Juan Andrés Almendárez-Saavedra,1 Martha Landeros-López,2 Ma. Alejandra Hernández-Castañón,3 Yolanda Galarza-Maya,4María Teresa Guerrero-Hernández2
1Servicio de Cirugía, Hospital Central “Dr. Ignacio Morones Prieto”, Secretaría de Salud, San Luis Potosí.
2Unidad de Posgrado e Investigación, Facultad de Enfermería, Universidad Autónoma de San Luis Potosí
3Unidad de Posgrado e Investigación, Facultad de Enfermería, Universidad Autónoma de Querétaro, Querétaro.
4Jefatura de Enfermería, Hospital Central “Dr. Ignacio Morones Prieto”, Secretaría de Salud, San Luis Potosí. México.
Correspondence: Juan Andrés Almendárez-Saavedra
Received: August 25th 2014
Judged: January 19th 2015
Accepted: February 2nd 2015
Introduction: The patients with intestinal stomas require self-care knowledge and practice to accept and keep their actual health status. The nursing personal has an important role in this.
Objective: To determine the level of knowledge of self-care practice in patients with intestinal stomas, pre and post nursing education intervention.
Methodology: Pre and post intervention study, made in a second level hospital in San Luis Potosí, México, between february and july 2013. The sample was made by convenience in 13 patients with intestinal stomas, previous consent informed. The instrument made on purpose, validated by experts and 0.670 Cronbach Alpha confiability, it had 20 items of closed questions. The analysis was made in SPSS v.17, using descriptive and inferential statistics “t of Student”, two related samples and matched with themselves. (Pre and postinmediatelly, 15 days pre and post; 30 days pre-post).
Results: The average age was 41.8 years, (21 minimum and 73 years maximum), the male was majority (84.6%) and the colostomy (46.1%). The self-care practices knowledge, about feeding and ostomy care was increased post intervention. Showed by comparisons the average measurement (t = -3.570, t = -6.390, t = -3.695, respectively) with significant differences statistically (p < 0.05).
Conclusion: The self-care practice knowledge increased, they showed active after nursing education intervention, aspects that promote patient adaptation to your health and improve their quality of life.
Keywords: Surgical stomas; Health education; Learning; Self care; Nursing care
Enterostomies involve the creation of a stoma (mouth) by a surgical procedure somewhere in the intestinal tract, in this case to facilitate the removal of the large or small intestine, and depending on its positioning it is called colostomy or ileostomy.1
Colon cancer has been closely connected with the execution of digestive ostomies; in the United States, colorectal cancer was the second leading cause of death and the third most common cancer, affecting men and women equally. In 2007 a total of 142,672 people in that country were diagnosed with colorectal cancer, which culminated in 53,219 deaths.3 This situation has led to the creation of nine programs for enterostomy patients and an average of two accredited stomal therapists per hospital.2
A study in 20 world regions, which was based on the reports of the International Agency for Research on Cancer, estimated new cases of cancer: colorectal remained among the top three causes of incidence, surpassed only by breast and lung. This study also revealed that 63 % of all cancer deaths occur in less developed world regions.3
In Chile colorectal cancer was reported as the third cause of death, with a history that between 1990 and 2003, mortality increased from 16 to 20 %, and was the leading cause of ostomy, followed by inflammatory bowel disease, abdominal trauma, anorectal malformations and megacolon.2
In this regard, rectal and colon cancer in Mexico has tripled in less than a decade. According to the report of the Registro Histopatológico Nacional in 2000, 18 out of 20 patients died; currently 11 of each 20 die. The official epidemiological information indicates that in Chihuahua, Torreon, and Merida this cancer has the second place morbidity, beating breast and prostate.4,5
Because of this, in Mexico the number of people who undergo an ostomy of elimination because of various health problems is increasing. In a multicenter study, which involved both public and private health institutions, medical diagnoses that led to enterostomy were oncological problems of the colon, rectum, bladder and uterus, which accounted for 35 %, followed by inflammatory diseases. The problem arose in age groups from 19 to 63 years or more.6
The patient of enterostomy undergoes important changes that alter their quality of life; this includes modifications to eating and elimination patterns, handling confrontations and accepting their ostomy; their body image can affect how they relate with people; finally, the patient must adapt to different self-care practices, with which they must become familiar. A thorough review7 showed that, according to various studies, there is evidence of a lack of preparation for self-care in this clientele and it is noted that it is necessary to plan the continuing education these patients need to receive.
It is important to consider that in the adult education process, the particular personality of an adult must be identified, to design guidelines for appropriate teaching methodology.8 In the process of adult learning, some principles taken from andragogy are considered. One is the use of experience and life history as a learning resource; the other relates to the immediate application of learning and therefore verifying the results through practical circumstances, to make decisions, act, and solve problems.9,10
In the Mexican health system strategies have been used to improve screening and early diagnosis of non-hereditary colorectal cancer in adults in first, second, and third levels of care according to medical practice guidelines, which include recommendations backed by evidence.5 There are also the evidence-based Clinical Practice Guidelines for the marking and integrated management of stomata, which aims to help improve health care, reduce variability of clinical practice, encourage efficient use of resources, serve as a tool to guide the clinician in decision-making, and be an important part in continuing education for health professionals in stomata.11
Ostomy care is a nursing intervention and both the education and training of stomal therapy staff should be taken into account, as should the creation of guidelines or protocols that promote patient self-care. In Brazil a total of 500 stomal therapists are reported, in Sweden 100, and in Mexico, although there is a deficit in the register of the incidence and prevalence of ostomy, there are 197 active stomal therapy nurses.2
Most studies conducted in various countries and Mexico suggest that the performance of digestive ostomies is due to many factors, among which are oncological problems, inflammatory bowel diseases, and injuries, among others; moreover, these studies agree that health education in this group of patients is poor, which causes the enterostomy patient to manifest behaviors such as fear, making them vulnerable to complications. It is therefore vital to strengthen education programs, through planning and standardization, in order to gain knowledge and skills that can change their lifestyle and effective self-care.12-21 Specific, systematic attention with direct interaction between nurse and enterostomy patient is part of the government's strategies in secondary and tertiary-level public institutions, and contributes to achieving the goals of the Plan Nacional de Salud.22
Based on the above, this study aimed to determine the level of knowledge about self-care practices in enterostomy patients before and after an educational intervention by nursing in a secondary care hospital.
This study had a quantitative approach with quasi-experimental design of the type pre-and-post intervention; it was conducted in a public secondary care hospital during the period from February to July of 2013 in San Luis Potosi, Mexico. The convenience sample consisted of 13 patients who, with informed consent, agreed to participate in the study. Hospital services were located where patients were: ER, Internal Medicine and Surgery.
We included patients of both sexes, over 18 years having a removal enterostomy (ileostomy or colostomy, temporary or permanent stoma), regardless of the medical cause and whether they could read and write. It was also required that patients be present for the entire educational session by the investigator and provide responses to the instrument each time requested, including once discharged from hospital, after signing informed consent. One patient was excluded for having only two surveys and for being in the reconnection process; other exclusion criteria were perceptual or cognitive impairment of the patient, their working in the health field, and their having stoma complications.
The study variables were: a) sociodemographics and health status; b) patient knowledge of self-care practices about food needs (type of diet and food, activities on prevention of constipation or diarrhea, medical consultation, exercise); c) ostomy care (stoma healing, changing pouch, monitoring features of the stoma, body showering and bathroom).
The instrument used was developed expressly based on similar studies14,15 and it was named "Knowledge of self-care practices survey.” Validation was made by experts and reliability obtained by Cronbach's alpha = 0.670. It had two sections: the first for variables of sociodemographics and ostomy; the second sought to investigate the knowledge of the enterostomy patient about self-care (eating and care of the ostomy). There were 20 were dichotomized response prompts described as correct = 1 point and incorrect = 0 points.
The survey was conducted before the educational nursing intervention and immediately after the session; it was then an applied at 15 days and finally at 1 month, with the purpose of observing the effect on knowledge. It is worth mentioning that during the course of the process of collecting data from patients discharged from the hospital area, they received follow-up at home by consent of the patient and family.
The educational intervention was conducted individually with each patient. Validation was made by experts and a process test was performed in 10 % of the expected population. During the intervention, a patient was shown a presentation (PowerPoint version 2010), which addressed self-care practices that the patient should have regarding food needs and ostomy care. The approach was interactive; the patient was encouraged to express questions and feelings, as well as contributions to the projected content based on their experiences; the patient was also given a document that complemented the projected presentation.
The capture, processing and analysis of information was done in SPSS, version 17 in Spanish. In the analysis, descriptive statistics were used as measure of central tendency (mean, median and mode) and dispersion (standard deviation, minimum and maximum) for quantitative variables; for categorical variables, absolute and relative frequencies were obtained. To demonstrate whether the enterostomy patient acquired greater knowledge about self-care practices, comparison of means was performed with respect to before and after the educational nursing intervention. Student’s t test was used for related samples and paired with themselves in the analysis; the confidence level was 95 % and statistical significance was a p-value < 0.05.
The purpose of the research was for ostomy patients to acquire knowledge through educational nursing intervention and therefore variables were manipulated. The study followed the Declaration of Helsinki and the Ley General de Salud in research. It was classified as minimal risk and included the patient signing informed consent.23 The Research and Ethics Committee of the health institution granted it registration number 31-13.
In the 13 patients, the mean age was 41.8 years and mode 45, the minimum age of the patients was 21 years and maximum of 73, with a standard deviation (SD) of 16.4. Males predominated with 84.6 %. In terms of marital status, single and married had equal percentages (30.8 %); the rest (38.4 %) had the status of divorced, widowed, or cohabiting. The majority (69.2 %) were still working and 69.3 % had completed secondary school and high school.
Regarding the type of enterostomies, 46.1 % had colostomy, 38.5 % ileostomy and 15.4 % had both types. Among the triggering causes for the surgical procedure were: intestinal obstruction and blunt abdominal trauma, both with 23.1 %; rectum or colon cancer 30.8 %; the rest (23.1 %) had causes such as firearm wound, mesenteric thrombosis and diverticular disease. Most (54 %) had between 15 and 30 days with enterostomy, the least was a week and the most 210 days.
The concerns expressed by patients on ostomy mostly focused on "the collection pouch leaking, and dermatitis" with 84.7 % and the presence of "loose stools" with 15.3 %.
The health personnel who provided information, according to the patient, was firstly the nurse with 38.5 %, followed by the doctor with 23.1 %, and 23.1 % indicated that nobody provided them information. 69.2 % reported "not having received self-care information," the rest (30.8 %) reported receiving information focused on "the pouch, cleaning the stoma, skin care, and eating", "handling of the pouch" and "specific information about the topic."
When asking patients if they did all their self-care, 53.8 % responded negatively and reported that people who helped in their care were family members in 38.5 % (wife, son, sister, father).
Knowledge of self-care practices were increased as a whole; in only three aspects they were found below 100 % (Table I).
|Table I. Correct knowledge of self-care practices on food needs and ostomy care, July, 2013 (N = 13)|
|Immediate||After 15 days||After
|Choice of diet||3||23.1||11||84.6||12||92.3||13||100|
|Choice of drink||6||46.2||10||76.9||10||76.9||13||100|
|Resolution of diarrhea||5||38.5||8||61.5||11||84.6||10||76.9|
|Resolution of constipation||4||30.8||11||84.6||13||100||13||100|
|Changing and cleaning pouch||12.3||94.8||13||100||13||100||13||100|
|Surveillance of ostomy||9.6||74.6||10.9||84.6||13||100||13||100|
|Measures to avoid complications||12.3||94.8||11.3||87.1||10.6||82||10.9||84.6|
|Habits during healing||12.4||96.1||13||100||13||100||13||100|
|Source: "Knowledge of self-care practices for the enterostomy patient" survey
* Average values for each measurement
As for the indicators "food needs" and "ostomy care" considered for the study, the overall results of correct knowledge about self-care practices showed an increase in educational measurement after nursing intervention (Figure 1).
Figure 1 Correct knowledge about self-care practices (N = 13). Source: "Knowledge of self-care practices" survey
Comparative descriptive statistics in the measurements before and after the intervention are shown in Table II.
|Table II. Measures of central tendency and dispersion according to final scores for each measurement|
|After 30 days|
|Source: "Knowledge of self-care practices" survey database|
When applying the Student’s t test for related samples and paired with themselves in the mean comparisons before the intervention (one) and three after the intervention, it was observed that there was a statistically significant increase in the level of knowledge about self-care practices, it was assumed because of the educational nursing intervention (Table III).
|Table III. Student's t test, comparison of means|
|Source: "Knowledge of self-care practices" survey database|
The age ranges of the patients enrolled were between 21 and 65; marital status, occupation, and educational level, together with diagnoses or indications why intestinal shunts were performed, coincide with similar studies in the country,6,12,15 as lifestyle, culture and health problems do not differ greatly between the cities of San Luis Potosi and Mexico City.
In this study the educational level of the patients was non-professional in more than half, in contrast to a study on the prevalence of ostomy,6 in which only a third of the sample was non-professional; other differences were in marital status and oncological reason for ostomy.
In an integrative review of factors that determine the psychological impact on this clientele, it was found that the performance of an ostomy has a negative impact on quality of life and changes different aspects of the life of the patient that has it.24
In this context, a study on the association of sociodemographic and clinical factors in the quality of life of enterostomy patients revealed impact in the psychological, social and physical domains. The psychological domain was the most affected in females; the social domain in patients who did not have sexual partners and also had metastases, and the physical domain affected people who were not oriented on the ostomy before surgery and those without sexual partners.25
Patients were asked about the time (in days) having an ostomy, the reason for its implementation, and information received about the issue prior to the start of the nursing intervention process; it was found that one of the most common problems was leakage of the collection pouch, which caused them distress, and fear that it would spill.12 Another problem was watery stools causing skin irritation and periostomal dermatitis as part of the late complications in this group of patients.16
Overall prior knowledge about ostomy management and care for self-care were provided by the doctor and nurse. And according to information reported by patients it was superficial. The topics were the pouch and its management, as well as cleaning of the ostomy. More than half said that they did not perform self-care and that a family member did it. This indicates that as in other countries there is no discharge plan as such, and nursing care is not specialized in a number of health institutions, since education to be provided pre-operation was postponed until discharge, without taking into account that the gear that at that time was financed or at least provided by the institution during the hospital stay would be brought home by the patient.2
The lack of initiative so that patients do not perform self-care independently and responsibly is mainly due to lack of information,14 which makes them see their quality of life and adaptation to the ostomy as impaired. This does not take into account other factors such as gender, as this affects women’s emotional and affective dimension, age, type of ostomy, time elapsed since surgery, preoperative preparation they may have had, encouragement received with respect to self-care, education received through medical staff, and familial support.16,19,20,26
Usually these patients tend to present some difficulties for achieving adequate self-care practices. One is the acceptance of their new status as enterostomy patients, and the other the lack of knowledge for the management and care of their stoma, which are the main obstacles that they face.27 This is why some studies share the idea that the use of Orem’s self-care theory is usually effective, since it favors nurse-patient communication, contributing effectively to the patient's health status and promoting their self-care.18
Considering the above, it should be mentioned that self-care practices carried out by the study group were inadequate before the educational intervention process, due to the condition of enterostomy involving changes in the lifestyle of patients and their caregivers, coupled with the lack of information, a reason why improving health education for caregivers and patients will promote self-care in hospitals, which will establish better planning, coordination and information of the staff involved and will improve the quality of care.7
Therefore it is important to mention that there was improvement in the knowledge of self-care that enterostomy patients had before and after the educational intervention in areas such as food needs, ostomy care, the normal characteristics of the stoma, practices, and preventive habits for their ostomy. With that they achieved a significant learning that allowed them to develop appropriate measures to improve their quality of life with self-care practices. This shows that this educational nursing intervention directed to the patient (and their family) is effective in relation to the care they should take with the ostomy, in accepting their new status as enterostomy patient, as well as to facilitate self-care in a responsible way.14,15,21,26,28-30
The impact of having an ostomy in the adult patient may be affected by age, as shown by a study which concludes that those over 70 have greater physical problems, while in those under 69 years sexual function is the most compromised.31 The results of our study group differ from the above; despite the male predominance, the biggest problems observed in this age group were not in these areas, or at least that was not expressed. Our patients focused on learning objectives, based on their experiences, needs, and aspirations and being active participants in the process of educational intervention, as marking the beginning of andragogy.32
In a qualitative study33 patients who had a permanent stoma were asked their motive or reason for getting together in groups. Most said the purpose was to obtain more knowledge, especially when in contact with patients with similar conditions; also they highlighted that the group reduced their sense of loneliness and thus they might have more reason to go. In this regard, a valuable information resource is seen in this study for patients with stomata, to encourage self-care and their desire to continue with their daily activities.
Overall in nursing practice, teaching patients is important and has a future prospect for the care of patients who undergo this procedure; nurses must be constantly trained to provide educational interventions for this group of patients.
Regardless of their demographic characteristics, the patient is a human being who, because of his new enterostomy status, is vulnerable and faces a number of problems adjusting to their new status, among which is the absence or lack of knowledge for managing their ostomy and new habits. This study allowed us to demonstrate that the level of knowledge about self-care practices increased in enterostomy patients after the educational nursing intervention.
An important aspect in achieving the objectives was that the group of patients had an interest in the subject matter presented in the educational intervention, especially because it was knowledge of immediate and significant application for solving their problems. Like other studies, this shows that educational interventions are vital resources that nurses can use to achieve adherence to self-care.