Impact of Nursing Intervention on Urostomy Patients Outcome Regarding Practicing Self-Care

Urinary diversion operations (urostomy) patients require a great deal of emotional and physical adjustment. They usually face many problems such as loss of body function and relationship with others, and change in lifestyle. They need to adapt to the external appliance, stoma alteration in toileting habits, skin irritation problems, infection, and odor problems. Selfcare for these patients is considered the most important factor that can minimize the complaints and complications. The aim of this study was to evaluate the impact of nursing intervention among urostomy patients regarding practicing self-care. The sample comprised 100 urostomy patients, divided into two groups: 50 study, and 50 control. For both groups, patients’ knowledge about urostomy and related self-care performance were assessed before intervention, immediately after, and after six-months follow-up at outpatient clinic. Data were analyzed using Epi-info 6.04 computer software package. Findings revealed statistically significant improvements in knowledge and performance among patients in the study group, compared to the control group. The study group became more knowledgeable about the definition, function, anatomy, and physiology of urostomy, and in self-care performance. The rates of complaints and complications were found to be lower in the study group than in the control one. The study suggests that urostomy patients should receive their self-care training regarding urostomy during hospitalization. Follow-up at outpatient clinic is highly recommended as well.


INTRODUCTION
Bladder cancer is one of the most common diseases treated by the urologists.
It is the second most commonly occurring genito-urinary cancer in adults.In men, it is the fourth most common cancer after prostate, lung, and colorectal cancers, while in females bladder cancer is the eighth most common type of cancers (1)(2)(3).
In Egypt, there is a high incidence of bladder cancer.
It is generally categorized into bilharzial and nonbilharzial types.Bilharzial type is prevalent in rural areas, and affects adult males.These patients usually present for Bull High Inst Public Health Vol.37 No. 2 [2007]   treatment at an advanced stage of the disease, and its pathology is commonly squamous cell carcinoma.On the other hand, non-bilharzial bladder cancer is observed among elderly patients who may present for treatment with transitional cell carcinoma (4,5).
The word urostomy signifies a type of surgery required when a person has permanent or temporary loss of the normal function of the bladder or bowel due to birth defects, cancer, injury, or other diseases (6) .The surgery allows for normal bodily wastes to be expelled through a new surgical opening urostomy on the abdominal wall.Most persons with ostomies wear special appliances over the stoma (7) .
Following urinary diversion operations, patients require a great deal of emotional and physical adjustment.They usually face many problems such as loss of body functions and relationship with others, altered sexuality, and change in lifestyle.They need to adapt to the external appliance, stoma, alteration in toileting habits, and urinary drainage, in addition to skin irritation problems, urinary tract infections, and odor problems (8,9).accepting stoma, and doing irrigation (10) .
Recently, there has been a growing realization and awareness of the importance of patient self-care concerning their surgical ostomy on discharge from hospital (11) .
Self-care for urostomy is considered the most important factor that can minimize the complaints and complications rate, as well as providing good health status.These patients have important tasks and responsibilities through hospitalization and at home.
They should be taught how to manage and minimize the complications (12) .
Nurses play a vital role regarding cystectomized patients.This roleincludes monitoring acute reaction, follow-up care of these patients, and providing education, counseling and support as the patient faces urinary diversion (13) .Also nurses play an important role to help these patients to cope and adapt to their illness.For this, nurses have to develop intervention programs that take the form of psychoeducational preparation aimed at helping the patients to develop acceptance of self despite the disability, to enhance their knowledge for effective coping strategies, and to increase their selfesteem and sense of control (8,14) .

Study aim:
The aim of this study was to: 1. Assess urostomy patients' knowledge and self-care practices related to urostomy before implementation of nursing intervention.

Evaluate the effect of nursing intervention on urostomy patients'
outcome in practicing self-care.

Research design
A quasi-expermental design was used in the conduction of this study, with comparison of the outcomes between study and control groups immediately after nursing intervention and at 6-month follow-up.

Setting
The study was conducted at the scoring, the responses "agree", "uncertain", and "disagree" were respectively scored 3, 2, and 1.The scoring was reversed for negative statements.The scores of the items were summed-up and the total was divided by the number of the items, giving a mean score.These scores were converted into a percent score.
The attitude was considered positive if the percent score was 60% or more, and negative if less than 60%.

The nursing intervention:
A self-care practicing was developed based on patients' needs assessment The content of the nursing intervention was developed after reviewing related literature (17,(22)(23)(24)(25)(26)(27) .The prepared material was then translated into Arabic.The

Statistical analysis
Data analysis was done using Epi-Info 6.04 computer software package.Data were presented using descriptive statistics in the form of frequencies and percentages.
Qualitative variables were compared using   and obstruction of the urinary bowel (6) .
Yet, when the physician first mentions an ostomy, every patient without exception has fears and worries about how to adapt to this change (28) .
Thus, the construction of the urostomy activities (29) .Prevention of such problems often requires education and health promotion strategies.The nurse can have an important role to play as a wound ostomy continence nurse (28) .
This study was carried out to develop term change in an individual's lifestyle and compliance with new patterns of behavior requiring a life long process of self-care.Various studies have shown that nearly half of long-term urostomy patients do not comply with self-care, such as diet, actual situation, it was obvious to the researchers that urostomy patients and their family members need to know as much as possible about this treatment modality, and the related selfcare.To the best knowledge of the researchers, some studies were done in Egypt for assessment of nurses' knowledge and nursing interventions for postoperative urology and abdominal surgeries.However, no studies were done on self-care for urinary diversion patients.

1 . 3 . 4 . 6 . 7 .
This study was conducted through a period of six months from October 2005 to March 2006.2. 5 senior faculty experts in the field judged the questionnaire , and self care performance check list .Obtaining the official permission to conduct the study, as well as the consents from patients to ensure their willingness to engage in the study after explaining its purpose and nature.Nursing intervention design and planning, with the objectives, teaching methods, and media to be used.5.A pilot study after development of the data collection tools.This was carried out on ten patients to test tools feasibility and applicability.Implement the nursing intervention for the study group members.This was in the form of a two-hour session per day.The session started with theoretical background followed by practical information.The total number of sessions was five, totaling to ten hours for the nursing intervention.Different teaching/learning activities were used during individual training, including discussion, demonstration, and redemonstration.Real urostomy appliances were used for training.Handouts such as booklets, pamphlets, and posters were also prepared and used by researchers.For the control group, hospital care and procedures were applied.They were practicing their own self-care according to Estimation of the effect of the nursing intervention on practicing self-care.This was done immediately after the intervention implemented and six months later.8. Patients in both groups were asked to come to the outpatient department to assess their self-care performance, and to record any complications.The visits were also used to provide a booster dose of health education to the study group members.9.The effectiveness of nursing intervention was evaluated using the same tools in both groups at discharge and at the 6-month follow-up visit.

Figure 1 .
Figure 1.Stoma problems among patients in the study and control groups throughout the intervention their relationship with themselves and their bodies, their relationships with others, and their participation in social and leisure time

a 30 Nevertheless
nursing intervention for patients with urostomy about self-care and evaluate the impact of the intervention on their compliance in practicing self-care.The study included two similar groups, a study and a control groups.Both groups were composed of patients mostly below the age of forty, predominantly males, illiterate or read and write, married, and working.Also, when patients' knowledge about urostomy was assessed before the nursing intervention, it was closely similar in both groups in almost all areas.After implementation of the nursing intervention, the study group became more knowledgeable about the reason of urostomy performance definition, its function, related basic anatomy and physiology, compared to the control group.These differences were noticed immediately before discharge and six months after the training at the follow-up assessment.The differences were all statistically significant.Although the knowledge levels have demonstrated some slight declines at the follow-up, they remained quite high, compared to baseline levels.These results are in agreement with(7) , who have also highlighted the importance of sound knowledge among urostomy patients to help them coping.They have stressed that accurate description of urostomy appearance helps ease shock at the first sight of it after ostomy surgery.To engage in self-care activities, the individual must have the knowledge, ability, and skills to initiate and sustain self-care efforts.The improvement of patients' knowledge in the present study was associated with better practice of self-care activities.Thus, findings of the study highlight the significant educational role that the nurse can achieve to improve patients knowledge and practice as regards urostomy selfcare.The remarkable increase in knowledge and improvement in practice about cleaning stoma and monitoring and reporting any abnormalities among study group patients points to their urgent need for such information, which was provided to them through the nursing intervention.Hampton et al., and Patwardhan have emphasized the importance of training patients in monitoring the color, size and shape of stoma for early detection and prevention of complications. 30,31According to the present study findings, patients in the study group have retained most of their knowledge and learnt skills six months after the nursing intervention at the follow-up.The study group members were able to successfully and independently assemble all materials needed, remove the old appliance and put it, clean stoma and dry it gently, prepare the appliance and empty it correctly, and irrigate the stoma.This success might be attributed to the guidelines provided to them through individual training of patients using simple and attractive media, and simulation techniques.In this respect, Doughtily et al., have stressed the importance of teaching basic stoma care principles to enhance patients' sense of control over the situation. 7Attitudes are usually shaped by knowledge, and do influence practice.The importance of self-care as an indication of positive attempts to cope with changes has been emphasized.In the present study, statistical significant improvements were revealed in patients' attitude towards urostomy in the study group, compared to the control group after nursing intervention.This could be attributed to the role of acquiring information about the procedure in helping patients cope with the new situation.In agreement with this, Hampton et al., have emphasized that patients' knowledge of structure and function increases their confidence, produces control, and reduces anxiety related to altered body function.not reached statistical significance, compared to control group.This is quite expected, since attitudes are difficult to change, especially as regards acceptance of stoma, which undoubtedly affects the body image negatively and permanently.As mentioned by Metcalf, patient needs time to heal, to learn how to manage the urostomy, and to mentally adapt to these changes. 32Contrary to common fears of people from ostomy, it almost always improves the quality of life for the patient by correcting the previous serious debilitating condition (6) .This was the case in the present study, where both control and study groups have experienced physical and/or psychological complications.However, these complications were more obvious among control group patients, especially skin complications, followed by bowel movement, then psychological disorders.These findings give support top the success of the nursing intervention in improving patientsunderscores the significant role played by nurses as care providers for urostomy patients during their transition from the initial shock stage to acceptance of the fact that they 32.Metcalf C. Practical aspects of stoma care.Best practice.Nursing Times.

(15-17) .
converted into a percent score.The practice was considered adequate if the percent score was 60% or more, and inadequate if less than 60%.Part three, to assess patients' attitude towards the urostomy and its appliance.It involved statements related to care of urostomy, daily life activities with urostomy, as well as acceptance of the stoma.For Bull High Inst Public Health Vol.37 No.2 [2007]