1.
A STUDY TO IDENTIFY THE LEVEL OF KNOWLEDGE
AND SELF CARE PERFORMANCE OF THE COLOSTOMY
PATIENTS AND ITS EFFECTS ON THEIR QUALITY OF LIFE.
Hanan Gaber**, Aida El-Gamil*
*Lecturer in medical-surgical nursing department Alexandria university
**Lecturer in medical-surgical nursing department Banha University.
ABSTRACT
The impact of a stoma on a patients life is little discussed and is
often underestimated, as well as the contribution of stoma therapy to
health-related quality of life colostomy patients were dissatisfied with the
information they received about the colostomy care, complications and
lifestyle changes. Information and counseling for those patients appeared to
be deficient and require continuous evaluation and revision. The study was
carried out to determine the level of knowledge and self-care performance
of the colostomy patients and its effect on their quality of life. The study
was conducted in out patients unit at Institution of oncology and Gastro
enterology Surgery Department at Messratta, Lypia. The study comprised
50 adult patients who performed colostomy and ileostomy within 3-6
months from the beginning of the operation. The study findings revealed
that only half (54%) of subjects were trained about stoma care and 60% of
them received oral instruction by doctors. As regards self-care performance
the highest mean scores were obtained in performing irrigation and removal
of old pouch, moreover a high significant difference was found between the
patient’s knowledge about self-care performance and the majority of quality
2.
of life domains. The study recommended that colostomy patients assessment
of self care performance, knowledge and quality of life is needed, so
specialist ostomy care nurses is particularly important during the first 3 to 6
months following surgery to improve patient’s quality of life.
INTRODUCTION
Physical illness is a multifaceted phenomenon that includes
biological, psychological, social, environmental, familial, psychosocial and
psychosexual factors. It is an existential crises involving issues of identity
and daily life.(1) Stoma patients have a surgically created opening on the
abdomen involving parts of the gastrointestinal tract. Colostomy involves
discharging feces from the large intestine through the surgical opening.
Due to this major change in physical appearance and bodily function,
patients with stoma are challenged with a number of quality of life (QOL)
issues.(2)
Various studies have shown that, the colostomy patients were facing
many problems after colostomy operation due to lack of knowledge, preoperative preparation and post operative management. So, those patients
were suffering from direct and indirect complications. It may be related to
stoma itself as stenosis prolapsed, retraction, stomal necrosis, laceration,
bleeding and parastomal hernia.(3) Furthermore the bowel alteration as
diarrhea, constipation, impaction of stool and/or excessive gases consider
source of problems for ostomy patients. As well as skin irritation, irrigation
of colostomy and application of pouching system correctly, problems of
3.
leakage and/or presence of bad odour.(4) Additionally, the presence of stoma
itself considered as a big problem which affects the body image of those
patients and create a psychological problems.
As regard the deprivation of normal control and alteration in physical
appearance can have profound psychological impact. The fear of offending
others because of the malodorous secretions and physical disfigurement can
make ostomates avoid family and friends.(3) The coping with new lifestyle
need to compliance with new patterns of behavior requiring a life long
process of self care. Self-care for stomates is considered the most important
factor that minimizes the complains and complications rate as well as
providing good health state.(5)
Previous studies have ensured that patients with a colostomy have a
poorer quality of life, and found that a stoma operation causes profound
changes in a patients life because of resulting physical damage
disfigurement, loss of bodily function, change in personal hygiene
restrictions in their level of social functioning and sexual functioning
impairment. Such changes are a cause of major concern for patients and
raise important issue for quality of care.(6,7)
Moreover, quality of life is an important issue for patients with
stomas. They have undergone mutilating surgery that can cause permanent
change in body image and affect quality of life. Most patients who receive
stoma surgery have colorectal cancer, therefore, they have to cope with
having cancer as well as the impact of extensive surgery, both can
4.
significantly influence quality of life. Enterstomal therapists help such
patients come to terms with their situation and help care for them
throughout their life with a stoma.(8,9)
Clients will experience emotional and psychological changes after
ostomy surgery, when instruction is provided to clients and their families
effectively, it promotes understanding, instills confidence and increases
clients ability to manage indepently.(9)
In a study conducted to assess the quality of care in colostomy
patients seen from a patients perspective, it was found that vast majority of
colostomy patients, rated many aspects of their quality of care as
unsatisfactory and they were dissatisfied with the information they received
about the colostomy care, complications and lifestyle changes.(10)
Another study done by turns, revealed that information and
counseling for patients having ostomies, both on the part of specialist
nurses and colorectal surgeons, appeared to be deficient, suggesting that
standards for quality of care require continuous evaluation and revision.(11)
Naget confirmed that colostomy has a profoundly negative impact on
QOL. Specialized counseling of these patients by a dedicated team
improves QOL significantly.(12)
An instrument of measurement in the clinical setting, QOL is defined
functionally by patient’s own perceptions of their performance in physical,
occupational, psychological, social, financial, and somatic areas.(4,5)
5.
Nurses caring for individuals with colostomy have an important role
to play in relation to information provision and reassurance. This nursing
role in the management of patients with colostomy has become
increasingly significant within healthcare provision due to increased
incidence and prevalence of this condition. It is important that the nurse
understands the impact that colostomy can have upon an individual. quality
of life.(9) Thus the aim of the present work was to identify the colostomy
patient's knowledge and self care performance and its effect on patient's
qualify of life.
Aim of The Study
 The aim of this study are:
1- To determine the level of knowledge and self care performance of the
colostomy patients.
2- Assess effect of patient’s knowledge and self care performance on their
quality of life.
Materials and Methods
Design
Descriptive research.
Setting
This study was conducted in outpatients unit at Institution of
Oncology and Gastroenterology Surgery Department at Messratta, Lypia.
6.
Subjects
This study comprise 50 adult patients from both sex who performed
colostomy and ileostomy within 3-6 months from the beginning of the
operation and willing to participate were included in the study. All patients
with chronic illness (cardiac diseases, diabetes and renal disease) were
excluded from the study.
Tools
Four tools were included in this study as follows:
Tool I. A questions to assess knowledge of ostomy patientss consists of
two parts
Part 1: It include the personal characteristics of the patients, type
and causes for ostomy, pre and post operative teaching and training was
taken.
Part 2: Questions to assess the patient’s knowledge. It stresses the
definition of colostomy, causes of colostomy, anatomy and physiology,
types of ostomy, complication of ostomy types of pouch and appliance for
stoma as well as questions related to self care. A three point likert scale of
responses was used such as No Understand=0, understand the Basic=1,
Good Understand=2, and Excellent Understand=3.
The total score of the questionnaire was 36 marks: (It comprised 13
sub items)
- Definition of ostomy.
(3)
7.
- Causes of ostomy.
(3)
- Anatomy and physiology.
(3)
- Complication of ostomy.
(3)
- Complications of mucus membrane.
(3)
- Abnormal skin condition.
(3)
- Types of pouch and appliance for stoma and
(3)
- Self care information (5 items).
(15)
Tool II. Self care performance checklist of ostomy patients
It was developed to assess the performance of ostomy self care. It
includes preparation of the pouch, removal of the old pouch, clean stoma
and skin around the stoma, apply the pouch, empty the pouch, clean pouch
and stoma irrigation. Each step of the performance was rated from 0-3 [not
done =0, weak performance =1, acceptable performance =2, and Good
performance =3].
The total score of the self care performance was 93 designed as
follow:
- Preparation of the pouch.
(6)
- Removal of the old pouch.
(12)
- Clean stoma and skin around the stoma.
(15)
- Apply the pouch.
(12)
- Empty the pouch.
(12)
- Clean pouch.
(9)
- Stoma irrigation
(27)
8.
Tool III. Quality of Life Index Instrument (QLII)
This instrument was adopted from Montreux Study.(13) It consisted of
33 items in the quality of life related questions were pooled into seven
domains: psychological wellbeing, physical well being, body image, pain,
sexual activity, nutrition, and social Concerns. Additional questions
measuring patient satisfaction and confidence were pooled into others
domains. The questionnaire can be divided into three main sections: quality
of life (consisting of 22 items in 7 domains).
- Satisfaction (consisting of 6 items in 3 domains).
- Self efficacy (consisting of 5 items in 2 domains).
Each questions is answered on a 6 point rating scale with end points
(from 0 to 5) labeled with opposite extreme responses (such as “none” at all
versus a great deal” “extremely poor” versus “ excellent” and the like).
Experts in jury changed these score to be measured on a 6-point
scale ranging from never =0, often =1, sometimes =2, occasionally =3,
frequently =4 and always =5. Also, the item of improvement integrated into
the area of patient’s satisfaction. Score 0 was allocated to the items
response choice never, indicating greater impact of quality of life. Some
items response choice always, indicating greater impact. The total score of
this instrument was 165.
9.
Tool IV. Stoma assessment sheet
It is used to assess the general condition of the stoma, skin and
mucose membrane as an indicators of the patient’s knowledge and self care
performance.
Methods
- Permission from Hospital directors was obtained to conduct the study.
- A structure questionnaire and observational checklist performance were
developed by the researchers based on the review of current related
literature(9) to assess the patient’s knowledge and self care performance.
- Content validity of the tools (I,II, III) was done through jury of 10 experts
in this field. The recommended changes were carried out and the tool (III)
was adapted according the culture and translated into Arabic.
- Test-retest of reliability for too II was done by the researcher, cronbach's
alpha =0.80. Test- retest of reliability for tool III was done by Marquis(13)
cronback's alpha = 0.92.
- A pilot study was carried out on 10 patients selected randomly to ensure
the clarity of the questionnaire (I, II, III). Modification were done based
on the findings.
- Data were collected from the patients by individual interviews in the
outpatients using the developed questionnaire (tool I,III) and observational
checklist (tool II) as well as assessment sheet (tool IV). Each interview took
a time of about one hour. The data were collected in 6 months, from
January until June 2007.
10.
Statistical analysis
The EPI INFO statistical program was utilized for data presentation and
statistical analysis of the results and correlation between variables. The
statistical measures used were: a. descriptive measures included were number,
percentage, arithmetic mean, standard deviation, b. statistical tests used were t.
test. The level of significance selected was P equal to or less 0.05.
RESULTS
Table (1): Shows distribution of the studied sample according to the
colostomy patient’s characteristics. As regards sex two thirds (64%) of the
studied sample were females, the majority 70% of the studied sample, their
age were more than 40-55 years. Very few of patients were divorced, single
and widow (2%, 4%, 8%) respectively, the rest of the sample were married.
Regarding the socio-economic status more than half of the studied sample
(52%) were moderate. Concerning educational level the majority of the
studied sample were illetrate or read and write (34%, 28%) respectively.
More than two third of the studied sample (68%) were not working.
Table (2): Shows distribution of colostomy patient’s concerning types
of stoma and causes of colostomy, around three quarter (74%) of the studied
sample were had permanent colostomy, while 48% were due to cancer colon.
Table (3): Illustrates the colostomy patient’s concerning the previous
teaching and training received, around two third (62%) of the studied sample
were received teaching about types of stoma and defecation process while
only 10% received teaching about types of clothes needed. Around half (45%,
11.
50%) respectively, of the studied sample were trained about How put empty
pouch and remove dirty one, and clean the skin and stoma care. However 60%
of the studied sample were received teaching orally by Doctors, while 20% of
patients did not received any instruction.
Table (4): Illustrates the total mean scores and standard deviation of
colostomy patient’s knowledge as regard colostomy. It was observed that
the highest mean score which patients obtained were in the following area:
definition of colostomy, types of pouch, and causes of colostomy (1.70 ±
.544, 1.70 ± .462, and 1.54 ± .645) respectively.
Table (5): Illustrates the total mean scores and standard deviation of
the colostomy patient’s knowledge as regard their self care. It can be seen that
the highest mean score which patients obtained were in the following items:
Types of clothes should wear, precaution should followed during food intake
and prescribed food (1.45 ± .760, 1.50 ± .646, 1.48 ± .708) respectively.
Table (6): Presents the total mean score of the colostomy patient’s
performance as regard their self care for the skin and stoma care. It ws
observed that the highest mean score (10.34, 7.68) respectively were in
performing irrigation of stoma and removal of old pouch while the lower
mean score (3.46, 5.62) respectively were in performing preparation of
equipment and application of pouch and fixation.
Table (7): Shows the total mean score of the colostomy patients
regarding their quality of life, satisfaction and self efficacy. As regards the
quality of life the patients stated that they were physically and
12.
psychologically wellbeing, with the highest mean score (10.30 ± 2.53, 8.82 ±
2.38) respectively while the lowest mean score were obtained in relation to
their sexual activity (1 ± 1.04). Regarding the patient’s satisfaction the study
revealed that the patients were satisfied for medical care provided with the
highest mean score (11.54 ± 2.92), on the other hand the patients mentioned
that the medical care provider had a lack of experience with colostomy
patient’s problems with the lower mean score 3.34 ± 823, concerning the self
efficacy the patient perceived themselves as self efficient with the highest
mean score (8.68 ± 2.26), while they were obtained lowest mean score (2.42
± .78) regarding getting help or instructions.
Table (8): Shows the relation between the colostomy patient’s
knowledge and their quality of life, satisfaction and self efficacy. This table
illustrates a highly significant difference between the patient’s knowledge
about self care performance and the following domains in quality of life
(psychological well being, physical well being, body image, pain, sexual
activity and nutrition concerns), in addition to patient’s satisfaction, self
efficacy and teaching, (P = .000 for each and .012 for sexual activity)
followed by high significant difference between the patient’s knowledge
about definition of colostomy and all domains of quality of life and self
efficacy except sexual activity (P = .032, .003, .002, .000, .025, .001, .001,
.013) respectively. It was observed that complication of mucus membrane of
the stoma significantly affect the quality of life of the following domain,
body image, pain, sexual activity, nutritional status, social activity and self
efficacy. As regards the significant relation between patient’s knowledge and
13.
their quality of life, satisfaction and self efficacy, it could be ranked as
follows: self care performance, definition of colostomy, complications of
mucus membrane, (complication of stoma and abnormal skin condition),
types of pouch, anatomical and physiological bases finally causes of
colostomy, Also the study revealed that there were not significant difference
between patient’s knowledge about causes of colostomy and quality of life.
Table (9): shows the relation between the colostomy patient’s self
care performance and their quality of life, satisfaction and self efficacy, this
table revealed that there were
a high significant difference between
patient’s self care performance regarding removal of pouch and irrigation
of stoma and quality of life, patient’s satisfaction and self efficacy (P
ranged from 0.000, 0.03, 0.003 and 0.05). Moreover a high significant
difference were found between self care performance regarding clean skin
and stoma and quality of life, patient’s satisfaction and self efficacy (P=.00
in each) except the experience of medical care provider. As regards the
significant relation between self care performance and patient’s quality of
life, satisfaction, and self efficacy, it could be ranked as follows, remove
old pouch and irrigate stoma, clean skin and stoma, clean and dry pouch
and apply pouch and fixation, empty pouch, and equipment preparation.
DISCUSSION
An ostomy may be the best and safest form of treatment for number of
conditions such as cancer of colon and rectum, trauma, obstruction of the
bowel, complications of diverticulosis, and Grohn’s disease.(14) Patients with
stomas face many difficulties both physical and psychological. Little is known
14.
about the long term problems and the impact on patient lifestyle of a
permanent stoma.(15) Stoma patient quality of life, knowledge and self care
performance can be assessed, as they changes over the time, and that patient
access to specialist ostomy care nurses is particularly important during the
first 3 to 6 months following surgery.(16) Quality of life is an important issue
for patients with stomas, both knowledge and self care performance can
significantly influence it.(15) The present study showed that two thirds of
patients received only oral instructions about the types of stoma and
defecation process, How put empty pouch and remove dirty one and clean the
skin and stoma care, it could be related to lack of stoma nurse intervention and
absence of such specialty. In agreement with Oueda study(17) found that non
of colostomy patients received any written instruction, while secord C.(18)
Stated that adjusting to the life with an ostomy requires education and support
during all phases of a patient’s episode of care.
The findings of the present study showed that colostomy patient’s
knowledge were acquired only in the following areas: definition of
colostomy, types of pouch and causes of colostomy, which reflects the low
level of knowledge among colostomy patients. Doughtily, (19) reinforces the
importance of teaching basic stoma pouching principles, to enhance the
client’s sense of control over the situation.
Regarding patient’s knowledge about self care the patient’s were
acquired knowledge related to types of clothes they should wear,
precaution should followed during food intake and skin and stoma care.
15.
The study revealed that the majority of patients were performing irrigation
of stoma and remove old pouch but they did not prepare the equipment and
apply the new pouch. Because the patient mainly depend on one of his
family members. Secord C.(18) Stated that managing stomas and their output
can be challenging, but patient with stomas need knowledge base of their
function and effect. Thorough teaching helping client to master pouch
procedure. Moreover, Oueda mentioned that after six months of training
and follow up, the colostomy patients were success fully independent
related to assemble all material needed, remove the old pouch and put it in
disposable bag, clean the stoma and dry it gently, prepare the pouch and
empty it correctly and irrigate the stoma.(17)
Furthermore, the finding of the present study found that patients
perceived themselves as physically and psychologically well being and self
efficient but the sexual activity was affected. Also the patients mentioned that
they were satisfied with medical care provided. In consistent with the finding
of the present study Sprangers M.(15) found that many patients cope extremely
well with a stoma, however, some patients experience some change in
lifestyle and considerable difficulty and distress. Improved assessment and
counseling with longer follow-up by the stoma department would be helpful
in the management of these patients and probably would contribute to
improvement in the quality of their lives. Another study found that one third
of colostomy patients were dissatisfied with the information they received.(10)
16.
The study showed a significant relation between patient’s knowledge
about self care performance and the following domains in the quality of life
(psychological well being, physical wellbeing, body image, pain, sexual
activity and nutrition concerns, in addition to patient’s satisfaction, self
efficacy and teaching), also it was found that patient’s knowledge related to
definition of colostomy and complication of mucus membrane of stoma
had a significant relation with the majority of quality of life domains. It
means that when the patients knowledge increased about stoma it had its
effects of patients psychological, physical and social well being and his
satisfaction and self efficacy it might be related to patients more
understanding to his condition.
In congruent with this findings Karadag A.(20) confirm that colostomy
has a profoundly negative impact on quality of life. Specialized counseling
of these patients by a dedicated team improves quality of life significantly.
The study revealed that there were a significant relation between self
care performance regarding removal of pouch and irrigation of stoma and
quality of life, patient’s satisfaction and self efficacy.
The ability to perform self care reflects the individual’s power of
agency. To engage in self care activities, the individual must have the
ability and skills to initiate and sustain self care efforts. Moreover,
knowledge and understanding of care practices and their relation to health
and disease are needy.(21)
17.
CONCLUSION
The present study suggest that colostomy patient’s quality of life,
knowledge and self care performance can be assessed, as they changes over
the time, so specialist ostomy care nurses is particularly important during
the first 3 to 6 months following surgery to identify potential concerns that
can be addressed to help improve overall quality of life.
RECOMMENDATIONS
Results of this study calls for the following recommendations:
- Colostomy patients should receive adequate education, simulation and
counseling regarding ostomy self care, lifestyle changes and self efficacy.
- Assessment of patients, self care performance, knowledge and quality of
life during first six months after operation considered as evidence to his
educational needs and concern.
- Training program for nurses to be well prepared to provide instructions
and training for colostomy patients.
18.
Table (1): Personal characteristics of the colostomy patients.
Variables
No.
%
Male
18
36.0
Female
32
64.0
From 25-40
15
30.0
More than 40-55
35
70.0
Married
43
86.0
Widow
4
8.0
Single
2
4.0
Divorced
1
2.0
Low
14
28.0
Moderate
26
52.0
High
10
20.0
Illiterate
17
34.0
Read and write
14
28.0
Primary
8
6.0
Preparatory
3
6.0
Secondary
8
16.0
No work
34
68.0
Employer
8
16.0
Teacher
4
8.0
Worker
4
8.0
Sex
Age
Marital status
Socio-economic
Level of education
Occupation
19.
Table (2): Distribution of colostomy patient’s concerning types of
stoma and causes of colostomy
Variables
No.
%
Permanent colostomy
37
74.0
Temporary colostomy
13
26.0
Cancer colon
24
48.0
Cancer colon and rectum
12
24.0
Ulcerative colitis
8
16
Trauma
6
12.0
Types of stoma
Causes of colostomy
20.
Table (3): Distribution of colostomy patient’s concerning types of
stoma and causes of colostomy
Variables
No.
%
- Types of stoma and defecation
process
31
62.0
- Types of diet
6
12.0
- Types of cloths
5
10.0
- Non
8
16.0
- How put empty pouch and remove
dirty one
27
54.0
- Skin and stoma care
25
50
- Clean the pouch
13
26
- Non
10
20
- Doctors
30
60.0
- Nurses
10
20.0
- Not received
10
20.0
- Pouch sample
10
10
- Orally
30
60.0
- non
10
20.0
Previous teaching
Previous training
Sources
Teaching aids
21.
Table (4): Total mean score of the colostomy patients ‘knowledge as
regard colostomy
Total number =50
Variables
Total score
Mean
SD
-
Definition of colostomy
3
1.70
±0.544
-
Causes of colostomy
3
1.54
±0.645
-
Anatomical and physiological bases
3
0.720
±0.783
-
Complication of stoma
3
1.34
±0.688
-
Complication of mucuse membrane
3
0.660
±0.557
-
Abnormal skin condition
3
1.12
±0.593
-
Types of pouch
3
1.70
±0.462
-
Total mean score
21
8.78
±3.49
Table (5): Total mean score of the colostomy patients’ knowledge as
regard their self care
Total number =50
Variables
Total score
Mean
SD
Types of clothes should wear
3
1.540
±0.760
Types of skin application
3
1.32
±0.745
Prescribed food
3
1.48
±0.708
Amount of fluids intake daily and why?
3
1.040
±0.781
Precaution should follow during food intake?
3
1.50
±0.646
Total mean score
15
6.880
±2.42
Total mean score for patient’s knowledge (Table 4 and 5) = 36 .
22.
Table (6): Total mean score of the colostomy patients’ knowledge as
regard their self care for the skin and stoma care
Variables
Total score
Total number =50
Mean
SD
- Equipment preparation
6
3.46
±1.15
- Remove old pouch
12
7.68
±2.04
- Clean skin and stoma
15
7.62
±2.62
- Apply pouch and fixation
12
5.62
±1.59
- Empty pouch
12
7.50
±1.15
- Clean and dry pouch
9
6.36
±1.69
- Irrigate stoma
27
10.34
±2.94
Total mean score
93
42.965
±13.18
Table (7): Total mean score of the colostomy patients’ regarding their
quality of life, statisfaction and self efficacy.
Variables
Quality of life
- Psychological wellbeing
- Physical wellbeing
- Body image
- Pain
- Sexual activity
- Nutrition
- Social concern
Patient’s statisfaction
- Patient’s statisfaction for medical care
- Experience
Self efficacy
- Self efficacy
- Help and instruction
Total mean score
Total score
(110)
25
25
20
10
5
15
10
(30)
25
5
(25)
20
5
165
Total number =50
Mean
SD
(47.8)
(±14.51)
8.82
±2.38
10.30
±2.53
8.44
±2.70
6.00
±1.86
1.00
±1.04
7.46
±2.24
5.78
±1.76
(14.88)
(±3.743)
11.54
±2.92
3.34
±0.823
(11.1)
(±3.04)
8.68
±2.26
2.42
±0.78
73.78
±21.293
23.
Table (8)
24.
Table (9)
25.
REFERENCE
1.
Kocaman N, Kutlu Y, Ozkan M, Ozkan S. predictors of psychosocial
adjustment in people with physical disease. Journal of nursing and
health care of chronic illness in association with Journal of clinical
nursing. 2007; 16(3): 6-16.
2.
Prieto L, Thorsen H, Juul K. Development and validation of a quality
of life questionnaire for patients with colostomy or ileostomy. Health
Qual life outcomes. 2005; 3 (62): 2-8.
3.
Abo elfadel S. Effect of individualized teaching on Bowel function for
colostomy patients. 18th annual meeting of the Egyptian Society of
Surgeons, Congress on colorectal
Surgery. The Cleveland Clinic
Foundation and University of Alexandria.
4.
Hampton, B. “Peristomal and Stomal Complication”, Ostomies and
Continent Diversions: Nursing Management. Edited by B. Hamton
and R. Bryant, Mosby Year Book, St. Louis, 1992,pp. 105-128.
5.
Patwardhan AA. Ostomy care and management. Tata Memorial
Hospital, Enterstomal Journal, April, 2000; 12.
6.
Bass M., Del Pino A., Tan A., Pearl RK., Orsry CP., Abcarian H.,
“Does Preoperative Stoma Marking and Education gy the Enteostomal
therapist Affect Outcome?”, Diseases of the Colon and Rectum,
40(4):, Apr, 1997; pp.: 440-3.
26.
7.
Bernnan J, Steele R. Objective assessment of morbidity and quality of life
after surgery for low rectal cancer. Colorectal disease. 2002, 4: 61-65.
8.
Perper B, Mikals C. Predischarge and Post discharge and concerns of
patients with an ostomy. Journal of ostomy and Continence, (1996;
23(2):pp. 105-9.
9.
Hocevar B, Bambrick M. overview of Ostomy management past,
present and future. February 2000 28 the annual meeting of the
Egyptian society of surgeons, congress on colorectal surgery, the
Cleveland clinic foundation and university of Alexandria.
10. Persson E. et al., ostomy patient’s perceptions of quality of care.
Journal of advanced nursing. 2005; 49(1): 51-58.
11. Turns D. psychosocial issues: pelvic exenterative surgery. Journal of
surgical oncology. 2001; 76(3): 224-30.
12. Nuget K. et al. Quality of life in stoma patients. Dis colon rectum.
1999, 42(12): 1569-70.
13. Marquis P., Marrel A., and Jambon B., Quality of life in patients with
stomas; The Montreux Study. Ostomy/ wound Management ISSN:
0889-volume 49- February 2003-pages: 48-55.
14. Frojd C, Larsson G, Lampic C, Essen L. Health related quality of life
and psychosocial function among patients with carcinoid tumours. A
longitudinal, prospective, and comparative study. Health Quality life
outcomes. 2007; 5: 18-21.
27.
15. Sprangers M, Taal B, Aaronson N, Velde A. quality of life in
colorectal cancer. Stoma VS. nonstoma patients. Dis colon Rectum.
1995; 38(4): 361-8.
16. Fatma L. et al. Quality of life in patients with colo-rectal cancers at a
Tunisian hospital center. A case control study of a population unhurt
by cancer. Tunis Med. 2007; 85(5): 380-4.
17. Oueda M, Haggag M, Mahmoud N. on going impact of nursing
interventions to ostomic patient self care. Alexandria scientific
nursing journal. 2003; 2(2): 51-56.
18. Secord C. et al. adjusting to life with an ostomy. A psycho educational
program. Canadian Nurse. 2001, 97(1): 28-30.
19. Doughtily G.B, and Jackson DB. Gastro intestinal disorders. St Lowis:
Mos by year book, 1997; 1-22.
20. Karadag A. et al. Impact of stoma therapy on quality of life in
patients with permanent colostomies or ileostomies. International
journal of colorectal disease. 2003; 18(3): 234-36.
21. Thomas C, Madden F, Jehu D. psychological effects of stomas.
Psychosocial
morbidity one year
after surgery.
psychosomatic research. 1997; 31(3): 311-6.
Journal
of