0 - Introduction This paper aims to respond to a moment of evaluation of the Guidelines Mentoring discipline of Nursing: Care for People

Undergoing Surgery, 3rd year of Bachelor of Nursing, School of Sousa Valley. We were offered a job done within a large t heme and Ostomy Drain ", and the Class B was chosen to deal with the subtheme" i leostomy and colostomy. As a methodology of research work has been done on books and magazines of Nursing. This work aims to gain knowledge about ostomy disposa l, to make known the types of ostomy disposal exist, as well as its indications, complications and nursing care involved. In the first part will address the typ es of ostomies that exist. In the second part we will talk about different types of ileostomies and colostomies as well as its indications and complications. A third section will talk of nursing care to have with the stoma as well as teachi ng the patient stoma. It is essential to a nurse to know what types of ostomy di sposal exist and what are the indications for doing this type of ostomy. It also has to know the complications that may arise from an ileostomy or a colostomy. To address these ostomies have to know which nursing care inherent in these. Thi s work is expected to help the nurses to deal with this type of stoma and know w hat to do if you encounter a stoma patient during his professional life. 1 2 1-Physiology of the Intestines The small intestine is about 2.5 cm wide and 6 feet long. It consists of three p arts - the duodenum, which connects to the stomach, jejunum, or middle part, and the ileum, which connects the large intestine. The large intestine is about 6 c m wide and 1.5 meters in length (Phipps, Sands & Marek, 2003). Also consists of three parts - the blind, which binds to the small intestine, colon, and rectum. The ileocecal valve prevents retrograde movement of fecal contents of the large intestine to the small intestine. The appendix, which has no known function, is an appendage near the ileocecal valve. The colon is subdivided into four parts the ascending colon, transverse, descending and the sigmoid. The places where t he colon changes direction are designated by the name of the adjacent organs - t he liver (hepatic angle) and spleen (splenic angle). The rectum is 17-20 cm in l ength ending in the anal canal 2-3 centimeters. The opening of the anus is contr olled by the internal sphincter smooth muscle and the external sphincter striate d muscle (Phipps, Sands & Marek 2003). The main functions of the small intestine are digestion and absorption of food nutrients. These processes occur in the je junum and the ileum. The contents of the small intestine (chime) is propelled in to the anus through peristalsis. These movements increase after meals (Phipps, S ands & Marek, 2003). The main functions of the large intestine are the absorptio n of water and electrolytes from the chyme and storage of food waste until defec ation. Every day about 450 milliliters of chyme reaches the blind. The transit t ime in the large intestine is slow, taking about 12 hours to reach the rectum (P hipps, Sands & Marek, 2003). 3 4 2 - Ostomy According to Slater (2002), a stoma is a Greek term meaning "mouth" or "opening" and he calls any surgical opening of a viscus to the exterior environment. " In some individuals the wastes are not excreted through the urinary bush or anus, but diverted by a removal surgically created, called for ostomy. An ostomy is cr eated by suturing a portion of the urinary tract or bowel to the abdominal wall, creating thus an opening to the outside of the body. The opening is called a st oma (Arkinson & Murray, 1989). The surgeries that give rise to the stoma are amo ng other laparoscopic surgery and Hartmann (Phipps, Sands & Marek, 2003). The st

oma may be temporary or permanent. When are temporary formed to allow a lower po rtion of the tract to heal after surgery, injury or inflammatory disease. Perman ents are created when there is removal of the lower tract or when it shows damag ed permanently (Arkinson & Murray, 1989). The stomata take different names depen ding on the viscera that is externalized and have different functions. There are three kinds of ostomies: breathing, feeding and elimination.€Within the disposa l there are the elimination of urinary and intestinal elimination (Simões, 2002) . The stoma breathing are the tracheostomy, which consist of a surgical opening in the anterior wall of the trachea. The permanent stoma scar obtained with the fixation of the trachea to the skin. May be temporary and cannula, or standing w ith or without a cannula (Slater, 2002). The Ostomy supplies are jejunostomy and gastrostomy. Jejunostomy consists of placing a catheter in the jejunum, with th e purpose of feeding, when is unable to use the higher parts of the digestive tr act, as in the case of operations, of tumors, among others. A gastrostomy is a s urgical procedure to fix May 1 feeding tube. The artificial opening is created at the time of the stomach and i s performed in patients who lost their temporary or permanent capacity to swallo w the food, both as a result of severe brain injuries or disorders of the upper gastrointestinal tract (Simões, 2002). In ostomy disposal, as noted above there are two types (Phipps, Sands & Marek, 2003): the Urinary elimination - in which we ureterostomy, which consists of placing commun ication in two different parts of the same ureter in order to restore its permea bility affected by a tightening or an obstruction, we also have a cystostomy, wh ich makes an anastomosis bladder to the abdominal wall between the pubic symphys is and the umbilicus, to allow the output of urine from the bladder when there i s an obstacle to the level of the urethra (cancer, stricture), we still have the nephrostomy, which is a surgical procedure which consists make an opening in a kidney with the aim of the drain. This allows the resolution of urethral obstruc tion and recovery of renal function in patients with obstructive uropathy and al so has an important role in urinary tract obstruction in advanced abdominal canc ers. Eliminating the gut - where we have a colostomy, which means the union of the an terior abdominal wall of a portion of the colon, in order to allow the evacuatio n of feces and gases, we also have the ileostomy, which is the union of the ante rior abdominal wall portion of the ileum, in order to permit the removal of fece s and gases. 6 3 - Ileostomy An ileostomy comes when a stoma is made from the ileum and is usually permanent (Arkinson & Murray, 1989). Any technique of ileostomy eliminates the ability of the colon absorb fluids and electrolytes, and drainage is profuse and watery (Ph ipps, Sands & Marek, 2003). There are different types of ileostomies (Phipps, Sa nds & Marek, 2003): • • • Brook ileostomy, continent ileostomy; Íleoanal Reservoir. The Ileostomy Brook is the oldest technique of colectomy. Involves removing the colon, rectum and anus, with final closure of the anus. The terminal portion of ileum expands with the passage of time and takes some of the functions of the bl ind. The volume of stools down, but a minimum 300-800 ml of liquid is also lost in the feces daily, along with substantial amounts of electrolytes, particularly sodium. The person suffers from a chronic deficit of liquids, since the small i ntestine is unable to make appropriate adjustments to the net deficit and any in

crease in fluid intake simply increases the volume of drainage through ileostomy (Phipps, Sands & Marek, 2003). The stoma is located in the lower right quadrant , and is usually protruded (Swearingen & Howard, 2001). The continent ileostomy was developed in the late 1960s by Dr. Nils Kock, to save the patient some of th e problems of traditional ileostomy. This technique involves creation of an abdo minal reservoir to store stool using a portion of the terminal ileum. A portion of the terminal ileum is invaginated to form a nipple valve which is placed at t he same level of the abdominal wall (Phipps, Sands & Marek, 2003). 7 The Reservoir Íleoanal involves creating a pouch from the terminal ileum, which is sutured directly to the anus. It leaves untouched the anal sphincter, which p reserves continence, added to approximately 2.5 cm in the rectum is stripped of its mucosa (Phipps, Sands & Marek, 2003). This is done in two operative times: t he first following total colectomy and removal of the anal lining (with anal sph incter preservation), involves the construction of an ileal reservoir in the sma ll intestine of the pouch opening is directed downward through a sheath of muscl e tissue and sutured or rectal anastomosed to the anal canal. The tank stores th e stool. A temporary ileostomy is performed to enable the healing of the anastom osis. In the second stage surgery,€after 3-4 months, the temporary ileostomy is closed and fecal continence is restored (Swearingen & Howard, 2001). 3.1 - Indications The Brook's ileostomy is indicated for patients having (Swearingen & Howard, 200 1; Phipps, Sands & Marek, 2003): → Ulcerative colitis; → Crohn's disease; → Canc er; → Trauma; → familial polyposis; → Patients between adolescence and middle age, with an average age of 40 years. 8 The continent ileostomy is indicated for (Swearingen & Howard, 2001; Phipps, San ds & Marek, 2003): Ulcerative colitis; familial polyposis; Patients between adolescence and middle age, with an average age of 40 years. The Reservoir Íleoanal is indicated for patients having (Swearingen & Howard, 20 01; Phipps, Sands & Marek, 2003): Ulcerative colitis; familial polyposis; The ideal patient for this procedure is 20-40 years old and has good control o f the sphincter; It is generally not used in people aged over 55 years, who ma y suffer from deterioration of the anal sphincter related age. 3.2 - Complications The complications for any type of ileostomy are both physical and psychical (Phi pps, Sands & Marek, 2003). Complications Physics (Phipps, Sands & Marek, 2003; H allouët, Eggers & Malaquin-Pavan, 2006): Early complications: hemorrhage, necr osis, shrinkage, eviscerated, occlusion. Late complications: occlusion, stenosis, herniation, prolapse, irritation peristomial skin, reintegration of stoma hernias paraestomais, 9 ulcers, infections, buildup of phosphate crystals, squamous metaplasia, which ma y cause stenosis. peri-stoma complications: skin irritation or contact mechanical, bacterial skin infections or candidiasis, hypersensitivity or allerg

ic processes, fouling of phosphate crystals, granulomas, peri-stoma varices, epi thelial hyperplasia, which can lead to stenosis. Brook ileostomy: malfunction of the stoma due to poorly digested food, which easily cause obstruction. Continent ileostomy: the problems with the nipple valve are common and often require open laparotomy for repair. This, added to the incidence of ch ronic inflammation in the bag, limits the usefulness of this technique and is se ldom recommended as first intervention. Reservoir Íleoanal "Pouchitis" is an a cute inflammation within the reservoir and is often a chronic problem. This caus es discomfort, bleeding and increased debt. Complications psychological (Phipps, Sands & Marek, 2003): Fear of los s, embarrassment due to noise and odor; negative effects on self-esteem, negativ e effect on body image, negative effect on sexuality. 10 4 - Colostomy A colostomy arises when a stoma is made from the colon and can be temporary or p ermanent (Arkinson & Murray, 1989). There are different types of colostomies Swe aringen & Howard, 2001): → Ascending Colostomy; → of Transverse Colostomy; → Transverse Colostomy with the Double Barrel; → Tran sverse Colostomy of the Ansa; (Phipps, Sands & Marek, 2003; → Descending Colostomy; → Sigmoid Colostomy. The Ascending Colostomy is the less common type of colostomy. It is located in t he upper right quadrant, or in the right lumbar area of the abdomen and is usual ly protruded. Being very close to the terminal portion of ileum, should eliminat e liquefied or pasty stools, flowing almost continuously (Swearingen & Howard, 2 001). A transverse colostomy is the most indicated that the ascending colostomy. It is usually temporary and is most often performed for fecal diversion of reli ef in cases of intestinal obstruction and perforation of the abdomen and subsequ ent plot. The location of the stoma is usually high on the abdomen, around the w aist and around the midline of the body. The feces are semi-solid. In cases in w hich the rectum is not removed, the patient may occasionally remove faeces by co lorectal (Swearingen & Howard, 2001). In the Transverse Colostomy with Double Ba rrel is opening up a double to provide the rest of the colon for anastomosis. Th e patient has two stomas: a proximal stoma which is active and drains stool and a distal stoma which is inactive and drains mucus (Swearingen & Howard, 2001). 1 1 In the Loop Colostomy Transverse of an intact segment of colon is sutured to the abdomen, without being completely severed. The tie is made in the outer portion of the body and secured with a support rod of plastic or glass by 70-10 days po st-operatively (Swearingen & Howard, 2001). The Descending Colostomy is the type of fecal most commonly performed. The stoma is located in the upper left quadra nt and may be flat or protruded.€The feces are pasty or semi-solid (Swearingen & Howard, 2001). A sigmoid colostomy is very similar to descending colostomy. It' s the other type of fecal most common being performed. The stoma is located in t he left lower quadrant and may be flat or protruded. The stools are solid in thi s case, because they are very close to the rectum (Swearingen & Howard, 2001). 4.1 - Indications The Ascending Colostomy is indicated for patients who have (Swearingen & Howard, 2001; Hallouët, Eggers & Malaquin-Pavan, 2006):

Diverticulosis; Hirschsprung Disease; obstruction of the colon; Trauma; rectovag inal fistula; inoperable tumors of the colon, familial polyposis, may be perform ed in patients of all ages.

12 A colostomy is indicated for the transverse (Hallouët, Eggers & MalaquinPavan, 2 006; Swearingen & Howard, 2001): • • • • • • Diverticulosis; Hirschsprung Disease; obstruction of the colon; Trauma; rectovag inal fistula; inoperable tumors of the colon, familial polyposis, may be perform ed in patients of all ages. • • The Transverse Colostomy with the Double Barrel is indicated for (Hallouët, Egge rs & Malaquin-Pavan, 2006; Swearingen & Howard, 2001) - Rest of the colon for an astomosis. Emergencies, such as intestinal obstruction or perforation. In the Loop Colostomy Transverse is indicated for the (Swearingen & Howard, 2001 ): emergencies. The Descending Colostomy is indicated for patients with (Hallouët, Eggers & Mala quin-Pavan, 2006; Swearingen & Howard, 2001): Cancer of sigmoid colon or rectu m; Diverticulosis; 13 Congenital anomalies; familial polyposis; Trauma;

Can be performed in patients of all ages, but most are done in patients aged o ver 40 years. A sigmoid colostomy is indicated for patients who have (Hallouët, Eggers & Malaq uin-Pavan, 2006; Swearingen & Howard, 2001): Cancer of sigmoid colon or rectum ; Diverticulosis; Congenital anomalies; Trauma; familial polyposis; Can be performed in patients of all ages, but most are done in patients aged o ver 40 years. 4.2 - Complications The complications for any type of colostomy are both physical and psychical (Phi pps, Sands & Marek, 2003). Physical complications (Phipps, Sands & Marek, 2003), (Hallouët, Eggers & Malaquin-Pavan, 2006), (Swearingen & Howard, 2001): Early complications: hemorrhage, necrosis, shrinkage, eviscerated, occlusion. Late complications: occlusion, stenosis, herniation, prolapse, irritation peristomial skin, reintegration of stoma hernias paraestomais 14 ulcers, infections, buildup of phosphate crystals, squamous metaplasia, which ma y cause stenosis. peri-stoma complications: skin irritation or contact

mechanical, bacterial skin infections or candidiasis, hypersensitivity or allerg ic processes, fouling of phosphate crystals, granulomas, peri-stoma varices, epi thelial hyperplasia, which can lead to stenosis. Ascending Colostomy: the fecal content contains digestive enzymes that are detrimental to the skin. of Transverse Colostomy: the enzyme content of liquefied faeces may cause skin irritation peristomial. Transverse Colostomy with the Double Barrel: the enzyme content of liquefied faeces may cause skin irritation peristomial. of Ansa's Transverse Colostomy: as is usually done in emergency, the patient is often ill-prepared, either physically or psychological ly for this procedure. Descending Colostomy: depending on the type of food eaten, some may cause diarrhea, gas, odor or even obstruction. Sigmoid Colostomy: depending on the type of food eaten, some may cause diarrhea, gas, odor or even obstruction. Complications psychological (Phipps, Sands & Marek, 2003): Fear of los s, embarrassment due to noise and odor; negative effects on self-esteem, negativ e effect on body image, negative effect on sexuality. 15 16 5 - Nursing From the pre-operative, which are fundamental to patient care, including educati on about what will change in your life. It is then the role of these nurses prov ide care and make this teaching the patient about this new stage in his life, wh ich may get a better quality of life possible. 5.1 - Nursing Care in Preoperative The Preoperative Care to the patient undergoing ostomy are centered on teaching the patient (Phipps, Sands & Marek, 2003). In Psychological preparation, with an ostomy technique that causes alteration of body image and bowel function,€the n urse must assess knowledge and understanding of the patient compared to surgery and its outcome. The nurse should also inform the patient about what to expect p ostoperatively. Beyond fear and anxiety inherent in the surgery, can also arise fear the reaction of family and friends before your ostomy. Feelings of shock, a nger, inferiority, depression or addiction may emerge. Besides these, the change in body image, in which the output of feces shall be made by unnatural opening in the abdomen, the patient may feel shame, disgust and take refuge in a social isolation. The nurse should clarify the patient and family questions about ostom y surgery and, demystifying fears, fears and misconceptions often. It is essenti al that nurses demonstrate willingness and develop a relationship with the patie nt empathy and trust, always with the main objective of the autonomy and rehabil itation 17 the patient as early as possible, promoting self-care and acceptance of the new body image (Serrano & Pires, 2007). The physical preparation including bowel pre paration, where cleaning is carried out according to the prescription and, depen

ding on the condition of the patient, may be conducted with (Serrano & Pires, 20 07): • • Mannitol 10% 1500cc, via Oral; industrial preparations for bowel cleans ing by oral administration (eg: Selge "," X-prep "or" Klean-prep ") • Enemas cle aning or other preparations for rectal administration (eg Clyss-Go). It is usual ly also performed prophylactic antibiotic coverage with metrodinazol and neomyci n-750 mg-1 gram, 3 doses orally the day before surgery. It is shaving the pubic region, abdominal and perineal (when the patient will undergo abdomino-perineal amputation), a peripheral vein puncture and administration of serum polyelectrol yte with dextrose, the day before surgery, to compensate for losses caused by bo wel cleansing and consider the cleansing of the skin (Serrano & Pires, 2007). It is also marking the stoma site, where the shape and contour the skin fold of th e abdomen of the patient are taken into account, not only in the sitting positio n but also standing. The site should be visible when the patient is seated or st anding, be located within the rectus muscle and away from scars, bony prominence s or skin folds. The waist of the patient should also be avoided. Often, the sto ma site is the most significant factor that influences the capacity of the patie nt keep a bag tight and treat ostomy alone, after surgery (Phipps, Sands & Marek , 2003). Teaching the patient before surgery should include (Phipps, Sands & Mar ek, 2003): That should make an appointment with the Nurse stomatherapy Estomaterapeuta befo re surgery, in which this will show the 18 material which exists for the patient become familiar with the material that wil l have to switch to; What will be shaving the abdomen (where the patient has a lot of body hair) What has to be fasting before surgery; If the patient has some sort of allergies; Explain to the patient, which may have drains, cath eter and naso-gastric; That will have to be fasting after surgery to prevent str ain or stress on suture lines; You may have pain and that you will be given analgesia; Teach the patient as process of breathing and coughing after surgery, so you do not have pain; Display material in the case had not gone to consulting stomatherapy; Explain wh at is the surgery, explaining the physiology of the intestines. 5.2 - Nursing Care on Postoperative In Nursing Care on Postoperative nurses must, like any post-operatively, the pat ient correctly observe and monitor their vital functions. The nurse should encou rage the uprising after 24 hours and if it is possible to walk (Phipps, Sands & Marek, 2003). It should therefore be alert to the monitoring of (Serrano & Pires , 2007; Phipps, Sands & Marek, 2003) - Soros and other infusions - gastric drain age; 19 - Drain abdominal and perineal (if available) - I think abdominal and perineal ( if available) - bladder drainage; Drainage from the stoma and the beginning of its operation (drainage of fluid is initially serohemático and mucus, restarting bowel function usually 3-7 days po st-surgery); Cleaning the Stoma: During the hospital cleaning of the stoma should be done wit h sterile compresses and saline solution to avoid infections.€One should gently wash the skin and peri-stomal stomal circular motion and dry without rubbing the

stoma and peri-stomal skin and keep skin that is under the bag clean and dry; Maintenance of fluid and electrolyte balance: The person with ileostomy, it is e ssential to pay attention to fluid and electrolyte balance. After surgery, drain age by fecal ileostomy is liquid and can be permanent. The patient may have feca l debts ranging between 1000 and 1500 ml per 24 hours. This amount should begin to decrease slightly within 10-15 days, as the terminal ileum begins to absorb w ater and the feces become thicker. However, the losses are even more significant and is essential to register careful fluid balance. Patients with ileostomy eas ily dehydrates. Feces can not become thick, if the patient had previous small bo wel resections due to Crohn's disease. The more intestine has been resected, the greater the likelihood of a high volume of liquid stool. Some patients need med ication to help reduce the volume and control fluid loss. The bag may need to be emptied every 1 to 2 hours. Volumes greater than 1500 ml per 24 hours are consi dered excessive. The hydro-electrolyte problems are usually not a 20 major concern after colostomy surgery, but must be for a moment, to restore a no rmal pattern of elimination. Evaluation of Stoma: The patient has undergone surgical ostomy surgery usually c omes with an ostomy bag placed. The nurse regularly observes the stoma on the hy peremia and edema. The color reflects the infusion and a stoma or dark brownishblack indicates ischaemia and necrosis. The color changes must be reported immed iately. The initial swelling of the stoma, is an expected response to surgical m anipulation. The shape of the stoma continues to change slightly in response to peristalsis and the opening of the bag needs to be adjusted to adapt to changes in the size of the stoma. The swelling usually disappears in 5-7 days. A small s ignificant bleeding should be reported immediately to a surgeon. The abdominal i ncision and the sutures that secure the stoma, are examined in relation to their changes. Some of the mucosa of the stoma can externalize itself in the abdomina l wall before healing is complete. The surface fragments heal by granulation, bu t the deeper may require repositioning or to be re-sutured. The draining of the stoma is formed, initially, mucus secretion and sero-hematic. As peristalsis rea ppears, usually 2-4 days, start the flatus and fecal drainage. The bag should be emptied when there is a third or half of its capacity, with stools or more ofte n if there is excess gas. Handling Perianal Wound: The perianal wound may require more than six months for complete healing, so it is necessary to take care of this wound, such as washin g and sanitary pads until the wound be closed. The perianal wound hinders the pa tient feels or find a comfortable position. Soft pillows or foam may increase co mfort, while the patient is sitting. The nurse teaches the patient to avoid pill ows that will do away the buttocks and hindering 21 wound healing. Generally, patients prefer the lateral position. Initially, the w ound drainage is abundant and serohemática and must be removed efficiently to pr event infection and abscess formation. Initially the wound washings are made, us ually with saline, but the patient may gradually evolve into a manual massage wi th shower. Dressings must be changed whenever necessary. Nursing care to be provided when there are complications (Loureiro & Fernandes, 2007): Skin Irritation / peristomal dermatitis: the most common causes are

corrosiveness of the discharge, sensitivity to the device, epithelial hyperplasi a, dermatitis and alkaline infection. Care must realize how good hygiene and the stoma; mislead the cause and act accordingly, increase the protective skin, cha nge your device, and if they continue to be guided to the Nurse Estomaterapeuta. stenosis: where there is a narrowing of the stoma caused by scar tissue. How to care, we should perform the care of oring the size of the stoma, to promote the dilation of apply a convex plate or ring and complementary route to peristomal hernia: where there is a protrusion of the the stoma hygiene, monit the stoma, if necessary the surgeons. colon or the ileum

subcutaneous layers. How care should be made to the care of stoma hygiene, imple ment, if necessary support without a belt tightening; alert if necessary for the costume changes, changing device, go to the surgeon, surgery. Prolapse: There is a strong manifestation of the intestine out of stoma itself. How care should be made to the care of stoma hygiene, reduce the a nxiety of the stoma; ask ostomate to lie supine and check color of the stoma and signs 22 necrosis, hemorrhage and ulceration, and engaging the stump with bandages soaked in dextrose 30%, when there is swelling or saline if there is swelling. Wait a few minutes and with the help of middle finger and index finger, hold the intest inal stump and cut with the thumb. After reduction, the stoma should remain lyin g down for 30 minutes; teach ostomate bolster / compress the abdomen when you co ugh, sneeze or do work; equip with two-piece system, given the size by the possi bility of outsourcing in the stump; teach ostomate doing manual reduction; go to a surgeon. Shrinkage: when there is deepening of the stoma. Care should be made to the care of stoma hygiene, using one device convex / moldable; go to a surgeon. Bleeding stoma: when there is bleeding from the stoma. Us Care must realize the care of the stoma hygiene; procedese normally if a haemorr hage; forward to the surgeon, if bleeding continued. 5.3 - Patient Education Ostomized Patients The teachings of the stoma patient start on pre-operative, with the patient's pe rception of what it knows about the surgery, why and how this will be done there after, may not forget to answer any questions that the person has ( Correia, 200 7). Not always this process of change, it makes for a quiet and taking this into account, the teachings postoperative should be started when the person is more receptive to them, so you can learn them and use them to greater autonomy in the care, achieving a better quality of life possible (Cooper, 2007). 23 Teaching for high patient is done by nurses, this being the coach with more resp onsibility in teaching about the care of the stoma. Education facilitates the pr ocess of acceptance of the ostomy, as part of the patient himself. This training should be started as soon as possible, always involving the patient, family, or people who the patient considers important. It should continue to be assessed a nd their effectiveness: assessing knowledge and whether the patient is autonomou s and able to care for your stoma at home (Serrano & Pires, 2007). In addition t o all education verbal and practical demonstration of care, nurses should also p rovide additional material and literature to the patient and inform you about su pport services available in the community (Portuguese Association of Ostomates) as well as reimbursement and other benefits that entitled to enjoy (Serrano & Pi

res, 2007). The patient should, after discharge from hospital, going to appointm ents for follow-up and there will be an evaluation of your stoma, you will be ma de teachings and could ask questions (Serrano & Pires, 2007). The teachings of the postoperative patient are to be performed (Cooper, 2007; Lo ureiro & Fernandes, 2007; Phipps, Sands & Marek, 2003): 1. Choose Device According to the anatomical location of intestinal stoma at t he fecal characteristics are different. Thus, the choice of the device must take in to account these characteristics. The nurse must explain to the patient again th e physiology of the intestines. should also take into account the patient's age, is a carrier of defects physical, mental, person living alone, whether active or retired and has time fo r himself. The material chosen must meet certain characteristics, such to remain closed at least 24 hours, providing security day and night and be easy to handle, comfortable, 24 allow freedom of movement, should be small allowing the use of fashionable cloth es and even bathing suits; isolate noise and smells, do not irritate the skin an d the stoma; easily obtained in various sizes. The nurse should inform the patient about the types and models bag on the market, allowing it to try, so that you can choose what will be most effective in your case, should inform the patient that there are two types of sy stems for disposable bags with skin barrier: the system with a part, where the b ag is adapted to a base of protective skin, adhering to the skin itself, having to remove the entire assembly when necessary;€the system of two plays in which t he bag is separated from the plate, taking the advantage of changing only the ba g when necessary and may keep the card while it is well suited, which turns out to be not so aggressive to the peristomal skin frequent change of the plate. The re is also reusable bags that are cleaned and used again and drainable bags that are easier to keep clean, both systems are available in single and double plays . It is important for the patient correctly measuring the stoma in each changing bag in the first weeks after surgery. Outer parts, cut, of different di ameters are included in the box of bags. Skin barriers are cut approximately 3 m m more than the stoma to adapt to the stoma swollen. Later in the first year, th e size of the stoma is occasionally re-evaluated to ensure a perfect fit. The control of odor, the bags typically have a filter coal on top, which deodorizes and releases gas if you do not have the patient ma y choose to put deodorant tablets or solutions to eliminate odors. 25 should also tell you do not need to buy the material, because with a prescript ion you can contact the health center or pharmacy, ordering the material you nee d and they will give it to them free. However, this option should be taken by the patient according your needs. 2. Change Device → The teaching begins with the first replacement of the bag. Th e patient may

or not prepared to see the stoma, but the nurse should encourage the patient to slowly look at the ostomy and touch it. The nurse should explain briefly and obj ectively each step of the procedure. It should also remind the patient that the stoma has no sensitivity to touch, but the rest of the abdomen is still sensitiv e and painful due to surgery. The pain should be carefully checked before each t eaching session. → Before you start changing the ostomy bag, the person must prepare all material, you will need during the care of the stoma and skin hygiene. Cut t he plate / bag according to the diameter of the stoma is important to avoid cont inuous contact with the skin from feces peri-stomal. → Remove the bag of feces s hould be performed from top to bottom. → Place a paper over the stoma, while per forming another activity, avoiding the exit of feces. → A skin cleansing should be done with soft toilet paper and warm water, and we can use a pH neutral soap, to remove feces that may have been in the area. → Dry skin with gentle movements, and without rubbing, using paper towel or soft. Carefully evaluate the skin surrounding the 26 stoma and the stoma for signs of irritation or infection. If necessary the epila tion of peri-stomal area, do it with scissors rounded top, avoiding the use of r azors, which may cause the injuries and the increasing vulnerability to follicul itis. → You can use a skin barrier, when the skin is peri-stomal is macerated with lesions or with folds, which protect the skin. Although no sci entific studies proving its effectiveness, application of egg white, slightly be aten gives good results. Its justification can be related to the known function of proteins in tissue repair. The use of a skin barrier is an important means of protecting the peri-stomal skin. How can we have skin barriers: the powder, whi ch is applied to the skin should be sealed because the setting does not allow th e bag to the skin, the pulp, used to fill wrinkles and folds around the stoma an d additional barriers skin for a more durable seal; skin barrier discs: they can be used in a variety of bags and protect the skin from feces, and the opening i n the disc is carefully measured so that it fits the base of the stoma without c ausing friction inside or up the stoma; Skin sealants: there are in the form of sprays, liquids, gels and lotion net, these products seal and coat the skin with a thin film, and working under the bags and adhesive when the adhesive is remov ed from the skin thin film is also removed. → Remove the protective role of the device (card / bag) to apply, and fix upwards, compressing the abdominal muscles to make it easier to apply and massag ing it to get a good grip. → To see if the bag is properly fixed, the patient must pull slightly the bag and if it does not leave is because it is well placed. → The bag should be emptied when there is a third or half of its capacity, with st ools or more often if there is excess gas. 27 3.€The Food ostomate not need to have a special diet, you should keep that previ ously had surgery, but should have some general care: - It is recommended that i t go trying a new food different each time, so as to determine their effect - Ch ew your food well, because it facilitates digestion and reduces flatulence - Eat regularly - Have a varied diet - Increase water (especially in ileostomizados b ecause 90% of stool weight is water) - According to their own situation, control the intake of foods: •

Cause constipation, such as rice, bananas, potatoes, dried fruit, applesauce; • Cause diarrhea, such as milk, beans, watermelon, fig, kiwi, strawberries, vegeta bles, oranges, beer, plums; • Increase the smell of faeces, alcoholic drinks, asparagus, onion, garlic, fish, cheese, cabbage, eggs, coffee, pears, beans; • Reduce the odor of feces, as spinach, parsley, green vegetables, lettuce, yogurt , butter; • Cause flatulence, for example, carbonated drinks, beans, peas, sweet potatoes, c auliflower and broccoli, melons, mushrooms, chocolate and cakes, onion. 28 4. Clothing If the stoma is well located (or is well marked in the preoperative period), there is no need to change clothing. In case during surgery, not being able to avoid the waist line, it should be advising men to that instead of belt, which can traumatize the stoma, use braces. One can use strap, if you feel more comfortable, since it is not too tight. 5. Travel When a person goes on vacatio n with colostomy, should take a larger quantity of bags to which uses the same t ime, because with the change of location, can lead to change in bowel habits. Wh en traveling by plane the user must carry bags in the trunk of hand because ther e may be a lost bag that is in the basement. Regarding the use of seat belts tha t should be used under the same or higher than the stoma to prevent rubbing or p ressure that can damage it. 6. Sex Life A person with an ostomy can have normal sexual life. However if ther e is damage to the pelvic nerves may arise dyspareunia in women and in men a deg ree of impotence. This degree of impotence is related to the magnitude of the in jury, causing different manifestations. The user can change the bag before sex, choose to switch to a mini-bag or cover the bag during intercourse. The couple s hould explore positions for sexual intercourse, which minimize the stress and pr essure on the bag. It should not have sexual relations by stoma. In case of preg nancy, the fact of having a stoma does not affect the baby or their own they sho uld be accompanied by professionals from the preconception. There should be unde rstanding and good relations between the two partners, trying to overcome diffic ulties, fears and insecurity. 29 7. Sport The stoma can practice exercise, however if violent contact sports (lik e boxing, rugby ...), you should use a protective nut on the stoma. In physical activities, one can use strategies such as those mentioned above (changing bags, use of mini-bag). 8. The Tax Benefits ostomates have several benefits, which are legislated and in force in Portugal, as in: - Purchase of vehicles (Decree-Law no. 103-A/90 of Ma rch 22) - Structuring Pensions (Decree Law no. 92/2000 of May 19) - Acquisition of Housing (Decree-Law no. 230/90 of July 16) - Holiday (Decree-Law no. 321-B/90 15 October) - Exemption fees and reimbursement on the purchase of prostheses / orthoses (Decree-Law no. 54/92 of April 11) - Flexibility of working hours (Decr ee Law No. .159/96 04 September).

9. Complications education about the complications is also important, because ju st knowing the changes, you can use the appropriate bodies if necessary. Some of the most common complications are mechanical or allergic dermatitis, folliculit is, granulomas, prolapse, stomal retraction, stenosis, peristomal hernia, bleedi ng, infection. 30 10. Support for Positive Self-Esteem The formation of a stoma is seen as a mutil ation, and most patients need time and help others to cope through their feeling s. The removal of any part of the body involves a feeling of loss and heartbreak . The nurse should encourage the patient to express these feelings of loss and n ot suppress or minimize. The resolution of grief is not a quick or easy process and will not be achieved during hospitalization.€Patient and family need to be w arned that the resolution may take as long as a year or more and can impede the return to independence in self care. The nurse encourages the patient to observe the stoma and care for him in a natural way. This gives emotional support at al l sessions of self-care, helping the patient to express himself. It also encoura ges the patient to resume their daily activities without any restrictions. 11. Irrigation Ostomy An ostomy irrigation is an enema administered through the stoma to stimulate intestinal emptying, with regular time intervals and appropri ate. The procedure is not recommended routinely and is only used in the sigmoid colostomy, which expel stool shaped. Irrigation is never part of routine care of an ileostomy, because the drainage is continuous and semi-liquid. A patient who makes irrigation successfully, may be able to dispense an ostomy bag and use a stoma cap, a small bag with an adhesive absorbent dressing. Since the ostomy con tinues to secrete mucus and free gas is a desirable filter gases. If irrigations are planned, they begin about 5-7 days after surgery, but can only be explained and held at a later stage, in clinical follow-up. Several are available 31 equipment and most sets include an irrigation hose, a cone to enter the stoma, a bag to contain the solution and to close the hose clamps. The procedure is idea lly explained in the bathroom. Cramps during an irrigation can be caused by the instillation, too fast, water or solutions that are too cold or too hot. The flo w should be interrupted until the cramps disappear. Irrigation is done as follow s: Equipment - container for water, irrigation hose, belt, articles for skin car e, new bag system, ready to use, remove the used bag and put in the trash, the C lear the stoma and by around the stoma with water and assess; Apply irrigation h ose and belt; Putting the end of the hose in the toilet, fill the container with irrigation 500-1000 mL of tap water and warm suspend the container at shoulder height, the Making runs water through the tube to remove air, the gently introdu ce the stoma cone irrigation and slowly start the flow of water. The probes are introduced to no more than 50-10 centimeters. Do not force. If cramps occur, sto p the irrigation and wait, the wait for about 15-20 minutes of leaving the feces , the Rinse the hose, dry basis, Erol up and close the end. The patient should d o regular exercise for 30-45 minutes, remove the hose, clean the stoma and apply the new bag, the Clear and keep the irrigation system. 32 6 - Conclusion In conclusion I can say that the objectives of the study were achieved. Can I co nclude that to care for a patient with ostomy disposal is necessary to know what types of ostomy disposal exist. You must also know what the indications for whi ch they are determined ostomy. To care for an ostomy is necessary to know what t he complications that can arise, as both early and late specific to ileostomy an d colostomy. It is also essential to know which nursing care to be provided in p re-and postoperatively, and the education being provided to a patient stoma. It was very gratifying to me to make this work, because I could understand the diff erent types of ostomies disposal that and understand a little more of the care o

f these ostomies. In short it is expected that this work may have contributed to a clarification on the elimination of ostomies, what are their specific indicat ions, complications, precautions, pre-and postoperatively and the patient educat ion and thereby help improve the care provided to people with ostomies disposal. 33 34 7 - Bibliography Atkinson, L. D., & Murray, M. E. (1989). Fundamentals of Nursing. Rio de Janeiro : Editora Guanabara Koogan.

Cooper, R. F. (November 2007). A person with Intestinal Stoma Elimination ... Te achings that? Vital Signs Magazine, No. 75, pp. 29-32.

Hallouët, P., Eggers, J., & Malaquin-Pavan, E. (2006). Bookmarks Nursing (1st Ed ition). Lisbon: Editorial Climepsi.

Hood, G. H., & Dincher, J. R. (1995). Fundamentals and Practice of Nursing: Pati ent Care Complete (8th Edition). Porto Alegre: Editora Artes Médicas.

Loureiro, O. M., & Fernandes, A. M. (September 2007). The Sick ostomate. Vital S igns Magazine, No. 74, pp. 33-37.

Phipps, W., Sands, J., & Marek, J. (2003).€Medical-surgical nursing (6th edition ). Loures: Lusociência.

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Serrano, C. M., & Pires, P. M. (July 2007). Nurse and Patient ostomate. Vital Si gns Magazine, No. 73, pp. 48-52.

Slater, I. (November 2002). Nursing the Patient ostomate. Reference Journal, p. 80.

Suzanne C, S., & Bare, B. G. (2005). Treaty of Nursing medico (10th Edition, Vol I). Lisbon: Editora Guanabara Koogan.

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Swearingen, P. L., & Howard, C. A. (2001). Photo Atlas of Nursing Procedures (3r d Edition). Porto Alegre: Editora Artmed. 36