Background: Taking into consideration the needs inherent in the new health-disease state, stoma marking can be a turning point in the whole process of transition. Thus, can be considered a factor inhibitor or facilitator, in part due to how it is diagnosed, seen and experienced.

Objective: Understand the impact of preoperative stoma marking in context to patients undergoing colorectal surgery.

Methodology: Bibliographical research, followed by analytical reading of selected articles and use of the theory of Afaf transitions as theoretical support.

Results: The analysis of the scientific evidence, this orients to the recognition of the needs inherent to the candidate the ostomy.

Conclusion: Preoperative marking of stoma in context is of great importance as it allows a diagnosis prior to planned nursing interventions associated with a contingency plan facilitates the healthy transition process, resulting in health gains.

 Keywords: ostomy, preoperative care, stoma site marking

Over the years, studies have been developed in order to understand the impact that an ostomy has on a person's quality of life, the difficulties experienced by the person with an ostomy and their family, the information they expect to receive from professionals and the resources they can find in the community. Being aware of the dimension of this problem, present in my daily clinical practice, the need arises to understand the impact of stoma marking in the preoperative context on patients undergoing scheduled colorectal surgery.

To this end, I propose to identify good practices; identify existing gaps and analyze improvement measures.

Bearing in mind that in order to develop a professional action that facilitates living with this reality, it is essential to know the impact on the self-care of the person with an ostomy, given the health-disease transition process, it seems appropriate to refer to the Afaf Meleis Transitions Model.

Due to the amount and complexity of information currently produced in the health area, it is clear that it is essential to gather the best possible evidence, which answers a clinical question that needs to be clarified, taking into account the validity and relevance of the evidence found. Stoma marking in the preoperative context is of great relevance because despite the fact that it is a patient's right, it is proven that the stoma well located in the abdominal wall contributes to a more effective postoperative recovery, minimizing the occurrence of complications, facilitates self-care activities in addition to enabling early social reintegration, thus facilitating a healthy transition process.

Hospital Professor Doutor Fernando Fonseca EPE (HFF), where I work, was recently recognized as a Reference Center in the treatment of rectal cancer¹, with the consultation of stomatherapy contributing to the realization of this recognition.

A center of reference, encompassing all aspects inherent to it and requiring the concentration of highly specialized resources and recognized merit, it allows offering patients excellent care adapted to their needs.

If, on the one hand, we have at our disposal all the necessary tools to acquire an excellent clinical practice, on the other hand, we have the challenge of meeting very high expectations.

People with ostomy face important obstacles, including self-care due to physical limitations, financial constraints, emotional and social support, and sooner or later these people experience moments of great relational fragility due to the health-disease transition process. In this assumption, there are factors that can act as facilitators or inhibitors of an effective transition, and nurses perform an important job in facilitating the passage through this life transition and can influence the transition processes if their intervention is centered on the person and their real needs.¹ The nurse, due to the proximity to people, deals with various transition processes and is the main caregiver of people in transition, promoting and encouraging the acquisition of new knowledge and learning skills and abilities related to the situation experienced, providing a better adaptation.²

¹ Dispatch 3653/2016 – Reference Centers’ recognition

Based on the research question and considering the knowledge I intended to synthesize, I conducted a literature review, according to the descriptors: ostomy; preoperative care; stoma site marking; children. I used the Boolean characters AND and NOT to combine the different descriptors. The bibliographic search was carried out between April and June 2016, using national and international electronic databases for this purpose, using specific search engines in the databases available in the health area, namely PubMed, EBSCOhost and b-on. Works published in the last 8 years were selected, with an abstract available and using English as the language of choice.

Scientific papers that addressed the ostomy in a preoperative context were included; with full text available and that answered the guiding question of the study. I used as an exclusion criterion age less than 19 years and works whose theme was centered on the approach to ostomy made in emergency situations.

The existence of a specialized service for education and monitoring of people with ostomy, makes it essential for nurses to have a greater awareness of the important role they play, by interfering in the privacy space of people dependent on their interventions. Even so, there is an area that needs urgent development - the preoperative consultation. All candidates for a scheduled ostomy should have adequate information and follow-up to enable them to prepare for impending changes, including a stoma site marking (anticipating the appearance of future complications). In national and international nursing, nurses need to overcome different barriers to the use of research results in clinical practice.

Of the fifteen hundred and fifty scientific productions obtained initially, after applying the inclusion and exclusion criteria, I obtained a set of fourteen articles that were analyzed carefully, in order to perceive the impact of the stoma marking. This work made it possible to highlight the added value most frequently expressed in the scientific literature, in order to provide possible guidance for nursing practice with greater quality and efficiency in relation to the marking of the stoma. Effective communication by the multidisciplinary team should result in an early referral to Stomatherapy. Family support appears as a facilitating factor. The economic factor that makes it more difficult, as well as the associated diseases, the family problems inherent in their life path, the daily impact with the multiple limitations to their performance in self-care.

Capital gains can be called into question if there is no training of the team with specific knowledge and which guarantees assistance every day of the week. Taking into account the scientific productions produced and the interest of this topic in the Portuguese context, it becomes interesting to elaborate the same type of analysis, starting from the same research terms, but in the Portuguese reality.

The opportunity exists to promote successful adaptation in this surgical population through the implementation of interventions based on evidence of preoperative education and stoma marking.

Time is required for surgical preparation, time that is sometimes lacking in inpatient services, so it must be done in an outpatient setting in order to achieve a methodical process and the desired result, while having the opportunity to make a difference for the user.

Getting the stoma experience right is vital as it allows for healthy management that is of paramount importance.

The time spent in the ideal location of the stoma will guarantee good results in the long run.²

Preoperative marking of the stoma is crucial to improve the quality of life of users in the postoperative period, promoting their independence and reducing the rates of postoperative complications.

Despite the relevance of preoperative stoma marking in preventing postoperative complications, not all health institutions have adopted this practice.

Institutions with stoma therapy consultation should:

• Increase the preoperative aspect in your clinical practice;
• Increase the number of nurses with knowledge and skills in the area of ​​stoma and wound care;
• Develop teaching programs with appropriate teaching material in order to increase awareness, knowledge and skills.

In all surgeries that may result in the creation of a stoma, the user has the right to a preoperative consultation to mark the stoma site.⁴

Preoperative education and stoma marking are supported by research and included in the guidelines of clinical practice.

Despite the large number of surgeries performed and the increasing number of specialists involved, complications are still very common.⁵

Significant risk factors for early stoma complications were identified: type of stoma; stoma length; body mass index; emergency surgery and lack of preoperative marking.

A study was carried out in 2014 that addresses the location of the stoma related to the anatomy of the abdominal wall and its correlation with posterior herniation rates.⁶

The results of another study confirm that the location of the stoma must be marked preoperatively in all scheduled surgeries in order to reduce the risk of infection and postoperative complications.⁷

There are measures that can be taken to decrease the potential for peristomal skin problems, namely through preoperative consultation where the location of the stoma is marked - a critical component to generate positive results as well as conducting preoperative education - component fundamental in the care of the stoma and its management.^9,10

Preoperative stoma marking contributes to better postoperative recovery and reduced mean delay. The preoperative consultation applied to patients with or without a stoma also produces similar effects. Therefore, preoperative evaluation is imperative in scheduled surgery.¹¹

Intestinal surgery that results in the formation of a stoma is designed to improve the condition and quality of life of users. However, the creation of a stoma produces changes not only in physical appearance but also in function.¹² A poorly positioned stoma will result in complex ostomy management problems that lead to a lack of confidence restricting social life, which can result in psychological frustration and possible social isolation with obvious impacts on quality of life.¹³

The role of the stomatherapist is complex, often extending to different specialties and as such can occasionally be misinterpreted by others with less experience or understanding of the role. The existence of a clinical pathway for stoma care provides a framework for providing high quality care based on evidence and research.¹⁴ The stoma therapist is in a privileged position to increase the knowledge base and evidence-based practice for other health professionals.¹³

The major objective of the stomatherapy preoperative nursing consultation is that it serves as an instrument to improve the quality of life of the person with an ostomy, enabling an efficient learning of self-care. The monitoring of these users must be done individually, planned and systematized, allowing a better understanding of the ostomy and its treatment, which will have beneficial effects upstream. Although articles on this theme have been growing, additional research is still needed to prove its effectiveness and produce evidence that pre-operative nursing consultation in stomatherapy should be regulated and implemented in hospitals that manufacture stomata, essentially when recognized as Reference Center for colorectal surgery. This suggests that new strategies are needed to improve the rate of preoperative visits, stoma location, specific information and participatory teaching.

Taking into account the needs inherent to the new state of health-disease, the stoma marking can be a turning point in the entire transition process. Thus, marking the stoma can be considered an inhibiting or facilitating factor, partly due to the way it is diagnosed, viewed and experienced. Validated the importance of nursing consultation with the inherent stoma marking and believing that nurses are concerned with the implementation of practices that offer safe and quality conditions for the performance of their activities, it becomes necessary to question established routines, essentially in what the preoperative phase concerns. Decision making in nursing needs to be based on several principles, hence it is necessary to develop a reflective practice, "Nursing care, materializes in acts (or omissions) that result from decisions with fundamentals of different nature".¹⁵

Attentive and proactive professionals are required to reinforce the attention to the most vulnerable users, anticipating needs and including the family in the training / information process. The ultimate goal is to provide a unique and quality nursing care, focused on the user's needs and improving their quality of life, thus contributing to the acquisition of Health Gains.

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1. Meleis. Experiencing transitions: an emerging middle-range theory. Advance Nurse Science. 2000;23(1).
2. Meleis AI. Transitions theory: Middle range and situation specific theories in nursing research and practice. New York, NY: Springer. 2010;ISBN: 978-0-8261-0535-6.
3. Cronin, Elaine. Stoma siting: why and how to mark the abdomen in preparation for surgery. Gastrointestinal Nursing. 2014.
4. Baykara ZG, Demir SG, Karadag A, et al. A multicenter, retrospective study to evaluate the effect of preoperative stoma site marking on stomal and peristomal complications. Ostomy Wound Manage. 2014.
5. Watson AJ, Nicol L, Donaldson S, et al. Complications of stomas: their aetiology and management. British Journal of Nursing. 2013.
6. Al-Momani H, Miller C, Stephenson BM Al-Momani H, et al. Stoma siting and the 'arcuate line' of Douglas: might it be of relevance to later herniation? Colorectal Disease: The Official Journal Of The Association Of Coloproctology Of Great Britain And Ireland. 2014.
7. Welyczko Nikki. Is the preoperative stoma site always marked? Gastrointestinal Nursing. 2014.
8. Stelton S, Zulkowski K, Ayello EA. Practice implications for peristomal skin assessment and care from the 2014 world council of enterostomaltherapists international ostomy guideline. Adv Skin Wound Care. 2015.
9. Stelton S, Zulkowski K, Ayello EA. Practice implications for peristomal skin assessment and care from the 2014 world council of enterostomaltherapists international ostomy guideline. Adv Skin Wound Care. 2015.
10. Cronin E. What the patient needs to know before stoma siting: an overview. British Journal of Nursing. 2012.
11. Burton Julie, Allison Joanna, Smart Neil, et al. Impact of stoma care on enhanced recovery after colorectal surger. Gastrointestinal Nursing. 2011.
12. Noone P. Pre and postoperative steps to improve body image following stoma surgery. Gastrointestinal Nursing. 2010.
13. Preece Vicky, Pearson Trudi. Stoma site selection: getting it right for the patient. Gastrointestinal Nursing. 2015.
14. Davenport Rebecca. A proven pathway for stoma care: the value of stoma care services. British Journal of Nursing. 2004.
15. Deodato, Sérgio – Supervisão de cuidados: uma estratégia curricular em enfermagem. Revista Percursos. Nº18; 2010. p.3-7. ISSN 1646-50-67.