding 292 publications.

OnCochranedatabasethesearchwasdonewith“self-care”

and “ostomy” [keywords], returning three studies. Lastly, on LILACS was used “autocuidado”, “ostomia” and “idoso”

[Subject descriptors in Portuguese], resulting in 22 references.

Theeligibilitycriteriaadoptedwere:articlesfreelyavail- ableand online, thatapproachedthe themeofself-care of theelderly,publishedinthelasttenyearsandinPortuguese, Spanish and English. Atotal of 533potential studies were found.However,aftertitleandabstractreadings,theappli- cationof eligibilitycriteria and critical reading, 13 studies wereselectedtocomposetheﬁnalsample.Thebibliographic selectionprocess isavailableon PRISMAﬂowdiagram¹⁰ in Fig.1.

Stepthree:dataassessment

The aim ofthis stepwas todefine, establish and synthe- siseinformationfromthestudiedreferences,elaboratingan accessible database, with double typing, in the Microsoft Excelsoftware2016version,including:typeand countryof thestudy,aims,appliedmethodology,subjects,sampleand sampling,findingsandmainconclusionsofeachstudy.The referenceswerevalidatedbycriticalreading,verifyingthecri- teriadefinedinthepreviousstep,besides,therelevanceof eachstudytothereview,methodqualityandself-carerelated information.

Ontheinformationthatwereextractedfromthestudies, the authors deﬁnedthat the following datacould be used and highlighted on the reviewdiscussion; amongthe data were:self-careabilityandperformance,self-careinformation and health education, the role ofthe nursing in the edu- cationtowardtheindependenceforself-care,amongothers thatallowedageneralcontextualizationofself-careofelderly peoplewithanostomy.Furthermore,aimingtogivetrustwor- thinesstothereview,wasadoptedthe EvidenceLevel,¹¹ to categorizeeachstudy.

Stepfour:dataanalysis

In this phase, the data of the selected references were critically analyzed and classiﬁed, codiﬁed, categorized and synthesized in the form of conclusions; to answer the researches questions,⁹ regarding self-care in elderly people with ostomies; by the authors (RPS, SMCLF and EMRD) between May and July 2017. By constant

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comparison, conclusive evidences were categorized into groupsbysimilaritiesanddifferences;whichidentiﬁedthree mainthemesthatarepresentedposteriorly.

Stepﬁve:datapresentation

Finally,thelastphaseconsistedinprovidingessentialdataof eachresearch,seekingtoapprehendthedepthoftheobject beingstudied–self-careofelderlypeoplewithostomies.The phaseofdiscussionandﬁnalpresentationofresultsisfunda- mentaltodelineatehowisself-careinthisspeciﬁcpopulation;

whichwasevidenced inthereferences thatcomposedthis IntegrativeReview.

TheoreticalframeofOrem’sself-caretheory

Tobasetheanalysisofreferences,weoptedforOrem’sSelf- CareDeﬁcitTheory.Inthissense,itisperceivedthatthecare, consideredbyOremasself-care,isthatcarriedoutbytheown individualtohisbeneﬁt,throughactionsoractivitiescapa- bleofsatisfyingthebiopsychosocialandspiritualneedsofhis ownbeing,throughcertainrequirements,bethemphysiolog- icalorbehavioral.¹²

Orem’sSelf-care Deficittheoryinitsentireencompasses eightdistinct functionsthatmustbetakenintoaccountby thenurse,theyare:(1)Definewhichtermsaremoreappro- priatetonursing,inrelationtothehumanbeing;(2)Choose themostappropriatenursingapproach;(3)Establishalan- guageoftheprofession;(4)Defineguidinglimitsofthought, practice,researchand education;(5) Tominimizecognitive load,aimingtoproposesubsidiestoreceiveinformationand enabletheapplicationtocategorizetheconceptsinorderto relateinsightsaboutthecharacteristicsofconcretenursing situations;(6)Allowinferencesregardingthearticulationsof nursingwiththemostdiversedomainsofhumanactivity;(7) Encourageandgenerateinnursesandnursingacademicsa standardizedstyleofthinkingandcommunication,andfinally (8)Toinsertthenursesintheacademicscope.¹³Thus,being awareoftheexistenceornotoftheself-caredeficitandthe aspectsthatmaybecontributingtoit,whetherpositiveorneg- ative,areimportantindicatorsfornurses,sothattheycanuse theTheorytoguidetheircareplanning,implementation¹⁴and evaluation.

Results

The characterization of the analyzed studies regarding authorship,Country oforigin,study focus,conclusionsand evidencelevel, is shown inTable 1. Furthermore,the level ofevidencewasanalyzed,ofeachstudy,basedontheclas- siﬁcationofMelnyk and Fineout-Overholt,¹¹ bethe quality of evidences seven classiﬁcation levels: (1) Evidence from meta-analysisofmultipleclinical trials; (2)Evidences from individualstudieswithexperimentaldesign;(3)Evidencefrom quasi-experimentalstudies;(4)Evidencefromdescriptiveor qualitativeresearches;(5) Evidence from systematicreview ofqualitativeordescriptivestudies;(6) Evidencefrom only adescriptiveorqualitativestudy,experienceorcasereports;

and,(7)Evidencebasedontheexpertexperienceandopinion.

Regarding evidencelevel,¹¹ eightpapers(61.5%)had the levelVI,twolevelII(15.4%)andoneofI,IVandVlevel(7.7%).

Inthissense,mostofthepapershaddescriptivedesign,the researchescurriedinspeciﬁcpopulation,withageneraliza- tionbias;twopapershadarandomized-controlleddesignand onlyonestudy had,asadesign,evidencesfrom asystem- aticormetanalysisreviewofrandomized-controlledclinical studies.Thisindicatesthattheliteratureisnotincipient,however,moststudiesusedescriptiveorqualitativeapproach;we emphasizetheimportanceofnewresearcheswithrandom- izedclinicalandexperimentalorquasi-experimentaldesign, as well as meta-analysis, scope or systematic reviews. To better comprehend,indepth,the multifacetedthematicof self-careoftheelderlywithanostomybycolorectalcancer.

Discussion

Aftercriticalanalysisofthechosenreferencestothereview, wereelaboratedthreemaincategories:contextualaspectsof ostomybycolorectalcancer,interveningfactorsofself-care andtheroleofnursesinthemanagementofcareandself-care oftheelderlywithostomy.

Generalaspectsofostomybycolorectalcancer

Initially,anostomycanbesummarizedasasurgicalproce- durethat resultsinanexternalbypasstothehumanbody waste. Mostcommon are intestinal ostomies, that encom- passescolostomiesandileostomiestodivertthefecalﬂow.¹⁵ Thecolostomyisformedinthecolon,thesurgeonremoves partofthetissuetoformacommunicationwiththeexterior, asawayofleavingsolidshumanwaste;isusuallyperformed ontheleftsideofthebodyandrequirecollectorequipment.

Theileostomyisformedintheileum,ontherightsideofthe body,asawayofleavingmoreliquidhumanwaste;require a drainageequipment and has aﬁlter.¹⁶ Inthis sense, the individualswholivewithanostomydemandspecializedcare managementtomaintainphysicalandpsychologicalhealth andqualityoflife.¹⁵

The studies usedin this review,in their contexts,indi- cateahigherincidenceofostomyconstructioninmen.^5,17–19 It is significant to mention that distinct cultural contexts may influenceattitudes towardthe ostomy.⁵ Nevertheless, someaspectsmustbeobservedandrequirecontinuousatten- tionafterthesurgery,suchastheostomyitselfandcurrent collectorequipment,thetreatmentofperistomecutaneous complications,theaccesstotheostomysupplementsandthe financialassistance,theconsultationswithnutritionistsand emotionalsupport,whichareconfiguredasstrategiesforthe managementofcarewithostomies.¹⁵

WasnoticedthatthereisalackinExpandedandShared Clinicinhealth,whichshould, primordially,valuetheindi- vidualwithanostomyinhissingularitiesanddevelopactions aimingtopreparethispersontodailycopingandthedevel- opmentofpersonalautonomy,sothattheycantakecarefor themselves.²⁰Itisalsoemphasizedthatmostofhealthpro- fessionals still focuson technicalaspects, alimiting factor toprogresstowardthepatient’spersonalautonomy,thatis, thedevelopmentofco-autonomydoesnotoccur.²⁰Thus,to

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Authorshipandyear ofpublication

Country Studyfocus Method Conclusions Evidence

level Martinsetal.(2015) Brazil Rehabilitationofindividualswith

intestinalostomyunderthe perspectiveoftheSociologyof health.

Qualitativestudybasedon Ethnographywithasampleof15 patientswithanintestinalostomy.

Thethematicanalysiswasmade fromtheperspectiveofsociology ofhealth.

Nursescanhelpinimprovingcopingandadaptationsof individualswithostomies,withtheirownbodiesand society.Theprogressiveteachingofself-carereafﬁrms tothepatientthathecanachieveself-reliance.

VI

Motaetal.(2015) Brazil Factorsthatfacilitatethe transitionfromdependenceto self-careofindividualswith ostomies.

Descriptiveandqualitativestudy with27ostomizedparticipants.

Wereusedsemi-structured interviewstocomprehendthe factorsthatfacilitateordifﬁcult self-care.

Thefacilitatingfactorswere:toattributepositive meaningtotheostomy,toreceiveguidinginrelationto self-carewiththestomaandadaptationsindailyliving;

psychologicalstabilityandseekforcomfortinfaithand religiosity.Conditionsrelatedtothecommunity:receive Governmentequipment,familyandhealthprofessional teamsupports,especiallynurses,theexchangeof experienceandcontactwithotherswithostomies.

VI

LopesandDecesaro (2014)

Brazil Factorsinvolvedintheprocessof adaptationofindividualswith gastrointestinalostomy.

Literaturereviewperformedonsix databases,withaﬁnalsampleof 21papers.Theauthorsapplied Bardin’sthematicanalysistoform threecategories.

IndividualswithostomyneedtimeandFamilyand professionalsupport,thepresenceoffriendsisalso important.Thissupportincludesovercomingthe appearanceandsocialstigma.CaregiversandHealth professionalscareprovidersshouldactasinformation resourceswhilestimulatingautonomyand

independenceinself-care.

V

Maydick(2014) UnitedStates Qualityoflifeofindividualswith permanentostomiesandcosts involvingthecollectordevice.

Comparative,descriptivestudy;

performedwith140individuals withapermanentostomy.

Theauthorssuggestthatthereisarelationbetween qualityoflifeandﬁnancialstatustobuycollector devices.

VI

Chengetal.(2013) China Knowledgeabouttheostomy, self-careabilityandpsychosocial adaptationofindividualswith ostomies.

Studywithadescriptivedesign, theauthorsalsousedcorrelation intheresearch.The54

participantswereindividualsthat hadanintestinalsurgeryand returnedforfollow-up.

Individualswithhigherknowledgeabouttheostomy hadhigherpsychosocialadaptationlevels.Inthissense, toprovidingknowledgeandteaching/emphasizing self-caremayhelptheseindividualstomake adaptationsindailyactivitiesandsociallife.

VI

PolettoandSilva (2013)

Brazil Assistanceofhealthprofessionals toindividualswithostomies,from theperspectiveofExpandedand SharedClinic.

Qualitativestudy,basedon ExpandedandSharedClinic.Ten patientsthathadsurgeryandthey familycarerwereinterviewed afterhospitaldischarge.

Therewasanabsenceofexpandedandsharedhealth assistance,inwhichprofessionalsvaluedpeoplein theirglobalcontextanddevelopedactivitiesaimingto preparethemfordailycopingandthedevelopmentof personalautonomy.

VI

Recallaetal.(2013) Canada Caremanagementwiththe ostomyandmanagementof peristomeskin.

Systematicreviewofliterature.

Theresearchprocesswascarried onfourdistinctinternational databases.Wasfoundatotalof 929papers.However,61articles composedtheﬁnalsample.

Itwasevidencedthatnurseshaveunderstanding regardingthephysicalandpsychosocialimpactofthe ostomyinthedailylifeoftheindividual.

I

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jcoloproctol(rioj).2019;39(3):265–273

–Table1(Continued) Authorshipandyear ofpublication

Country Studyfocus Method Conclusions Evidence

level Zhangetal.(2013) China Telephonefollow-upbynurses

aboutadaptationlevelsofpatients withostomies.

Randomizedcontrolledtrial, performedwith103peoplewho hadundergoneostomysurgery.

Nurse’stelephonefollow-upofpatientswithostomies mayenhanceself-careabilitywiththeostomy, conﬁdenceandshouldprovideemotionaland informationalsupport.

II

Sunetal.(2013) Canada Constantconcernsandlong-term adaptationsincancersurvivors withostomies.

Qualitativestudy.Theauthors completedeightfocusgroupswith 33ostomizedpatients.

Theadaptationstrategyfocusedontheexhaustive monitoringofthecollectordevicetoprevent embarrassingaccidents;odorcontrolisaconstant battletocancersurvivorswithostomies.

VI

Charúa-Guindic etal.(2011)

Mexico Qualityoflifeofpatientswith ostomies.

Cross-sectionaldescriptivestudy withasampleof83ostomized patients.

Theconstantfearofleaksontheostomyandsexual functionweretheaspectsthatmostaffectedthe patientswithostomies;whichwereresponsibleforthe decreaseinqualityoflifeinthisstudy.

IV

Loetal.(2010) Taiwan Effectivenessofamultimedia educationalprograminrelationto ostomyknowledge.

Randomizedexperimentalstudy.

102patientswithastomawere divided,randomly,intwogroups.

Aneducationalinterventionwiththeuseof multimedia,earlyinpreoperativeperiodhaspositive effectonthelevelsofknowledgeandpromotes attitudesandbehaviorsofself-careinpatientswithan ostomy.

II

Black(2009a) United Kingdom

Assistancetopatientswith ostomiesregardingtheirself-care.

Clinicalreviewabout12papers;

withadescriptiveandreﬂexive design.

Thecaregiverprofessionalshouldunderstandphysical, emotionalandpsychosocialneedsoftheelderlypatient withostomy.

VI

Black(2009b) United Kingdom

Changesinthecareof institutionalizedelderlypeople witharecentorunstressed ostomy.

Reviewofliterature;witha discussionofself-carebasedona sampleofelevenpapers.

Problemsrelatedtoostomycareincreasedrasticallyin theelderlyindividual.Theroleofthecaregiver professionalistoencourageandteachthepatientto self-care,aimingfortheirindependence.

VI

Source:Authors.

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providespeciﬁcknowledgeandemphasizeorteachself-care beforehospitaldischarge,mayenhancequalityoflifeofpeo- plewithostomies.¹⁸

Thus,thecreationofanostomyforthediversionofefflu- ents can have a great impact on the dailylife, autonomy andotherfieldsoflifeoftheindividual;suchimpactcanbe enhancedwhenthisindividualiselderly,generatingagreater demand forself-care, especially in relation to the ostomy managementandthecollectionequipment.Thereisalsothe possibilityofadecrease inself-esteemduetothe corporal change,ofsocialisolation,becauseitisfearedtheleakageof effluentsandgasesinpublicplaces,amongothers.

Intervenientfactorsofself-careinelderlypeoplewithan ostomy

The self-care should be stimulated since the period of ostomies implementation.¹⁶ Theadaptation process ofthe ostomy in the elderly can be considered as complex and unique,thereforethecapacitytoperformself-care,aswellas theunderstandingofhealth,maybeharderforthisspeciﬁc population.Inthissense,thechangesinthelifeoftheelderly withostomiesincludestheacceptanceofthenewconditions, theacquisitionofknowledge,theadaptationtonewmateri- als,beingurgentthedevelopmentofskillsandcompetences forself-care.²¹

Proceeding, an ostomy is a medical treatment that, althoughveryeffective,impliesaphysicalandpsychological

“attack”.Byaffectingbodyintegrity,theisalsoachancein self-image,infunctionalandsocialcapacity,withimpactsin overallqualityoflifeandonthedailylifeofthepatient.¹⁹The rehabilitationofindividualswithintestinalostomiesisacom- plexprocess,non-linear;mayoccur instabilitycrisis,which mayberelatedtotheevolutionofthediseaseortotheconse- quencesoftreatmenthowever,thesenegativefactorscanbe overcomewithfamilyandspecializedprofessionalsupport.²² Theprocessofadaptationtotheostomywillthendepend on the most varied factors, among which the following stand out: current illness, concomitant treatments, condi- tionsofsurgicalintervention,complicationswiththeostomy, postoperativesequelae,prognosis, social,psychologicaland environmental characteristics, beliefs and values, physical limitations,pain,amongothers.¹⁹Intheadaptationprocess somefactorsarefacilitators,suchas:theattributionofpos- itive meaning to the ostomy, the prepare to the self-care experiencebeginninginpreoperativeperiod,tohavepsycho- logicalstabilityandthesearchforcomfortinreligiosity,aswell asfamilyandmulti-professionalhealthteamsupportandthe contactwithpeopleinsimilarlifesituation.²¹

Theeverydaylifeofelderlypeoplehascertainpeculiari- ties,duetothedeteriorationoftheorganismandtheaging processitself,whichcanmakeitdifﬁculttheperformanceof self-care.Itisbelievedthattheostomy,bychangingthepat- ternsofeliminationandfoodintake,cannegativelyimpact thequalityoflifeofthiselderlyindividual.Inthissense,the abilitytolearnalsodecreaseswithaging,sotheprocedures involvedinself-carewiththeostomyshouldbeasuncompli- catedaspossible;Inaddition,itshouldbeborneinmindthat moretimeisrequiredfortheelderlypatienttoassimilatethe newabilitiesandchangesintheirexcretoryfunctions.¹⁶

However,itisquestionedtheassistanceprovidedtopeo- plewithostomies, since,evenaftertheperiodofasurgery, theyremainquestionedandunawareofessentialcarefora lifesustaining,²⁰ofalifewithquality,comfortandwell-being.

Thus,inrelationtotheteachingofself-care,thenurseshould payattentiontosomedetailsthatwillfacilitatetheprocess ofacquisitionofknowledgeandskillsbytheelderly,among them, alarge chairand a mirror may beuseful,since the patientcansee itsabdomen,¹⁶ theperistome skin,thecol- lector equipment,whether theyare cleaningorputtingthe collectionbagcorrectly.¹Elderlypeoplewithostomiesbycol- orectalcancerneedcareinformationwiththestomaandwith thecollectorequipment,suchinformationcanbeofferedby the nurse and include:peristome skincare, emptying and changingthedevice,inclusionandavoidancefoods,control ofgasandodors,andthesupplementsacquisition.⁷Thepro- gressiveteachingofself-carereafﬁrmstothepatientthathe canachieveindependence;hence,toberesponsibleforcaring forone’sownbodyallowsthe patientthecapacitytoiden- tifypotentialcomplications withtheostomy and improves handlingwiththecollectorequipment.²²

Itisperceivedthattheentirebiopsychosocialcontextofthe patientshouldbeconsideredsothathealthcareisaseffective aspossible.However,thesefactorsmaybelimitingtoself-care.

Inthemeantime,afactortobehighlightedispain,whichhas thepotentialtoaffectthepsychosocialaspectsofthepatient’s life,suchastheabilitytoworkandtodevelopactivitiesofdaily living,restpatternsandemotionalstate(depression,anxiety andstress).¹⁹Also,odorsandgasesarechallengingforpeople withanostomywheninpublicplacessuchasrestaurantsand restrooms. Numerous patients reported having “accidents”

relatedtotheleakageofgasesandliquids,andoftenthese incidentsoccurredinpublic,causingshameandanxiety.²³

Itcanbenoticedthatthesocialcontextmaybethemost affected aftertheostomy surgery,consequently,withnega- tiveimplicationsinthedailylifeoftheelderlypersonwithan ostomy;highlightingthesocialisolationandthedifﬁcultyof returningtoworkactivities,duetotheconstantfearofacci- dentswiththecollectorequipment,aswellasthepain,gas andotherdiscomfortsthatcanaffecttheelderlyperson.

Theroleofthenurseinthemanagementofcaretothe elderlypatientwithanostomy

Withtheincidenceofcolorectalcancerbeinghigherinthe longer-livedpopulation, theelderlywho undergoasurgical procedure usuallyperceivetheostomyasthelast threatto theirindependence.¹⁶Inthissense,thefollow-upperformed bythenursepractitionershouldcoverallspheresofattention tohealthprimary,secondaryandtertiarycare.Thisfollowup canbeperformedinperson,duringnursingconsultations,in domiciliary careandevenbytelephone.Itcanenhancethe levelofadaptationtothenewcondition,byimprovingself- careabilitywiththeostomy,trust,competencetodealwith theostomyitself,aswellasprovidingindividualswithinfor- mationalandemotionalsupport.⁵Ateachingplanforself-care fortheelderlywithcolorectalcancercanbeuseful,helping themtoadapttothenewconditionandgivingthemarou- tinetofollow.¹⁶ Thus,earlyeducationalinterventioninthe

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postoperativeperiodhasapositiveeffectonknowledgeand promotesself-careattitudes.¹⁷

Patients who undergo colorectal cancerostomy surgery, regardlessofthestageoftheirlifecycle,willneedinformation tomanagetheirself-care.Sucheducationalprocessencom- passesthetriadhealthprofessional–individualwithostomy– familyandshouldincludeinformationsuchas:howandwhen toemptyor replace the collectorequipmentdevice, which foodsandﬂuidsaremostappropriateandwhichshouldbe avoided,howtomanageodorandgases,howandwhereto getthe necessarysupplements,and whom toseekhelp in casesomeproblemsarisewithostomy.⁷Therefore,itisuse- fultothenurseprofessionaltoputintheplaceoftheelderly personwithostomies,aimingtoperceivehowtomanagecare withthestomaandhowitwouldaffectthedailyactivities.¹

In the context of professional nurses, they stand out fortheir expertisein thissubject, having the capacityand abilitytoprovideeffectiveevaluation,careplanningofnurs- ing interventions, and patient evaluation,⁷ about self-care, which should be global and consider the entire biopsy- chosocial, spiritual and health context of individuals and their families. Thus, educational materialscan beused by nurses,aimingatsupplementinghealtheducation,⁷inrela- tiontotheostomy.Moreover,allhealthprofessionalsplaya unique role inaddressingchanges inbody image and loss ofsphincter control (and its repercussions on the individual’slife),aimingtostimulateknowledgeregardingself-care and self-esteem,potentially inﬂuencing their socialreinte- gration,thatis,movingtowardpersonalautonomy.²⁰Finally, health professionalsshould provide appropriate assistance andsupportsothattheseindividualscanfacetheirdailylife limitations.²²

Intheperspectiveofrecoveryofthepatient’shealth,self- carehasaleadingrole,howeverthepatientshouldseekto takecontrolofthesituation,forthisthenursesshouldensure thattheself-careproceduresareuncomplicated.¹⁶ Tobetter achieveself-carepositiveresults,thenursewiththeperson withtheostomyshouldperceivebarriersandidentifypossi- bleresourcestoovercomethem,toincreasetheimpactofthe educationalprograms.¹⁷Inaddition,theapproachofteach- ingthepatientwithostomyshouldbegininthepreoperative periodandremaininthepostoperativeperiod.Thephysician, thenursingteamand,whenavailable,anostomyspecialist nurseshouldbeinvolvedinthishealtheducation.Ifpossible, thenurseshouldvisitthepatientpriortoadmissiontoiden- tifytheplaceofinstallationoftheostomyintheabdomenand initiateconversationsaboutdiet,thecollectorequipmentand skincare.²⁴

Thus,nursesandotherhealthcareprofessionalswhowork withpeoplewith ostomiesshouldexpandtheir knowledge and understanding ofthe feelings that canemerge during theprocessofadaptationtotheostomy,aswellasitsconse- quencesandpossiblealternativesthatmayhelpthepatient torestructuretheirlives.Inthisperspective,nursesmustbe preparedsincethegraduation,tobeempoweredtoprovide careandshareknowledge,sothatanexcellenceincarecanbe achieved.⁸Itisimportanttomentionthatelderlypeoplehave distinctcharacteristicsthat,combinedwithlongerexposure toenvironmentalrisktodiseases,beingthemvulnerableto chronic-degenerativeillness,suchascancer.²⁵

Finally,thenursemustbeawareofpatient’smentalhealth status,sincetheostomizedindividualmayarriveattheoutpa- tientclinicwithfeelingsofanxiety,frustration,notaccepting oradaptingtoself-care,andtheycanexpressfeelingsofloss.²⁶ Underthisperspective,itisvitaltothenursetoconsiderthe patient, withspecialattentiontonegativefeelings,because theycanalterthewillingnesstoperformself-care.

Conclusion

The present review sought to present scientiﬁc evidence regardingself-careofelderlypeoplewithostomiesbycolorec- talcancer.Itwasobservedthescarcityofpublicationsonthe themeandthepredominanceofdescriptivestudies.Studies haveshown thatthe presenceoftheostomy compromises notonlythebiologicaldimension,duetothestoma,thepres- enceofthecollectorequipment,thechangesinthepatternof eliminationandalteredbodyimage,but,abovealltheimpor- tantrepercussionsinthesocialandpsychologicaldimensions, whichhascontributednegativelytotheadaptationtothenew condition.

Itisimportanttomentionthatthecommunicationwith the ostomizedpatientmustbeclearandobjective,forbet- tercomprehensionbytheclient,consideringthataneffective nursingcareshouldbeginpreoperatively,withtheprepara- tionoftheindividualfacingthesurgery.²⁷Inthiscontext,it isalsofundamentalthevaluationofthesingularitiesofthe peoplebeforethepresenceoftheostomy,todevelopactions thatmeettheirbiopsychosocialand spiritualneeds.There- fore,thenurseneedstobecomeaprotagonistintheactions ofHealthEducation,andshouldprevailforthedevelopment ofco-autonomyandself-careskills;itshouldalsoprovidethe elderly personwithanostomythenecessary knowledgeto recoverthepotentialtomanagetheirself-care.

Thereviewpresentslimitationsregardingnumberofinves- tigateddatabases,thefocusonthegeneralaspectsofself-care and a limitednumber ofpapers; wealso endorsethat the speciﬁc knowledge regarding self-care of the elderly with ostomiesstillneedfurtherstudies,withapplicationofdiffer- entmethodsandapproaches,sohealthprofessionalcanoffer ahumanizedandindividualizedcare;aimingattheindepen- denceoratleastco-autonomyforself-careandimprovements ingeneralqualityoflife.

Conﬂicts of interest

Theauthorsdeclarenoconﬂictsofinterest.

Acknowledgement

Coordenac¸ãodeAperfeic¸oamentodePessoaldeNívelSuperior –CAPES(Brazil).

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