CUIDADO INTEGRAL À PESSOA ESTOMIZADA NA ATENÇÃO BÁSICA - CONHECIMENTO E ATUAÇÃO DO ENFERMEIRO

Complete care for the person with the stoma is an activity performed by the nurse in primary care, shortly after discharge from the hospital, carrying out specific nursing care, explanation to user and family doubts, and guidelines for self-care and prevention of possible complications. The study aimed to appreciate the knowledge and the performance of nurses caring for the stomized person in primary care. A qualitative, exploratory and descriptive study, for data collection a semi-structured interview, with guiding questions, recorded and transcribed in full, applied to twenty-six nurses of the municipal primary care were used. From the analysis of the thematic content emerged the following categories: identifying care with the ostomy; the nurses' perceptions regarding the assistance provided to the ostomy patient. Nursing education and permanent education can contribute to a competent and effective performance of integral care to the ostomy patient, and this would reflect in the adaptive process and quality of life of thestomized patients and their families.


INTRODUCTION
Regardless of the type, any stoma requires special nursing care, considering its specificities and complications that affects the intentionally open orifice through surgical intervention to communicate hollow organs to the body surface area of the patients, the most common being hemorrhage, aseptic and hydroelectrolytic disorders caused by excessive drainage of the stoma.Besides that, there may also be skin irritation caused by pressure from the collection bag on the stoma or on the skin around the lesion by the contact of the acidic digestive enzymes present in the drainage (1)(2) .
The first care to the stomized person happens in the hospital, where the nursing, before surgery, explains the daily life of the person who is hospitalized while delimiting the stoma site.And, right after the surgical procedure, patient orientation such as the specific care with the stoma, adjacent skin and collection bag (3) .
The care of these patients with stomas needs continuity in primary care units after their hospital discharge.The ordinance of the Ministry of Health n. 400, from November 16th, 2009, article n. 02 determines that care for the health of people with ostomies is composed of interventions developed in primary care and expanded actions in the care services to the health of ostomized people, which will have to provide guidelines for self-care and prevention of complications in the ostomies (1) .
The primary care nurse has specific duties caring for individuals and their families and, when necessary or indicated, at home.It should also carry out nursing consultation and health education, because even that the user and his/her family receive the appropriate nursing care during hospital admission, on discharge it may not be sufficiently about caring, e to which service seek to continue the care of the stoma or to clear doubts about home care (4) .
This study is relevant to identify the knowledge and performance of the nurse in primary care, by the person entirely, being a reference after hospital discharge.In the face of these imbalances, it arouses the interest in knowing how the nurse deals with the situation of the stomized person considering knowledge and performance.
This way, this study aims to assess nurses' knowledge and performance in the care of the stomized person in primary care.

METHODOLOGY
This is a qualitative, exploratory and descriptive study, carried out in a medium-sized municipality in the southern region of Brazil, with nurses from health care units that are part of the primary care, who formally and voluntarily participated in this study, as the invitation was personally made at the workplace.Only after accepting to participate in the survey, an interview had been scheduled for the collection of the information.
In order to preserve the anonymity of the subjects participating in the study, the identification of the nurses interviewed was given by the letters ENF, followed by the numbers 01 to 26, which correspond to the chronological order of the interviews.The inclusion criteria were: to be a Family Health Strategy (ESF) nurse and to be working in the regardless of time service in primary careteam.Those professionals who were not present at the health unit at the day of the invitation were excluded from the study.Out of 29 nurses invited to join the study, only 26 accepted to participate.
Data collection took place from June to September 2014, through a semi-structured interview, with the following guiding questions: Describe everything you know about ostomies.As a professional nurse, do you think you are able to perform the care and guidance to the stomized patient?Do you think that it is the role of the primary care nurse to perform care for the patients with ostomies?The interviews were carried out in a private place, with privacy for such, predetermined by the nurse, preferably in their place of work.It was recorded in digital resource, later transcribed in full, and stored in a safe place at the institution of origin of the researchers, where it will be kept for five years.Before the interviews were started, the Informed Consent Form (TCLE) was read, any doubts about the study were explained, and the interviewers' anonymity guarantee was explained in relation to the information provided.After consent of the nurse, the TCLE was signed in two sheets, one for the nurse another for the researcher.As followed, the interview began.
Data analysis was performed after the full transcription of the interviews, according to the thematic content analysis method proposed by Bardin (5) , with pre-analysis, material exploration, inference and interpretation.The data analysis and discussion were contextualized with theoretical references available in health and related areas.
The research respected the ethical precepts determined by Resolution 466/2012, of the National Health Council, and was approved by the Permanent Committee of Ethics in Research involving Human Subjects of the State University of Maringá, CAAE26049514.7.0000.0104.

Characterization of Participants
Of the 26 nurses interviewed, 23 were female.The participants' ages ranged from 25 to 57 years, with a career time of 13 years.The duration of primary care services varied from 6 months to 14 years.
The nurses were questioned about the accomplishment of training on stoma care, of which 14 reported that they did not perform any type of training and 12 reported that they have already done updates in this sense.Of those who did some training, fourhad done it at the time of under graduation, six performed activities of permanent education in the work institution, one reported that had done activities of updating in nursing under graduation, and another carried out training by the city and also by contribution acquired in a private course.
The professionals were also asked about the existence of ostomy patients in their areas of coverage and the types of stomas they presented.Nine of them said that they had no patients with stomies in their coverage areas, and of the 17 who answered that there were, seven had colostomies, six gastrostomies, four tracheostomies, and four had not reported any type of stoma that users of their area of coverage were in, two reported visits to cystostomy and a jejunostomy.It was noted that there was a report of the patient being treated with NGT as a stoma.
In the data analysis, two thematic categories emerged which will be described as follows: Identifying care with ostomies and Nurses' perceptions regarding the care provided to the ostomy patient.

Identifying care with ostomies
Cienc Cuid Saude 2017 Jul/Set; 16 (3)   When investigating the types of ostomies that the nurse had knowledge, it was possible to perceive divergences of concepts.Some have even revealed erroneous or superficial definitions of what is a symptom: Gastrostomy is the one I most see, as I told you, it depends on the height of the opening, it can be either orally, as a nasal route, gastric route, asit may be in the first portion of the small intestine, which is the jejunum [.The interviewees revealed that the stoma they attend most at work is the colostomy, due to demands for attention.However, some were able to report that this is is located in the intestine, but they were unaware of its association.This lack of knowledge was evident in the statements that associate the ostomy to the orogastric or the nasogastric catheter, saying that they could be oral or nasal.
A nasogastric (NGT) or orogastric tube is not characterized as a stoma, since there is no surgical procedure for its installation, nor does it have an external carotid artery to conduct feeding or elimination.The nurse reported the NGT as an ostomy because the food does not pass through the gastrointestinal tract in the usual way, as occurs in healthy individuals, a knowledge misunderstanding (2,6) .
It is believed that the fact that the colostomy is the stoma best known to nurses, that is based on its highest incidence worldwide.Studies have shown that the majority of health service users who are stomized have a colostomy in South Asia (74.4%) (7) , Poland (71%) (8) , Rio Grande do Sul-Brazil (85.7%) (9) , in Maceio-Brazil (84.6%) (10) .
There are several types of ostomies, the name of it dependents on the body region in which it is inserted, so an opening in the ileum is called ileostomy, in the jejunum is jejunostomy, in the stomach it is gastrostomy, in the trachea it is tracheostomy and in any portion of the intestine is called colostomy (11) .
It is clear from the reports of several nurses of primary care that there is a gap in knowledge about ostomies, but this professional is responsible for caring the people with ostomies.The participant's speeches describe the nurses' basic knowledge about the definition of ostomies and care skills: Oh, basic, basic care, we can do, a food orientation, hygiene care at home, the changes, care before leavig the house, prevention if something burst, the basic we can do[...] (Enf 10) Part of the nurses refer to the ostomy as being specifically an opening in the intestine that communicates with the external side and aims to eliminate feces.Others define it as na opening of an organ to the outside of the body.This interpretation in parts is correct, however the professionals do not have minimum knowledge necessary for the care.
A stoma is not only in the abdominal region and is not only used to expel feces, it is a surgical opening when there is the convenience of permanently or temporarily displacing the normal flow of food and/or elimination that can be both, feces and urine (12) .
It can be noticed, that the absence of a theoretical-scientific foundation once again highlights that professionals are able to give guidance and care only for what is "basic", as they name the care of the sostomies, which indicates that, anything over that, could not be done properly as for actions and reference for the care.
This lack of knowledge of the nurse on caring for the patient with stomies may lead the user to misinterpret this fact, understanding that the nurse in his/her area of coverage has the capacity and competence to attend to his/her difficulties and, therefore, not to account for his assignments, thus losing confidence and leading him/her, at an adversity time, to no longer seek for the nurse of his unit of reference and seek other service, resulting in a distancing of the user with the nursing professional and the service (6,12) .
It is understood that caring is an exchange of knowledge between the professional and the user that brings positive results to care.For this, actions with attractive scientific basis for users should be developed motivated to seek their improvement (10,12) .
Cienc Cuid Saude 2017 Jul/Set; 16 (3)   The primary care user should be the protagonist of care, not being dependent on the health professional or the service to perform care with his full-time stoma, and their autonomy and independence must be preserved and encouraged to maintain their own health, in order to contribute to the recovery process (13) .
Others have shown a concept of ostomy a little deeper, as revealed by the following statements: Ostomy is an opening [...] colostomy because it is in the colon, gastrostomy because it is an opening made in the region of the stomach [...] tracheostomy because it is also in the region of the trachea, always an opening, something that is done surgically[...] (Enf 02) In order to correctly orient the patient and his/her family, the nurse may have a simplistic view of a stoma, several processes besides the techniques of the surgical procedure must be understood, such as the risk factors and pathophysiology of the underlying disease.However, the reports denote the lack of scientific knowledge of nurses, since most have confined themselves to saying that they have a provisional or definitive surgical procedure (14) .
The following excerpts show knowledge about possible ostomies complications: [...] you have to check the fixation correctly, you have to always observe if the skin is not red, irritated, with signs of inflammation [...] in case of tracheostomy, to be alert to some signs of irregularity like reddish edges, pain, discharge that is not normal from that region [...] I had the most contact with cystostomy ... you have to be careful when changing the catheter ... not to close ... with opening ... it has to be well sealed as well, to avoid contamination by the bacteria from the external environment [...](Enf 08) [...] the skin must always be intact ... it can be exposed to the sun as long as the ostomy is protected in some way, it can stay in the sun for about five minutes, the day of changing the bag, the morning sun can be usefull to strengthen the skin around the ostomy [...] Little bleeding is normal, so we'll ask them if there is a bigger bleeding, it is a warning... he/she has to take care only with the cleaning, the hygiene, can not be rubbed, because there will be bleeding, because it is very sensitive, that is it.(Enf 19) Intestinal ostomies deserve special attention because of the corrosive content that comes out with the feces, causing loss of skin integrity.In this sense, the reports show that the knowledge about necessary care with the ostomies refers to the peristomal hygiene, care with whole body and with the phlogistic signs that can happen.
Peristomal skin care should be a continuing concern due to complications such as abrasions and contact dermatitis occurring easily.Nurses' knowledge about skin changes brings the users more security and autonomy for self-care, making them more optimistic to perform the care at home (15) .
Regarding the importance of hygiene and preserving the integrity of the stoma, it was recalled: You have to take care of the hygiene, always be checking if there is not any inflammatory process[...](Enf 07) Regarding hygiene, people are very afraid to put their hand ... they think that it, will fall out, and will not, is to clean and it has to be cleaned!The people do not have this type of care [...]because they are afraid, I think...(Enf 06) One nurse commented on the need to be aware of the signs of inflammation, however, the others did not report this preocupation.
Although stomatal hygiene is important, practitioners have not cited other care that should be taken into account as peristomal colouring and edema.
The color represents the stoma perfusion, a dark, brownish or black coloration is indicative of ischemia and necrosis.Initial edema is an expected response due to the surgical procedure, but disappears after the 5th to 7th postoperative day.Small hemorrhages are also predictable, as long as they are small in number.In addition, there are no nerve endings in intestinal stomas, so people do not feel pain, and due to this, care must be taken with trauma and at the time of hygiene, because it is a mucosa that can be easily injured (8,16) .
In some courses, the nursing student has classes regarding the types of nutritional diets for each type ofinjury.However, after college, the same does not seem to require a nurse's performance egress in this area, due to the professional nutritionist to act in basic care.Thus, the nurse is accommodated by having a specialist working with him, failing to apply a knowledge learned, and who do not always carry out dietary guidelines when necessary, as shown in the following: The user with intestinal ostomies can have a very diverse diet, he/she may be verifying which foods are more tolerated by him and which ones should be eliminated from his/herdiet (11) .
In the case of gastrostomy and jejunostomy, where feeding is through tube, the diet can be prepared in a homemade way or be industrialized.Care should be taken to prevent obstruction (15,16) .
It is recommended that the tracheostomy patient take in food under some care, such as remaining seated at mealtime, eating slowly and chewing well before swallowing, however, it should be given lots of water to fluidise the pulmonary secretion (11) .
It is important, in order to continue the service and care at home, the involvement of a multiprofessional team, and this is provided by the Family Health Care Center (NASF).
It was highlighted in this category that a large number of nurses have lack of knowledge on what they are in fact, the symptoms, with consequences that implies in low quality assistance to the user and his/her family.

Nurses' perceptions regarding the care given to the stomized patient
In this category it was noticed that the nurse assumes the need to perform training and mention the greatest difficulties in providing assistance to the stomized user.
[...]who knows, we could be having a training session facing it, it is like I told you, I had the experience there at graduation and I still remembered some things to help our patients here, but it's not everyone who has this experience, and so I told you that there is a need of na updating, the products have changed [...] (Enf 01) [...]the difficulty I find in the care is that there are few patients for you to provide this kind of assistance, then when you are going to provide care, you end up not having a lot of skill because you do it eventually, so I think that's the biggest problem(Enf 14).
The speeches, in general, indicate that professionals believe that permanent education activities on ostomies are important and even essential, since, due to the peculiarities of the care and because they are encountered sporadically with this type of practice, they become out of date on the care and therapeutics that exist in the market.
Continuing education has the purpose of ensuring the quality of work and offering effective care, taking into account the difficulties encountered in the practice of their profession, when activities that contribute to the development and motivation of professionals must be taken into account (17) .
For such, the convenience and little professional willing can be factors that justify the limited search for scientific development, being that comfort brings to the person a fake comort about the performance in the work, failing to improve, even les to get updated.If what you "know" is minimally sufficient, within your conceptions, it is fine.
For effective care, the practitioner needs scientific knowledge and practical ability to treat ostomies, unprepared care for users with stomies can bring feelings of fear, insecurity and rejection to their own stomized condition.And this will spoil in the adaptive process of stomization (14) .
With regard to the role of the ESF nurse with care and guidance, the information presented by the subjects involved reveals a concern not only with the user, but also with the family, and included in the health promotion actions that derive from the work processes of nursing.
We are a program that encompasses the family, so it is inserted in our work process in fact, it is not only an ostomy patient, he/she is a patient as a whole, so it is our role to be caring and guiding(Enf Cienc Cuid Saude 2017 Jul/Set; 16(3) 20).
[...]but if suddenly something happens... we are the ones who are going to help, we who are the PSF, we are his/her reference, right there for him/her to get the bag and receive the care, but inside the home, we are the ones we have to do that, we have to provide assistance...(Enf 05) The ESF nurse is the professional who can be more in contact with the user and his/her family, due to the proximity of the health unit with the domicile.The nursing professional ends up knowing the economic, cultural and life conditions of the patient and the community, and can easily intervene in the care of the patient and his/her family, as mentioned in a talk about the agility of intercurrences (14) .Some say that the orientation of the caring process is not only the nurse of the ESF, but the whole team's.
It's the role of everyone, the whole team, the help too... the nurse, the doctor when you observe ... give guidance when you need it for the family ... I think the whole team!(Enf 06) Oh, I do not think it's the role of the nurse, I think it's the whole team's role because ... we can be like this ... coordinating, supervising isn´t it!But if we train a technician or a nursing assistant, he may be doing it too... (Enf 10) Nurses' reports indicate that there is a need for interdisciplinarity and professional transdisciplinarity.Teamwork allows for a greater interaction between nursing and health professionals, and their actions developed to provide care to the health care to the ostomized user contributes to the organization of the health service and to the changes in the actions that interfere in the health of this population and collectiveness.
Law No. 7,498/86, which regulates the practice of nursing, in its Article 11, says that it is the exclusive responsibility of nurses to provide nursing care of greater technical complexity and that require scientifically based knowledge and the ability to make immediate decisions.In the same law, Article 12 says that the nursing technician can be involved in nursing orientation and follow-up activities and participate in nursing care planning (18) .This way, the nursing technician has a legal responsibility, as long as supervised by the nurse, to perform the care and dressing in stomized patients who do not have intercurrences in their ostomies.In cases where there is inflammation, loss of skin integrity, need for tracheal aspiration, or some variation in the stoma, nurses must take action, since, by law, they are the most prepared professional to solve care requiring a deep scientific knowledge.
For nurses to conduct the orientation process and reduce the concerns of the family and the stoma person, it is important that the nurse has the capacity and ability to carry scientific equipment, due to the variety of high-tech equipment and materials (3) .
This way, the more knowledge, development and commitment the nursing professional has, the better prepared it will be to provide a quality care to the patient and his or her family.

FINAL CONSIDERATIONS
Nurses have shown a superficial knowledge of the care of stomized users.They also rely on other health care professionals for effective care, making shared care planning relevant, where professional knowledge and user knowledges are linked for a participatory and prolific assistance.
The speeches accuse a deficiency in knowledge and in the nurses' performance in the care of stomized users, possibly provoking a stimulus for the search for updating the area and future research.A subject that should have a more accurate look at nursing teaching in the undergraduate, since athematic care of users with cesomnia is common in the day-to-day life of the nursing professional, of basic care and is very present in the daily life of the community, thus favoring health care.
In addition, the provision of courses and/or training through permanent education could be offered to nurses throughout the health care network, contributing to the longitudinality of care in the municipality, promotion of health, control of basic diseases, care the resulting complications and their improvement, improving the quality of life of users, reducing avoidable hospitalizations and, consequently, public spending, qualifying the whole care to the users.
The speeches accuse a deficiency in knowledge and in the nurses' performance in the care of stomized users, possibly provoking a stimulus for the search for updating the area and Cienc Cuid Saude 2017 Jul/Set; 16 (3)   future research.A subject that should have a more accurate look at nursing teaching in the undergraduate, since athematic care of users with cesomnia is common in the day-to-day life of the nursing professional, of basic care and is very present in the daily life of the community, thus favoring health care.
The accomplishment of this study shows gaps in the theoretical/practical knowledge about nursing care by the nurse, which requires investment actions in permanent education and teaching to qualify the nursing actions and relevant guidelines for comprehensive care to the citizen.
..](Enf 17) It is an opening, a communication of the body with the external side.(Enf11) Well, what I know is just this one from the intestine [...] the colostomy.If there is another one, I do not know.(Enf05) [...]it is an opening in the intestine, deviating the passage of feces that would go to the anus, going to a region above, to the abdomen, this due to a problem that it has in the course along the intestine [...].(Enf 15) [...]It is an opening of an organic tissue for excretion or for feeding [...] in a provisional or definitive way, in the treatment of a dysfunction[...] (Enf 12) [...]the diet is usually prescribed by the doctor, and we don´t interfere much [...].If the doctor prescribes an industrialized diet, we forward to a social worker, if he suggests a home made meal, there is the nutritionist of the NASF, who's the one who guides, I do not give orders, they tell us what has been ordered and we replicate what has been said[...] (Enf 07) [...]we end up not doing this kind of orientation because today the PSF counts on the nutritionist of the NASF, so we have this multidisciplinary team, we used to do all this and today things have already improved, so the diet we forward to the nutritionist[...] (Enf 14)