RESEARCH ARTICLES

 
Patients with urinary derivations: an approach on the affected basic human needs

Raquel Conceição de Almeida Ramos^I; Cristiane Maria Amorim Costa^II; Elizabeth Rose da Costa Martins^III; Araci Carmen Clos^IV; Macio Tadeu Ribeiro Francisco^V; Thelma Spíndola^VI 
INurse. Post-Graduated in Surgical Nursing and Intensive Therapy. Contracted Professor from the Faculty of Nursing at the University of the Rio de Janeiro State. Nurse from the Care Program for Men’s Health at the Piquet Carneiro Polyclinic. Rio de Janeiro, Brazil. E-mail: raquel_rcar@msn.com
^IINurse. PHD Student in Nursing. Assistant Professor from the Faculty of Nursing at the University of the Rio de Janeiro State. Head of the Sector of Urological Ward at the Pedro Ernesto University Hospital. Rio de Janeiro, Brazil. E-mail: cristiane.costa@ig.com.br
^IIINurse. PHD in Nursing. Adjunct Professor from the Faculty of Nursing at the University of the Rio de Janeiro State. Brazil. E-mail: oigresrose@uol.com.br
^IVNurse. Master in Philosophy. . Assistant Professor from the Faculty of Nursing at the University of the Rio de Janeiro State. Brazil. E-mail:
araciclos@yahoo.com.br
^VNurse. PHD in Collective Health. Associated Professor from the Faculty of Nursing at the University of the Rio de Janeiro State. Coordinator from Nursing Graduation Course at the Veiga de Almeida University. Rio de Janeiro, Brazil. E-mail: mtadeu@uva.br
^VIPHD in Nursing. Adjunct Professor from the Faculty of Nursing at the University of the Rio de Janeiro State. Brazil. E-mail: spindola@predialnet.com.br

ABSTRACT: This study aimed at describing the everyday problems experienced by patients with urinary derivation and relating these problems to the Basic Human Needs Theory of Wanda Horta. This is a descriptive research with quantitative and qualitative approach performed with 10 patients from a urology ward of a university hospital, in Rio de Janeiro, in the period from June to September 2011. The data analysis has covered the statistical method, the content analysis of the statements and its systematization in themes and categories. The results showed that patients with urinary derivations feel affected in their psychobiological and psychosocial needs, being that the first ones are the most expressed. We have concluded that it is indispensable that the nursing staff performs a comprehensive, individualized and systematic care towards the patients with urinary derivation, aiming at solving or minimizing the reported difficulties.
Keywords: Ostomy; Urinary Derivation; Quality of Life; Nursing Care.

INTRODUCTION

This paper aims at addressing the problems identified in the daily lives of urostomized patients related to the basic human needs described by Horta1. Specifically, before patients undergoing surgery in which there is the need for performing an ostomy, which is characterized as a manifestation of the digestive, respiratory or urinary system, through an opening², it is perceived the occurrence of feelings of anxiety and fear of changes in lifestyle that this procedure can give rise.
By observing this reality and seeking theoretical basis for this issue, it should be noted that a large proportion of the published studies is directed to the discussion on colostomies, externalization of a segment, through the abdominal wall, creating an artificial opening for the exit of fecal contents². Accordingly, there was a motivation to address other ostomy type, which is also present in surgical wards, the urostomy surgery, highlighting the impact that it can cause on the lives of those who are subjected to this technique.  
Urostomy surgery consists in making an opening for creating a drainage pathway for urine. It can be performed by means of various surgical methods and has as the main purpose to preserve the kidney function².
Before these implications, we have prepared the following guiding questions: What are the everyday problems that the urostomy can bring to its bearer? What are the basic human needs, described by Wanda Horta, that are affected?
In this sense, we have defined the following objectives: to describe the everyday problems experienced by urostomized patients related to their post-operative condition and relate them to the Basic Human Needs Theory, according to Horta¹. 
This study is relevant as it enables the nursing professional to reflect on the care to be provided to this patient, in an attempt, if necessary, to encourage changes. A differentiated and holistic care might improve the adaptation of patients to their new conditions and, hence, the quality of life. The study might incite interest for further researches on this matter, in addition to serving as a source for future researches covering this same area of ​​interest.

THEORETICAL BENCHMARK

Any form of urine drainage outside the natural conduits, involving kidney pelvis, ureters, bladder or urethra might be considered a urinary derivation. This derivation might be of permanent or temporary nature³. Urostomy is indicated in cases of bladder tumors, pelvic malignancy, congenital defects, stenosis, ureters and urethra traumas, neurogenic bladder, chronic infection and in cases of interstitial cystitis without possibility of treatment. As to incontinence, urostomy is indicated only as a last resort⁴. 
There are two types: cutaneous urinary diversion and continent urinary diversion. In the first, urine is drained through an opening located in the abdominal wall and in skin, and is stored in a collection bag. In the second, a part of the bowel is used to create a new reservoir of urine⁴.
The nursing care of ostomized people should be started in the pre-operative period, through interviews, physical examination, diagnosis and planning of nursing shares. It is important that the nursing staff physically and emotionally prepares the patient, assesses its physical abilities and emotional possibilities to perform the self-care of the stoma and of the skin peristome, besides helping it, together with its family, in coping physical, social and emotional changes resulting from the surgery⁵.
The post-operative period involves the care of psychosocial and physiological needs of ostomized patients⁵. The immediate nursing care shares mainly cover the maintenance of the hemodynamic balance and the restoration of bodily functions⁵. In the immediate post-operative period, one should guide these people regarding the specific actions of self-care and the gradual return to daily activities⁵.
Basic human needs express tension levels, conscious or unconscious, which are the result of hemodynamic imbalances of vital phenomena¹. Thus, such shortcomings are evidenced when there is an installed imbalance, and it might be apparent, conscious, verbalized or not by an individual, family or community.
The Basic Human Needs Theory, according to Horta, has been widely used in studies of the nursing field and focuses on three levels of need: psychobiological level: nutrition, sleep and rest, physical integrity, sexuality, removal; psychosocial level: safety, love, leisure and acceptance; and psychospiritual level: religious or theological needs, ethics or philosophy of life1.

METHODOLOGY

This is a descriptive study with quantitative and qualitative approach. The study setting was a urological ward at a university hospital located in the municipality of Rio de Janeiro defined from the observation of patients submitted to surgical procedures that required the elaboration of a urinary derivation. The above mentioned hospital unit receives the monthly average of 20 patients for urological surgical treatment. Furthermore, there can be the return of these patients after discharge, with sights to hold a post-operative assessment. 
Regarding the investigated set, 10 patients agreed to participate in this study. The inclusion criteria were: patients belonging to this unit submitted to a surgical procedure that triggered the elaboration of a urostomy, voluntary acceptance to participate in the research and age equal or over 18 years. The quantitative of subjects was defined by the discursive data saturation method.
All ethical requirements proposed by the Resolution nº 196/96 of the National Health Council were respected. Accordingly, this project was referred for appreciation of the Research Ethics Committee from the Pedro Ernesto University Hospital, winning the opinion for approval n° 2822/2010-CEP/HUPE. The data collection was conducted only after the issuance of the said opinion and the authorization of the institution. The participants have signed a Free and Informed Consent Form, thereby preserving their autonomy and their anonymity. Thus, the respondents were identified by the letter E, followed by the serial number for participation in the study: E1, E2, E3 and so on.
The data were collected at the time in which these patients returned to the hospital for consultation concerning the surgical revision. Thus, they had already experienced a moment with their new living conditions, as well as identified, even if subconsciously, situations in their everyday lives related to the urostomy surgery. Moreover, this strategy did not bring financial expenditures to participants.
The period of data collection covered the months from June to September 2011. As an instrument for data collection, we have used a semi-structured interview with the following essential question: What were the problems faced in your everyday life after the urostomy surgery? The interviews were recorded and later transcribed. The data were subjected to statistical treatment and to content analysis⁶ of the statements, being that these procedures have followed their systematization in themes and categories⁷. 
The results of this study were discussed in the light of the pertaining literature^1-5,8-18.

RESULTS AND DISCUSSION

Social Profile
There was a predominance of male interviewees (60%). The highlighted age group was the one comprised of people aged 50 or over, in which 40% had up to 59 years old. Most proved to be a resident from the Baixada Fluminense Region (60%) and the other ones (40%) lived in the North Area of the city of Rio de Janeiro.
A large proportion reported living with family members (80%). Furthermore, 60% are married, 20% are widowed and 20% are divorced. All respondents have children. Regarding their schooling level, 40% had uncompleted the Elementary School, 20% finished the Elementary School, 20% the High School and 20% the Higher Education. As to religion, 40% are Evangelicals, 40% are Catholics and 20% are Spiritists. None of the respondents has an employment link, 40% are retired, 20% receive a sick-pay, 20% are unemployed and 20% reported never having worked.  

Affected basic human needs
The present study has identified 320 registration units (RUs) defined by means of the rule of cutting through meaning⁷. These RUs were associated with defined themes, considering the basic human needs¹. These themes were grouped into two different categories: psychobiological needs and psychosocial needs. The psychospiritual need1 will not be discussed because it was not pointed out in the reports of the surveyed respondents.

Category 1: Psychosocial needs
This category has grouped 214 (66.9%) RUs, thereby it was characterized as the category with the highest number of RUs, going against the assertion that the most affected needs are the ones of psychobiological nature8. The covered issues were acceptance - 30 (9,4%) RUs; love - 28 (8,8%) RUs; gregarious - 30 (9,4%) RUs; self-image - 30 (9,4%) RUs; self-esteem - 34 (10,6%) RUs; freedom - 14 (4,4%) RUs; leisure - 40 (12,5%) RUs; and self-fulfillment - 8 (2,5%) RUs.
It was possible to analyze how the condition of a patient urostomized can affect the psychosocial issues^12-18 involving both its feelings as from the others of its conviviality. It should be emphasized that its quality of life¹³ and psychosocial needs^12-18 suffer direct interference from the presence of the stoma, plus the collector device, reflecting in the ideal body image imposed by the society at large.
Before the psychosocial needs, leisure was the most mentioned. There is the deprivation of moments with family members and friends and the long stay in its home. The fear of making public the condition of an ostomized subject induces it to keep this isolation⁹.
I already gave up going out of home because of that, I've stopped attending some places. (E2)
But, if you have to go to a party, if you have it, you won’t go there. (E8)
I am not free to go, for example, to a theater, cinema, [...] beach. (E9)
The deprivation of leisure, to which a patient with urinary derivation is submitted, might be related to body image itself conceived by the individual. A urinary derivation directly affects the human physical structure; added to this, there is the experience in a cultural environment where the representations of the ideal body image are permeated by the concepts of health, vigor and beauty⁹. The bearer, when facing these social parameters, ranks itself as incongruous, generating stigmas¹⁵ and concepts that consider its own being as inappropriate before the society^13-18.
The meaning of body image is closely related to the social scope, based on the representations and stereotypes of social groups valued and propagated over time, being modified by the subjectivity and routine of individuals^9,14-17. Before this social and subjective construction, the patient bearer of a urostomy feels and verbalizes the interference of this derivation in its self-image:
But I still cannot [get used], I think about overcoming it. (E10)
Did you see? The bag is very large [...] If it were something that could hide [...], if they could do it in one way smaller so that we could hide ... so, it has no way to hide. (E3)
When feeling its self-image transformed by the presence of the stoma, the individual performs a subjective assessment of its body, reaching critical conclusions. This assessment, which was presented as negative in all recorded statements, directly reflects the low self-esteem. This is because the subject dissatisfied with its image has also affected the manner of dealing with itself and other people. In many cases, the patient incorporates the social stigma, strengthening difficulties in its own acceptance and in the process of adapting to its new condition^10-15.
At first, I just cried. (E1)
In the past [before the procedure] I was not ashamed; today, I’m ashamed, because of the little bag. (E6)
It's embarrassing, it's bad [having a urostomy]. (E7)
The human being is a social being and, therefore, feels the need to live in groups. Nonetheless, feelings of inability and discredit generated by the alteration in self-image and the low self-esteem might directly affect the social relationships.
The social needs of the human being are evidenced through the lack of acceptance, affection and participation in groups⁸. This thought meets the basic human need for being gregarious1. However, it was highlighted in the reports of the respondents that they, occasionally, isolate themselves from their environment and keep away from relationships with social groups.
People look, pointing to the bag and know that this is not normal, it's different. (E2)
If you have something [...] people are looking, draws attention [...] even if people do not want to look, but they look. (E8)
Regarding the basic human need for love1, it is perceived from the interviews that the main reason of the hindrance of regular sexual intercourse is the shame of their own bodies. In other cases, the hindering factor was the fear of the reaction of the partner itself, believing that sexual intercourse could be a source of pain for the spouse. Some ostomized patients do not return to the sexual practice not to expose their bodies to others, thereby avoiding a possible rejection and disapproval or due to the fear of rejection on the part of the sexual partner¹¹.  
In the initial phase, both the ostomized subject and its partner need for adaptation, and it might often be configured as a period of crisis because of the state of psychological imbalance, which is triggered when the individual faces situations that it presupposes like threatening. Most ostomized patients cannot resume their sexual activity, or only partially resume it, claiming physical problems, device-related discomforts, shame or fear of not being accepted¹⁰.
For the patient, the stoma influences the sexuality because of the constant use of the collection bag is not visually attractive. For the sexual partner, the presence of the stoma might cause conflicts due to the feeling of longing for the companion and, at the same time, revulsion, disgust and compassion¹⁰. 
I'm afraid to get a boyfriend, because of the little bag, since it can hinders a relationship, a boyfriend. (E1)
It already has a certain time; some four months without sexual relations [...] I know it does not hurt [...]. But my wife thinks I will feel pain ... there is the issue of pain [...]. (E5)
With all the implications stressed by patients with urinary derivation, with regard to the self-image, the self-esteem, the leisure and the need for love, it is perceived that the presence of the urostomy and of its collection device generates feelings of powerlessness and deprivation. It should be noted that patients do not feel free in their daily lives, in their tasks and in their attitudes. When an individual is deprived of feelings, desires and attitudes, the basic human need for freedom is also affected. 
We do not feel totally free, it is always a nuisance. (E7)
There will be a moment I'll do it, but not now. (E4)
The ostomized patient might feel itself at the margins of the labor market, disguising a social rejection by means of the compulsory removal of the workplace. By fearing of being an object of curiosity of professional colleagues, the patient bearer of ostomy might express the feeling of self-pity and disability, causing the withdrawal of the labor environment. This removal might initially generate another complication, which is characterized by the decreased socioeconomic status, in which the role is usually reversed – the financial provider becomes dependent on its family members^8,16,17. 
This condition of removal contradicts the sociological need for exercising a labor activity, i.e., feeling itself useful^1,15-18. One can also perceive that all surveyed interviewees reported that they did not exercise labor activities any longer, thereby affecting the need for self-fulfillment¹.
I prepared snack chips, now I have to take care of myself. (E3)
I've had clients, because I audited people. Audit, the team has to go to the location, but I could not go, because I’m urostomized. (E4)
By considering the already mentioned affected basic human needs, it should be inferred that this client, in its current clinical condition, might not accept and/or do not feel accepted in its social environment. All these needs are closely related to the basic human need for acceptance^1,15-18. It is the starting point of imbalance for all other needs. One subject that does not accept its own body and image, hardly, will be accepted by others.
This point is not being easy [...] People do not accept, and my fear is [...] they don’t accept me. (E6)
I asked to take the bag out, because I could not support it anymore, but you have to wait for the opportune moment to remove and start to have a little more quality of life. (E9)
In this category, we have discussed about the psychosocial factors involved after the surgical procedure of urinary derivation. Many of these factors strongly interfere with the patterns of life of these subjects, being that they are hindering factors for a healthy social and psychological life.

Category 2: Psychobiological needs
This category has grouped 106 (33,1%) RUs. The addressed psychobiological factors are: removal - 30 (9,4%) RUs, sleep and rest - 24 (7,5%) RUs; body care - 46 (14,4%) RUs; and body mechanics with 6 (1,9 %) RUs.
The category of the psychobiological needs is intended to discuss on the biological needs that are essential to the human life, that is to say, characterized as those that the body needs to keep in balance for achieving a healthy life^!.
When starting this discussion, it is perceived that the need for removal was identified as the second most affected. This is because during the human development, the first social control established on the infant took place by means of the encouragement from the mother in the field of the sphincters¹¹. Over the years, the human being learns to see itself as someone with the potential to keep its body clean, independent and worthy of respect, however, the presence of a urinary derivation causes the loss of such a sphincter’s control, thereby bringing discomfort and exposure of intimacy to other subjects¹². The presence of urinary derivation directly interferes with the control of eliminations that this same individual was forced to early learn in its life. This change in self-control generates conflicts and annoyances, far beyond the visual aspect.     .    
I've woke up totally pissed. (E1)
It constantly leaks out urine, wets everything, and even wets the bed. (E3)
It leaks out, leaks too much and wet the swimwear. (E9)
The above mentioned dirtiness requires a greater body care in relation to what was previously required. This caution was cited by the bearers of stoma as the most affected psychobiological need. The reason is closely related to the lack of sphincter’s control in these patients. When there is the need to move around to certain places, some patients, in order to meet this need, make certain adaptations by taking pots, water and towels to mitigate the potential damages caused by the leakage of urine. Others point out that the urostomy causes discomfort even during the aspersion bath, whether for lack of skills or for fear during the handling of the device.
To go out, the things work like this [...] I prepare my own procedures for me, take a little towel and two small cups, some water [...] because if I piss, I'll wash and wipe myself, so I can clean, I already let the things prepared. (E10)
[...] It has affected for bathing. (E2)
Regarding the whole issue of hygiene, the issue of hygiene is very disruptive to me. (E5)
Another essential need for the human being is the condition of sleep and rest¹, which if it is not well satisfied will provoke physical and mental stress¹². The presence of a urostomy can cause changes in the sleep patterns, whose main causes are the efforts to change positions that the subjects feel compelled to avoid. These adaptations not always will be tolerated, thereby causing discomfort and impossibility to sleep^9,10,12.
Sleep is hard, it disturbs a little. (E6)
[...] it disturbs me to sleep, I cannot sleep well, I have to sleep on one side [...] have to sleep only on the right side. (E7)
The discomfort I feel is at the bedtime, I cannot stand in many positions because I'm afraid to lie on that side, here, and later some problem happens to me. (E8)
The presence of the stoma and its collection bag also interfere with the body mechanics^1,16,17 because of the physical presence or even the sensation that the stoma can cause. Many ostomized patients have pointed out as a difficulty the conduction of simple movements of the daily life, such as accommodation in a seat.
To sit, you have to be careful. (E3)
At first, it was bad to sit [...]. (E10)
These reports make clear how much a urinary stoma can interfere with activities judged simple to perform in the daily life. Nevertheless, one should consider that certain difficulties imply greater or lesser degree of wear. This is because every human being is unique and differs in the way of facing illness and/or health-related problems^13-17. Thus, we should take care of the whole of the human being, i.e., in its psychological, psychosocial and psychospiritual dimensions^16-18.

CONCLUSION
This study has provided a survey of affected needs and their impact on the patient's everyday lives. We have found that basic human needs are affected in urostomized patients and, usually, when one of them gets out of balance, all others are impaired with greater or lesser intensity, reverberating across the several biopsychosocial levels. 
Two categories were emerged from the statements: psychosocial needs, which were predominant, and psychobiological needs.
The rules and concepts created by society can interfere with psychosocial needs and their respective care. An individual, who, before its values ​and beliefs, does not accept itself, will face difficulties for being accepted by others. This non-acceptance is reflected in several other fields, such as, for example, low self-esteem, deprivation in the pursuit for love relationships and the need to belong and participate in social groups, thereby interfering with the needs for loving and living in groups, respectively.
By considering the standards created by society with regard to self-image, the patients with urostomy perform a self-trial and classify themselves as incongruous. This classification also affects the condition of freedom because of the deprivations imposed by the bearer itself, since it leaves to attend public places for feeling ashamed. Many still consider themselves unable to work.
In addition to psychosocial factors, urostomy interferes with psychobiological needs like sleep and rest, body mechanics, physiological elimination and body care. This turns routine activities into uncomfortable and complicated actions.
Humans are always searching for quality of life and permanent feeling of welfare. This quest takes place in a subjective manner, with the purpose of satisfying the established human needs.
By considering that this quality of life is also a right of the urostomized patient, we have concluded that the nursing staff should provide a full, individualized and systematic assistance towards this patient type. With the proper preparation, many of these problems could be minimized or solved.
Among the limitations of this study, it should be highlighted the surveyed small sample, which prevents the generalization of our findings. It becomes relevant to conduct further studies that enable the discussion of this issue at stake, since this area is still narrowly discussed in current days.

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