NURSING INTERVENTION ACTIVITIES " CARE FOR OSTOMY

Objective: to evaluate the scientific evidence about the activities proposed by the NIC "Care with ostomy" intervention. Method: integrative review, conducted in March 2016 in the MEDLINE, CINAHL, Web of Science, SCOPUS and LILACS databases. The studies were categorized from the identification of the interventions according to the taxonomy of the intervention in the NIC << Care for the ostomy >>, as well as the proposed activities. Results: collection resulted in 23 articles, mostly qualitative (52%), with level of evidence IV (60.9%), identifying, in these, 23 of the 25 Nursing activities proposed in the NIC, and the activity "Orient the patient / important person regarding the use of ostomy device / care "the most frequent (60.9%). Conclusion: it was verified, therefore, that the most frequent actions performed by the nurses refer to the management guidelines of the ostoma with the inclusion of the caregiver and that there is a need for more studies with better levels of evidence in this subject. Descriptors: Ostomy; Nursing; Assistance. RESUMEN Objetivo: evaluar la evidencia científica sobre las actividades propuestas por la intervención de la NIC "Cuidados con la ostomía". Método: revisión integrativa, realizada en marzo de 2016 en las bases de datos MEDLINE, CINAHL, Web of Science, SCOPUS y LILACS. Los estudios fueron categorizados a partir de la identificación de las intervenciones concordantes con la taxonomía de la intervención en la NIC << Cuidados con la ostomía >>, así como las actividades propuestas. Resultados: la recolección resultó en 23 artículos, de mayoría cualitativos (52%), con nivel de evidencia IV (60,9%), identificándose, en estos, 23 de las 25 actividades de Enfermería propuestas en la NIC, siendo la actividad "Orientar al paciente / persona importante en cuanto al uso de dispositivo / cuidados de ostomía "la más frecuente (60,9%). Conclusión: se verificó, por lo tanto, que las acciones más frecuentes realizadas por los enfermeros se refieren a las orientaciones de manejo del ostoma con la inclusión del cuidador y que hay necesidad de más estudios con mejores niveles de evidencia en esa temática. Descriptores: Estomía; Enfermería; Asistencia. Mestre, Doutoranda, Programa de Pós-Graduação em Enfermagem, Departamento de Enfermagem, Universidade Federal do Rio Grande do Norte/PPGEnf/UFRN. Natal (RN), Brasil. E-mail: laysp_medeiros@hotmail.com ORCID iD: https://orcid.org/0000-0002-1753-5330; Graduandas em Enfermagem, Departamento de Enfermagem, Universidade Federal do Rio Grande do Norte/UFRN. Natal (RN), Brasil. Emails: isabelle_dasilva@hotmail.com ORCID iD: https://orcid.org/0000-0002-9865-2618; dannyelemunnyck@hotmail.com ORCID iD: https://orcid.org/0000-0001-5484-1014; Enfermeira, Universidade Federal do Rio Grande do Norte/UFRN. Natal (RN), Brasil. E-mail: silvia.kalyma@hotmail.com ORCID iD: https://orcid.org/0000-0002-1191-927X; Mestranda, Programa de Pós-Graduação em Enfermagem, Departamento de Enfermagem/UFRN (PPG/Enf/UFRN). Natal (RN), Brasil. E-mail: jullianafsena@yahoo.com.br ORCID iD: https://orcid.org/0000-0002-8968-1521; Enfermeira, Liga Norte Riograndense Contra o Câncer. Natal (RN), Brasil. E-mail: emilymesquita.em@gmail.com ORCID iD: https://orcid.org/0000-0002-4898-8762; Doutora em Enfermagem, Departamento de Enfermagem, Universidade Federal do Rio Grande do Norte/UFRN. Natal (RN), Brasil. E-mail: isabellekfc@yahoo.com.br ORCID iD: https://orcid.org/0000-0002-1476-8702 ARTIGO REVISÃO INTEGRATIVA Medeiros LP de, Silva IP da, Lucena SKP et al. Atividades da intervenção de enfermagem... Português/Inglês Rev enferm UFPE on line., Recife, 11(Supl. 12):5417-26, dez., 2017 5418 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v11i12a22899p5417-5426-2017 O ostoma ou estoma representa uma abertura originada de um processo cirúrgico, que permite a conexão de um órgão com o meio externo, com o intuito de eliminar resíduos que se depositam em uma bolsa coletora. Esse processo pode ser temporário ou definitivo, conforme as condições e causas de sua confecção, podendo ser classificado em colostomia, ileostomia e urostomia, mediante sua localização. A confecção do estoma ocorre por diversos motivos, sendo o mais frequente a neoplasia colorretal. Nos Estados Unidos, mais de um milhão de pessoas diagnosticadas com câncer colorretal se submetem à cirurgia e se juntam ao grupo de aproximadamente 700 mil pessoas ostomizadas, enquanto que, no Brasil, estimou-se um valor aproximado de 80 mil pessoas com ostomia distribuídas pelo país no ano de 2015, segundo a Associação Brasileira de Ostomizados e, além disso, conforme estimativas do Instituto Nacional de Câncer (INCA), há mais de 34 mil novos casos de câncer colorretal para 2016, acarretando o crescimento da população de ostomizados. O impacto gerado pela confecção de um sistema não habitual no corpo produz significativas mudanças na vida do ostomizado, que precisa se adaptar aos desafios associados ao cuidado com o ostoma, às alterações na imagem corporal, a aspectos funcionais e psicológicos do organismo. Além disso, o sentimento negativo que advém dessas transformações produz uma baixa autoestima e interfere no convívio social conduzindo ao isolamento. Nesse contexto, o enfermeiro tem papel essencial no cuidado do ostomizado, sendo de sua competência compreender as mudanças e ofertar o conhecimento necessário para as pessoas com ostomia e, desse modo, proporcionar a estas uma assistência digna e que propicie uma melhor adaptação frente às dificuldades enfrentadas. A assistência desenvolvida pela Enfermagem para pessoas com ostomia e seus familiares é de extrema importância para auxiliar na promoção da qualidade de vida, assim como favorecer a reinserção social do ostomizado. Além disso, o enfermeiro atua em outros aspectos, tais como a educação quanto ao tipo de alimentação, higiene, troca de bolsa e cuidados com a pele periostomal conduzindo, assim, ao desenvolvimento do autocuidado pelo ostomizado e, com isso, provocando o desenvolvimento da adaptação com o retorno às atividades de vida diária. A Sistematização da Assistência de Enfermagem (SAE) vem estabelecer o eixo que fundamenta toda essa prática da assistência de Enfermagem. Nela, é possível organizar e executar o processo de Enfermagem para atender às necessidades apresentadas pelo paciente e seus familiares. Ela garante o encadeamento do cuidado, o planejamento da assistência e a prevenção de futuros agravos e intervenções, por meio de etapas interrelacionadas. Nesse contexto, O Nursing Interventions Classification (NIC) é um sistema de classificação que constitui uma importante ferramenta de auxílio no processo de cuidado de Enfermagem, pois traz as intervenções de Enfermagem de modo padronizado propiciando, assim, a execução da SAE. Dessa maneira, esse recurso representa um modo de orientação para guiar o enfermeiro em seu plano de cuidados aos ostomizados. Mediante o que foi exposto, este estudo tem como objetivo identificar, na literatura, as atividades propostas pela intervenção da NIC “Cuidados com a ostomia”, bem como avaliar a evidência científica destas. ● Avaliar as evidências sobre as atividades propostas pela intervenção da NIC “Cuidados com a ostomia”. Revisão integrativa, na qual foram executados os seguintes passos: identificação da questão de pesquisa e objetivo do estudo, busca da literatura, avaliação dos dados, análise dos dados e apresentação. Essa revisão incluiu artigos indexados nas bases de dados Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing & Allied Health Literature (CINAHL), Web of Science, SCOPUS e Latin American Literature in Health Sciences (LILACS). A busca foi realizada em março de 2016, guiada pela seguinte questão norteadora: Quais as atividades propostas pela intervenção da NIC ‘Cuidado com a ostomia’ que são identificadas na literatura?”. Essa etapa foi realizada a partir do seguinte cruzamento utilizando os descritores identificados no Mesh Terms: Ostomy” AND “Nursing Care”. Foram incluídos artigos originais que apresentassem, pelo menos, uma atividade descrita na intervenção de Enfermagem NIC “Cuidados com a ostomia” e que estivessem disponíveis na íntegra nas bases de dados. Os INTRODUÇÃO

The ostomy or stoma represents an opening originated from a surgical process, that allows the connection of an organ with the external environment in order to eliminate residues, which are deposited in a collection bag.This process can be temporary or definitive, according to the conditions and causes of its manufacture, and can be classified in colostomy, ileostomy and urostomy, by its location. 13] In the United States, more than one million people diagnosed with colorectal cancer undergo surgery and join the group of approximately 700 thousand ostomized people. 4While the stoma is made for a variety of reasons, that in Brazil, an estimated 80 thousand people with ostomy distributed throughout the country in the year 2015, according to the Brazilian Association of Ostomates 5 , and in addition, according to estimates of the National Cancer Institute (INCA), there are more than 34 thousand new cases of colorectal cancer by 2016, leading to the growth of the ostomy population. 6e impact generated by the confiscation of an unusual system in the body produces significant changes in the life of the ostomy, which needs to adapt to the challenges associated with caring for ostoma, changes in body image, functional and psychological aspects of the body.In addition, the negative feeling that comes from these transformations produces a low self-esteem and interferes in the social life leading to the isolation. 7 this context, the nurse plays an essential role in the care of the ostomate, and it is within her competence to understand the changes and offer the necessary knowledge to the people with ostomy and, in this way, to provide them with a dignified assistance and to allow a better adaptation to the difficulties facing. 8rsing care for people with ostomy and their families is extremely important to help promote quality of life, as well as to promote the social reintegration of the ostomate. 9 The Systematization of Nursing Care (SNC) establishes the axis that underlies this Nursing care practice.It is possible, to organize and execute the Nursing process to meet the needs presented by the patient and their families.It ensures the linkage of care, care planning, prevention of future injuries and interventions, through interrelated stages.
In this context, Nursing Interventions Classification (NIC) is a classification system that is an important tool to aid the Nursing care process, which brings Nursing interventions in a standardized way, thus, providing the SNC implementation.In this way, this resource represents a guiding method to guide nurses in their care plan to ostomates. 13e objective of this study is to identify, in the literature, the activities proposed by the NIC intervention "Care with ostomy", as well as to evaluate the scientific evidence of these.
• To evaluate the scientific evidence about the activities proposed by the NIC "Care with ostomy" intervention.
Integrative review, in which the following steps were performed: identification of the research question and purpose of the study, literature search, data evaluation, data analysis and presentation. 14is review included articles indexed in the Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing & Allied Health Literature (CINAHL), Web of Science, SCOPUS and Latin American Literature in Health Sciences (LILACS) databases.
The search was conducted in March 2016, guided by the following guiding question: "What are the activities proposed by the NIC 'Care with ostomy' intervention that are identified in the literature?This step was performed from the following intersection, using the descriptors identified in the Mesh Terms: "Ostomy" AND "Nursing Care".
Original articles were included that included at least, one activity described in the NIC Nursing care "Care with ostomy" and that were available in full in the databases.The exclusion criteria of this study were: review articles, theses, dissertations and editorials.

OBJECTIVE
English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.12):5417-26, Dec., 2017 5419 A total of 2797 articles were identified in the databases.Of these, 23 were selected to compose the final sample of the study after preliminary reading and later in full.Figure 1 shows the quantitative details of the steps of data collection.The studies were categorized from the identification of interventions consistent with the taxonomy of the intervention contained in the NIC entitled "ostomy care", as well as the proposed activities.
For the analysis of the level of evidence, the Joanna Briggs Institute was used, as a parameter, which classifies the studies into four levels of scientific evidence: Level I: Evidence obtained from a systematic review containing only randomized controlled clinical trials; Level II: Evidence obtained from at least one randomized controlled trial; Level III.1:Evidence obtained from well-delineated controlled clinical trials, without randomization; Level III.2:Evidence obtained from well-designed cohort studies or casecontrol, analytical studies, preferably from more than one research center or group; Level III.3:Evidence obtained from multiple time series, with or without intervention, and dramatic results in uncontrolled experiments; Level IV: Opinion of respected authorities, based on clinical criteria and experiences, descriptive studies or expert committee reports. 15e data collection resulted in 23 articles to compose the sample of this study.Figure 2 below shows the main results of the literature review classified according to the type of study, level of evidence, year, local and periodical of publication.Most of the studies found were national 14 (60.9%),performed with a qualitative approach 12 (52%) and presented level of evidence IV 14 (60.9%).The type of qualitative study as well as the level of evidence IV present in most studies present an important gap in relation to the quality of the materials produced, mainly at the national level.In the case of studies that approached Nursing actions and interventions, the encouragement to the accomplishment and publication of studies with better levels of evidence is fundamental in improving the quality of the materials that can subsidize the Nursing practice to the ostomized person, seeking the standardization and the safety in the execution of interventions that present good levels of evidence, adjusted to the local reality and with real possibility of improvement of the multiple aspects that permeate the coexistence with the ostomy. 39e most frequently encountered intervention in the sample was "Orienting the patient/important person regarding device/ostomy care".Other interventions found associated with the important person and the ostomate are related to demonstrating the use of equipment, encouraging the expression of concerns about body image, assisting in proper diet and identifying changes in eliminations, which indicates the need for care orientation both for the client, and for the important person, who is a close person who lives with the

DISCUSSION
English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.[42][43] With the making of the ostomy, several changes occur in the life of the ostomy, ranging from the modifications in the selfimage to the transitions in the routine, making necessary the insertion of the care with the ostoma. 41In the beginning, the adaptation is a challenge , since it involves multiple factors that are novelties for the person with ostomy, who needs a time to absorb the changes that are now part of their life and, therefore, the relatives who accompany the recovery of the ostomy, after the surgery, need provide support to carry out the care until it is able to adapt and develop self-care. 44ten, due to the lack of preparation for the new delegated experiences, the caregiver appropriates actions that have never been performed before, and sometimes not satisfactorily oriented, and are difficult to achieve.1] In this sense, the nurse has an essential function in developing, through effective educational communication, 45 guidelines that contemplate ostomized in an integral way, involving the caregiver in the management of ostomy care and also helping, him to obtain and provide emotional support.

40-42.46
Interventions involving the psychological aspects of ostomized care are evidenced in "assisting the patient in self-care", "Encouraging the patient/significant person to express feelings and concerns about changes in body image", "Discussing relative concerns to sexual function as appropriate" and "Demonstrate confidence that the patient is able to return to normal life with the ostomy" and relate to the importance of dialogue during Nursing care to the ostomy and/or important person.
Instruments such as active listening are essential for establishing a relationship of trust with the professional, which seeks, from this, to provide health care based on the guidelines of the National Humanization Policy.In addition, establishing a link between professional and client favors the adaptive process as it provides, the nurse, with relevant information about individual care demands, thus, facilitating the construction of a personalized care plan for improved adaptation and quality of life of the individual. 44,47ded to these activities, are the provision of psychological support, which involves encouraging the participation of support groups for ostomates.This type of intervention, that promotes planned group interactions, was carried out in Turkey, presented a level of scientific evidence II.2 and culminated, after completion of the intervention, in an important improvement of the adaptive adjustment of the ostomy patients submitted to this activity.The exchange of experiences, living with people in the same situation and the sharing of information assists in the acceptance of the ostomy and cooperates in the acquisition of knowledge arising from the practical experience of daily care. 36 the beginning, the process of accepting the new life condition is not always simple and fast.Sometimes, there is resistance, on the part of the ostomate, to adapt to the bag and to care for it.Thus, with nurses' orientations and conversations with relatives/caregivers, this resistance diminishes and the individual becomes aware that ostoma is now part of their reality. 41evious studies have provided the opportunity for newly ostomized individuals to access the nurse at various times after surgery.This opportunity made the exchange of information happen, the professional, with their scientific knowledge, and the patient, with his experience, there are guidelines on how to change the collection bag, maintenance of the various types of bags, autoirrigation, late complications, use of adjuvants, leisure, physical exercises, among others. 24In exercising their own care, they have become more independent and secure, thus, facilitating adjustment. 23wever, these professionals are not always able to perform and provide the necessary guidelines for ostomates.There are patient reports in other studies, which show that nurses, often do not know how to orient themselves about proper care with the ostomy, as well as perform hygiene and exchange of scholarships.This fact shows the need for more nurses with estomoterapia knowledge to provide adequate information to this population. 41ucational actions and guidelines are part of the interventions suggested in the care plans for ostomized patients as it ensures a quality of self-care.Among the analyzed actions related to teaching, the ones that present the highest incidence among the analyzed articles were to guide the use of the device/care with the ostomy and to help the patient to obtain necessary equipment.
English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl.12):5417-26, Dec., 2017  5423  This demonstrates that most ostomates are oriented toward basic care and relevant to living with the ostomy.Some articles, to a lesser extent, have shown concern not only with activities, but also with eating habits and possible complications. 48However, guidelines may not be sufficient enough for the clientele being assisted, new methodologies can and should be used for better effectiveness of actions.
Knowing this, teaching strategies should be elaborated for both ostomized patients and their caregivers and caregivers, not forgetting the health team, since this, well oriented, will be able to provide effective assistance and also be multiplying with caregivers.Strategies involving technologies -videotapes, interactive internet programs and even telephone follow-up -have been shown to be effective in stimulating learning, especially with regard to self-care. 49 was identified that most of the studies in the sample were qualitative, with level of IV evidence, with 23 of the 25 Nursing interventions proposed in the NIC on ostomy care being identified, indicating an indication of its use in Nursing care for people with ostomy.
In this sense, the most frequent activities identified were "orienting the patient/important person regarding the use of ostomy device/care", "assist the patient in self-care" and "make patient/person important demonstrate the use of equipment", respectively , which indicates that the actions performed by the nurses most refer to the management guidelines of the ostoma with the inclusion of the caregiver.
In addition, activities related to psychological and social aspects were identified, although they were identified to a lesser extent.These findings highlight the relevant role of the nurse who acts in the adaptive process of the ostomy in multiple aspects, however, many studies reveal failures in the Nursing training to act in the ostomy care.
It is necessary to produce more studies, with better levels of evidence, that focus on the nurses' behaviors and their knowledge about estomoterapia, since the extension of their learning, in accordance with more complete guidelines, will provide a greater effectiveness in the adaptation process, as well as facilitate the acquisition of a better quality of life of the ostomy.