TECNOLOGIA DO CUIDADO À PESSOA COM COLOSTOMIA: DIAGNÓSTICOS E INTERVENÇÕES DE ENFERMAGEM CARE TECHNOLOGY TO PEOPLE WITH COLOSTOMY: DIAGNOSIS AND NURSING INTERVENTIONS TECNOLOGÍA DEL CUIDADO PARA PERSONAS CON COLOSTOMÍA: DIAGNÓSTICO E INTERVENCIONES

The objective was to develop diagnoses/outcomes and nursing interventions related to the person with acolostomy. A descriptive study was conducted by reviewing the literature in the Medline and Lilacs databases for the period from 2000-2013, in Portuguese, Spanish, and English. The terms identified in the review were mapped with the International Classification for Nursing Practice to compose the 77 diagnoses/outcomes and 172 nursing interventions grouped by basic human needs. The needs assessment changed in the person with colostomy facilitates the identification of diagnosis and the development of nursing interventions, standardizing the care provided by nurses and improving the quality of care. This study confirms that the use of thenursing process is a technology that can be applied in the daily care in clinical practice in different scenarios of teaching-learning, research and nursing care scenarios.


INTRODUCTION
Among the problems that affect people undergoing surgery to the gastrointestinal tract, there are the colostomies, which are performed by surgical procedures in which there is the externalization of a loop of the bowel attached to the abdomen to remove the intestinal contents.They may be temporary and in some cases, they are definitive due to the inability to rebuild the intestinal transit. 1 The person with colostomy has modified basic human needs, such as physical and psychological changes generated by the disease impact, changing body image, feelings of grief and loss, with reactions and behaviors of those who had the stoma.Therefore, they need adaptations to their new condition, besides having to incorporate daily routines into their new life, with self-care and the maintenance of their social and interpersonal activities. 2 A colostomy has some physical restrictions and changes in lifestyle.The limitations of body movements increase the perception of the individual´s disability, who are unable to perform certain movements like stooping down quickly, squatting for a long time, which may cause the bag detachment.Furthermore, the intestinal elimination by colostomy is lack of control in the elimination of stool and intestinal gas. 3,4t is very important the participation of nurses in the preparation of a care planning geared to the prevention of complications and carrying out appropriate guidance, influencing the rehabilitation and improvement of the quality of life of the person with a colostomy 3 .From the nursing process, nursing care can be based on patients´ responses, the way they react to health problems, treatment and changes in daily life, ensuring that interventions are designed to the patient and not the disease. 5,6he nursing process is the dynamics of systematic and interrelated actions to assist the human being. 7It is a technological tool that promotes and organizes the conditions for care performance and to document professional practice.It can be considered the main methodological model for the systematic performance of nursing actions. 6,8t is necessary to use rating systems to perform some steps of the nursing process, such as diagnosis and intervention.These systems are technologies that provide a standardized language to be used in the clinical and therapeutic reasoning process, to support the clinical documentation of professional practice. 8n this study, the use of the International Classification for Nursing Practice (CIPE ® ) was chosen, because it strengthens the purposes of the nursing profession and in 2008 it was recognized by the World Health Organization as a unified classification for international use by nursing.8,9 After the literature review, there are no studies addressing nursing care to people with colostomy using the CIPE ® .Therefore, this study aimed to elaborate diagnoses/outcomes and nursing interventions related to people with a colostomy, based on the CIPE ® .

METHODOLOGY
This is a descriptive study whose performance goes through three stages as follows: 1. literature review on nursing care and colostomy: performed by textbooks of nursing, oncology and surgical care area and scientific articles from the following sources: Latin American and Caribbean Health Sciences (LI-LACS) and Medical Literature Analysis and Retrieval System Online (MEDLINE), with descriptors "nursing care", "nursing diagnosis", "classification", "colostomy" in Portuguese, English and Spanish, published from 2000 to 2013.
Conference papers were excluded from this review.The following guiding question was used to address the literature review: what are the phenomena and nursing actions related to the person with a colostomy?In this study, the phenomena are the health aspects relevant to nursing, including what nurses do on human needs to produce certain results. 10ere were 182 articles in LILACS and 252 articles in MED-LINE found.Of this total of 434 articles, only 47 were selected and used, since 30 were repeated and 357 did not answer the main question, that is, they did not address the theme: nursing and the person with a colostomy.dents by external causes or intestinal and anus diseases, such as colorectal cancer. 1 Important changes related to physiological needs of people with colostomy were identified according to the theoretical reference of Horta. 7Some of these changes are common to patients undergoing surgical procedures, such as those related to oxygenation, thermal regulation and neurological regulation.The other needs are very peculiar to the person with a colostomy and reinforce the specificity of care being provided.
For example, the colostomy in ascendant region causes a risk for the development of water-electrolyte imbalance, since the stool is more liquid and this diarrhea can cause decreased levels of sodium, potassium and magnesium and cardiac arrhythmias, necessary to control the hydration to avoid complications. 13,14 e person with colostomy need to learn new eating habits due to fecal incontinence, as some foods cause loose stools or constipation, others produce excess gas, and the effects of food in the organism varies from one individual to another. 15he discomfort caused by the gas elimination, leakage, and stool odor exhaled by the colostomy bag is a challenge for the person with a colostomy.][18] The systematization of care includes teaching the care required both to the patients as the family, as well as referral to the stoma program, thus stimulating their autonomy. 16It is also important that the family learn to live with situations such as fecal incontinence and its consequences, such as the odor and the need for more care with clothing and hygiene so that they can give the adequate support. 17t is necessary that the person with colostomy make adjustments to his life, as using larger clothing and accessories that disguise the use of the collection bag. 19Also, using the intestinal self-irrigation technique, which promotes further safety to the person with a colostomy, because the introduction of a volume of water in the colon stimulates the contraction and empties of the fecal content and reduces the formation of gas.Thus, it enables the bowel training to eliminate the fecal content in a scheduled time, providing peace and security. 20n the literature review, it was observed that body dissatisfaction and loss of control of the gas elimination and stool affect self-esteem generated feelings of self-exclusion.Also, there is the pain and fear that hinder the sexual desires and deny of the pleasure and sexuality of people with a colostomy.Therefore, guidance from the professionals who assist this person is necessary, helping the person and the partner in adapting to new conditions, seeking coping strategies, stimulating open dialogue between the partners so that together they can overcome the crisis and have an active and enjoyable sex life. 21,22 the terms identified in the literature review were mapped to the terms of Seven Axis Model of CIPE® 2013 11 and diagnostic statements/nursing outcomes have been prepared considering the ISO 18104: Integration of a terminology model reference for Nursing 12 .This was followed by the ICN's recommendation: it includes a compulsory term focus axis and a term judgment axis and includes additional terms of the other axes as required.11 The terms have been organized according to the physiological needs of people with a colostomy, following the theoretical reference of Horta.7 3. the nursing care identified in the literature review were mapped to the terms of Seven Axis Model of CIPE ® in 2013 and after that, the affirmative nursing interventions were built, according to the ISO 18104 and the ICN's recommendation: it includes a term axis of action and a target term.12 This study was approved by the Research Ethics Committee of the Health Sciences Center of the Federal University of Espírito Santo, under no 09167813.1.0000.5060 on22 February 2013.

RESULTS
The diagnoses/outcomes and nursing interventions were developed considering the physiological needs of people with a colostomy, according to the theoretical reference of Horta 7 .For this, 30 "focus" axis terms, nine "judgment" axis terms and four "location" axis terms were used.The terms of the "focus" axis were listed: the respiratory system process, cough, tissue perfusion, bruising, bleeding, body temperature, confusion, pain, foul odor, edema, fluid volume, appetite, weight, bowel incontinence, flatulence, diarrhea, nausea, constipation, rash, fissures, necrosis, skin integrity, maceration, sleep, fatigue, exercise, ability to perform self-care, sex, sexual impotence, patient´s rights.The terms of the "judgment" axis were: risk, effective, increased, decreased, appropriate, damaged, missing, improved and real.The terms of the "location" axis were: colostomy, colostomy region, skin near to the colostomy and stoma.
From these terms, 77 affirmative nursing diagnosis/outcomes have been prepared, and, of them, 24 were in the version CIPE® 2013 and 53 still did not appear.After the development of affirmative nursing diagnoses and outcomes, 172 interventions grouped by psychobiological needs of Horta were built.

DISCUSSION
The colostomy is part of therapeutic approaches of abdominal trauma with intestinal injury resulting from acci-

Need for vascular regulation
• hematoma in the colostomy region; • decreased tissue perfusion in the colostomy region; • effective tissue perfusion in the colostomy region; • risk for hematoma in the colostomy region; • risk for decreased tissue perfusion in the colostomy region; • risk for bleeding in the colostomy region; • bleeding in the colostomy region.• evaluating changes in the level of consciousness; • evaluating of the level of consciousness; • informing to the patient about the people, time, and place, to the extent necessary; • keeping the person oriented in time and space (provide clocks, calendars, glass, etc.); • keeping safe environment; • guiding the patient as to the time and space; • using simple sentences when communicating with the patient.

Need felt sense
• no pain; • pain in the colostomy region; • fetid odor away; • fetid odor in the colostomy; • risk for pain in the colostomy region; • risk for fetid odor in the colostomy.
• evaluating of pain as the location, frequency and duration; • evaluating changes in colostomy; • educating on the use of colostomy bag with odor barrier; • teaching hygiene measures with the colostomy bag; • maintaining pain control measures.

Need of hydration
• colostomy region edema; • risk for edema in the colostomy region; • risk for decreased fluid volume; • risk for an excessive fluid volume; • an adequate fluid volume; • reduced fluid volume; • excessive fluid volume.
• controlling fluid intake; • controlling fluid and electrolyte therapy; • instructioning the proper fluid intake; • investigating the cause of the edema; • monitoring the levels of serum electrolytes; • observing signs of dehydration.

Need for Nutrition
• appropriate appetite; • decreased appetite; • low body weight; • proper body weight; • decreased appetite risk; • low body weight risk.
• assessing BMI patient monthly; • teaching about dietary needs; • teaching about nutrition; • interviewing the patient about the food preferences; • stimulating food intake; • encouraging the preparation of food in various ways; • trying new foods in small quantities; • explaining the importance of chewing; • explaining the importance of nutrition in recovery of health status; • identifying the reasons related to low food intake; • weighing the patient monthly; • performing physical examination in patient monthly.
• evaluating stool consistency; • eating foods that neutralize strong odors; • teaching the method of colostomy irrigation; • emptying colostomy bag; • avoiding eating foods that enhance the odors of feces; • avoiding eating foods that cause diarrhea; • avoiding eating foods that cause flatulence; • avoiding eating foods that cause nausea; • avoiding eating foods that cause constipation; • explaining about the foods that increase the odor of feces; • explaining about the foods that cause diarrhea; • explaining about the foods that cause flatulence; • explaining about the foods that cause nausea; • explaining about the foods that cause constipation; • measuring drainage feces eliminated by the stoma; • monitoring fluid loss through the stoma; • monitoring serum electrolytes; • supervising the method of irrigation of colostomy; • training the patient in achieving the colostomy irrigation method.Thus, it is very important that the person has specialized care, in which the professional can give him continuously support, following his preoperative and postoperative evolution (early and late) to help him throughout the process of adapting to a new situation. 16n addition to technical expertise, it is necessary that the nurse has a sensitivity to capture customer needs and ability to stimulate innovative actions.][26][27] The use of rating systems such as the CIPE® provides nurses the development of logical thinking in the care process, because it establishes a concrete relationship between the clinical evaluations, diagnoses, interventions and nursing outcomes. 8,9,25he International Council of Nurses (ICN) has proposed the development of catalogs to facilitate the use of this classification for the execution and registration of the Nursing Process, which are subsets of CIPE® terminology, specifically affirmative diagnosis, outcomes and interventions for health priorities and customer groups.Thus, it is an easy-access reference for nurses in their care environment and ensures the quality of care. 10,12 is essential that people learn to take care of the stoma, properly installing the collection bag to prevent leaks and thereby reducing the odor of stool and protect stoma skin.There are several types of colostomy bag and accessories such as barrier creams that protect the skin.The guidance and supervision of nurses are critical to their proper choice, as well as how to properly sanitize, emptying and removing the colostomy bag without traumatizing the skin by washing with mild soap and warm water, removing any residue, and keeping a well dry before installing the new bag, and cutting the bag to the extent appropriate to the stoma size.All these are simple steps that can keep the stoma skin full and healthy. 22,23t can be observed that many of the elaborate interventions are related to the teaching of self-care and adaptations necessary for the person with colostomy resuming his daily routine.Thus, it is essential to develop strategies to live with the changes that occur in all dimensions of that person´s life.Health services should be organized to meet and support this patient efficiently. 13,17 ealth professionals are responsible not only for guiding on how to take care of the colostomy, handling the bag and supplying kits but mainly encouraging the return to social life, overcoming their limitations and prejudices of society. 18. continuation • encouraging the patient to return to his usual physical activities; • teaching the importance of physical activity; • teaching about the stoma protection during physical activity; • interviewing physical activity pattern.

Need for therapy and prevention
• effective capacity to manage the care of the stoma; • impaired ability to manage the care of the stoma.
• asnwering doubts regarding the stoma care; • stimulating self-care with the colostomy; • encouraging the participation of groups of people with a stoma; • encouraging the patient for the performance of the stoma care; • guiding the family/caregiver in colostomy care; • advising on the care related to colostomy; • guiding about the colostomy patients´ rights.
The development of terminology subsets is growing in the world.The CIPE® Center in Brazil has worked in this line and produced five dissertations in nursing.][27] This study proposed the organization of affirmative diagnosis, outcomes and nursing interventions related to physiological needs of people with a colostomy, as the theoretical reference of Horta 7 .It is emphasized that these statements must be submitted to a process of content validation by nurses and then to a clinical validation with people with a colostomy.After the validation process, they will be used to structure a terminological subset of CIPE® for people with a colostomy.

CONCLUSION
In this study, 77 nursing diagnoses/outcomes and 172 interventions related to psychobiological needs as the theoretical reference of Wanda de Aguiar Horta were elaborated.The analysis of the changes needed in the person with a colostomy facilitated the identification of diagnostics and guided the development of nursing interventions, standardizing the care provided by nurses.
Faced with the diagnosis, outcomes and interventions built in this study, it is realized the importance of the nurse´s work with the person with a colostomy.The new condition of life gives some adjustments to their way of life, both in the activities to be developed, and in the care for the stoma.Although the condition imposes some limitations to daily activities, it is possible to have a good quality of life.
To this end, the performance of the nursing process becomes important, since it provides the adaptation of interventions to the individual needs.With monitoring and appropriate guidance, it facilitates the physical and psychological rehabilitation, assisting in their social reintegration.The systematization of care provided by nurses contributes to quality care to this population, increasing visibility and professional recognition.
This research has enabled the development of a protocol of nursing care for the person with a colostomy and contributed to the production of new technologies in the field of nursing, as the CIPE® is a technological instrument that aims to standardize the nursing language used in health information systems and electronic documentation.
It is expected that this research will encourage the use of the nursing process systematically and individually to this patient; contributing to the development of new technologies in the area of information in health, and strengthening the use of CIPE® in nursing professional practice.In this sense, it is reiterated that the use of the nursing process is a possible technol- Continue... DOI: 10.5935/1415-2762.20160001REME • Rev Min Enferm.2016; 20:e931

Table 1 -
Diagnostic/outcomes and nursing interventions related to Psychobiological needs of the person with colostomy -Vitória / ES, 2014