CASE STUDY

Elderly patient with situs inversus totalis and rectal cancer: a case study

Andrea Bezerra Rodrigues¹, Patrícia Peres de Oliveira², Dayane Cindy de Castro Beserra¹, Camila Nogueira Colares Almeida¹, Ticiana Diva Prado Arruda¹, Edilene Aparecida Araújo da Silveira²

¹Federal University of Ceara
²Federal University of São João del Rei

ABSTRACT
Aim: To operationalize the nursing process for an elderly patient suffering from rectal cancer and situs inversus totalis based on the Callista Roy Adaptation Model, using NANDA-I, the Classification of Nursing Results and the Classification of Nursing Interventions.
Method: This is a qualitative case study carried out in a hospital located in the state of Ceará, with an elderly patient with rectal cancer and the rare congenital malformation situs inversus totalis. The study was carried out from October to December 2014. The study was approved by the Research and Ethics Committee, protocol number 888,606.
Results: it was observed that the care provided to the elderly favored his adaptation; therefore, insofar as the interventions/activities were implemented and evaluated, the patient showed improvement before the stimuli, which allowed the achievement of the set goals.
Conclusion: The use of Roy's theory allowed for recognition that the goals and actions implemented were paramount in the transformation of ineffective responses to adaptive responses.
Descriptors: Neoplasms; Nursing Process; Nursing Theory; Health of the Elderly

INTRODUCTION

Aging populations are significant in the global context and they have brought significant consequences and changes to society in terms of political, economic, cultural, scientific-technical and social planning. The reflections of these transitions are perceived in everyday life and are expressed in elderly people’s ways of living, thinking and acting. In this context, an essential need has emerged to investigate the health conditions of this population segment and the various aspects involving the aging process^(1,2).

Cancer is a major public health problem both in developed and developing countries⁽³⁾. The incidence of this disease increases significantly with age. This is most likely because, with advancing years, the risk factors for cancer are associated with the tendency for a lower efficiency of cell repair mechanisms accumulated in the elderly body^(3,4). Among the different types of cancer, colon and rectal cancer are the second most prevalent in the world. The latest estimate for the biennium 2013-2014 for Brazil was 15,070 new cases of colon and rectal cancer in men and 17,530 in women⁽⁴⁾.

There are four types of treatment for colorectal cancer: surgery; radiation; chemotherapy; and biological therapy, which may or may not be combined according to the tumor stage. Among the types of definitive rectal cancer treatment, surgery remains the most effective treatment. In some cases it is necessary to perform radiotherapy and/or neoadjuvant chemotherapy in order to take better local control of the disease, thus reducing the chances of recurrence⁽⁵⁾.

For quality care, the application of the nursing process (NP) is needed. This process involves five interrelated and dynamic steps: the collection of nursing data or history; diagnosis; planning; implementation; and evaluation⁽⁶⁾. The NP phases can change according to the chosen nursing theory. In this study, we chose the Roy Adaptation Model (RAM), whose elements encompass behavioral research and incentives, the identification of nursing diagnoses (ND), the setting of goals, the planning of interventions and evaluation⁽⁷⁾.

The elderly patient found himself hospitalized for rectal cancer. He also had situs inversus totalis (SIT), a rare congenital malformation with an incidence of 1/25,000 of the normal population. SIT is characterized by an inversion of the thoracic and abdominal viscera(8) with dextrocardia. This malformation is caused by defective rotation of the viscera in the embryonic stage^(9-10). Although SIT may be associated with diseases such as a perforated peptic ulcer, acute cholecystitis and intestinal obstruction, in most cases people are asymptomatic and have normal life expectancy, which is not considered an entity of premalignant lesions. However, rare malignant tumors have been reported^(9,11).

People with cancer tend to be more sensitive and vulnerable to stimuli caused by the cancer, which often interferes in promoting an effective response to these stimuli and contributes negatively to those people adaptation. It is the nurse’s responsibility to plan comprehensive care for these individuals and their families in an orderly and scientific manner, using the NP based on a theoretical framework, which in this study was the RAM(7). Cancer generates stimuli that require a response from its carrier (that can be both adaptive and ineffective) through home care. Home care includes the family as an interactive and collaborative element in healthcare, meeting their complex needs and using a range of institutional, community and family resources for producing effective adaptive responses⁽¹²⁾.

The choice to implement the NP for the elderly patient with rectal cancer and SIT was made given that the elderly population is considered a differentiated group, both in terms of social conditions and for the care appropriate to their health and well-being. Thus, a closer approximation to the elderly is essential for the identification of nursing care that best suits their needs, as it seeks to improve the patient’s quality of life and, consequently, the individualization of care. This is in addition to the fact that this is only the third time in the literature that describes the association between SIT and rectal malignancy^(10,11).

Therefore, the relevance of this study lies in the fact that the patient is a senior with SIT and rectal cancer, which illustrates the importance of applying the systematization of care for the patient and his family, as well as highlighting the fact that there has been no research published on nursing in a cancer clinical case associated with this congenital malformation.

Thus, the objective was to operationalize the NP for the senior with rectal cancer and SIT based on RAM, using the North American Nursing Diagnosis Association (NANDA-I), the Nursing Outcomes Classification (NOC) and the Nursing Interventions Classification (NIC).

Theoretical framework
The NP is constituted of phases that can vary according to the nursing theory used. The RAM presents four key concepts: the recipient of the care; the environment; health; and nursing goal. Roy understands the person as a system that constantly exchanges information with its environment, which causes internal and external changes. Given these changes, there is a need to continuously adapt in order to maintain integrity. That is, the person is an open system and can be called an adaptive system^(12,13).

The environment is the inner world around the person. Human systems interact with environmental changes, which results in adaptive responses to the environment. Health depends on the adaptation of the person to an environment that is constantly changing, endowing the individual with the ability to achieve the goals of survival, growth, reproduction and control^(7,13).

The nursing goal is to promote effective responses in the four adaptive modes and activities should promote adaptive responses in situations of health and disease. Nurses must know how to handle the focal, contextual and residual stimuli of their patients. Nursing care should focus on the person’s condition, as well as the focal, contextual and residual stimuli and the promotion of the patient’s adaptive reaction.

The adaptive system of the patient has inputs (stimulus=input), which are regulated by external or internal stimuli to the individual, provoking responses that will or will not lead him/her to adapt. The level of adjustment will depend on each individual; that is, adjustment will depend on the individual’s coping mechanisms. The adaptive system also has answers (behavior=output), which are the ways in which the individual behaves and how the individual responds to a given stimulus. The patient can respond adaptively or ineffectively^(12,13).

According to theorists, in these situations the nurses’ function is to promote a patient’s positive adaptation. For this, nurses should develop actions for assessment and intervention. In the assessment, the nurse should identify problem situations and their stimuli; in the intervention, the nurse will handle these stimuli in order to eliminate them, causing the patient to adapt^(7,12).

METHOD

This is a case study with a qualitative approach, which refers to how the study organizes the data, preserving the unitary character of the studied object. However, with the use of a case study, the aim is to investigate the important characteristics of the research study subject, represent empirical research and understand a comprehensive method using the logic of the planning, collection and analysis of data⁽¹⁴⁾.

This study was performed with an elderly man, a rectal cancer carrier and patient with the rare congenital malformation SIT, who was hospitalized in the surgical clinic of a university hospital located in the state of Ceará. The survey period was from October to December 2014. Initially, we used a data collection script based on the RAM developed by the authors. In the first phase of the research, the medical record reading was held for a rapprochement with the data on the health/disease process of the subject of the study. Later, data were collected by means of interviews and physical examination, in addition to the assessment of behavior and stimuli. For Roy, the NP features six phases: assessment of behavior; stimulus evaluation; ND; goal setting; intervention; and evaluation⁽¹¹⁾.

The script was designed to assess the behavior and focal, contextual and residual stimuli. From there, the ND was established using the NANDA-I⁽¹⁵⁾. The identification of ND used clinical judgment and diagnostic reasoning. The analysis period, understood as the separation of the data and the critical examination by the examiner, the data was categorized and the divergent indicatives or gaps were identified. In the phase that includes synthesis of the elements, grouping of evidence standards were made according to the chosen theoretical framework and the factors that influenced and contributed to the inferred changes were identified⁽⁶⁾.

Following this, the goals and interventions were established in order to promote a better adaptive response of the elderly patient. Faced with the objective of acting on the identified ineffective behaviors, the results and nursing interventions were defined according to NOC⁽¹⁶⁾ and NIC⁽¹⁷⁾.

The interventions were implemented and evaluated, and a process of judgment on the responses of the elderly patient regarding the generation of the stimuli of responses was carried out.
The specific project of this case study was approved by the Research Ethics Committee of the Federal University of Ceará, according to protocol number 888,606. The study participant accepted the invitation voluntarily and signed a consent form (WIC).

RESULTS

First, the data concerning the behavioral research are explained. The behavioral research includes the collection of responses or the individual output behavior as an adaptive system with regard to each of the four adaptive modes⁽¹²⁾ — in this case the physiological, self-concept and social modes. In the mode interdependence, the ND was not found. The data were obtained by a script based on the RAM, a physical examination and medical records.

The elderly patient
The patient is male, 80 years old, born and raised in Caucaia/CE. He is married, has eight children, is literate and lives in his own house with his wife and children. He is Christian and he reported spiritual well-being. He is an ex-smoker (exposure for 50 years) and a former alcoholic (exposure for 45 years). Clinical background: diabetes mellitus (DM) and systemic arterial hypertension (SAH). He was diagnosed with moderately differentiated rectal adenocarcinoma in the first quarter of 2014 and has undergone eight sessions of chemotherapy (CT) with 35 mg leucovorin and 160 mg fluorouracil scheme and 28 sessions of radiotherapy (RT). He reported that during the period of this treatment he felt much physical and mental fatigue. After the completion of the CT and RT neoadjuvant he was admitted to the surgical clinic to undergo the surgical procedure rectosigmoidectomy with colorectal anastomosis and the preparation of ileostomy. The elderly patient and his companion (son) were aware of the rectal neoplasia. In the study’s first contact with the patient, on the second day after surgery (2 October 2014), the patient was conscious and he was able to communicate. He had lost 8 kg in the last six months, was pale, hydrated with exudate dirtiness in the abdomen from leakage through the collection bag laminar drain (penrose) and was maintaining a full liquid diet with good acceptance and physiologic serum with five ampoules of short-stay hypertonic glucose through central venous access (CVA) located in the right jugular vein (RJV). The insertion site showed no signs of infection.

The chest was unchanged, featuring vesicular murmurs and adventitious sounds. Cardiac auscultation was difficult to implement due to dextrocardia, but it showed rhythmic and normophonetic sounds. The pulse ranged from 80 bpm to 96 bpm; blood pressure was between 130x80 mmHg and 140x90 mmHg; the patient’s pain score ranged from zero to four while maintaining dipyrone every six hours and tramadol hydrochloride in case of pain, both intravenously (IV). The patient showed: a distended abdomen with a median incision from the epigastric to the hypogastric region, with a clean and dry suture with no sign of inflation; a laminar drain on the right flank with a collection bag and an average amount of serous exudate; active bowel sounds; urinary elimination through an indwelling urinary catheter (IUC) with light yellow urine drainage; and bowel eliminations through intestinal ostomy on the left with a collection bag system, with a drainable piece with the presence of greenish liquid stool. The stoma was bright red, moist and the peristomal skin was intact.

It should be noted that the characteristics of the liquid stool in this portion of the bowel would lead to a clinical judgment of diarrhea, since the descending colon feces already presented a pasty consistency. The elderly patient showed anxiety every time professionals handled the stoma and the bag switch, and he also expressed revulsion. In the medical record, there was a helical computed tomography of the abdomen and pelvis performed in another health service in 2012, identifying SIT, and an X-ray of the chest showing dextrocardia (heart positioned in the right hemi thorax with its axis base-apex directed to the right and inferiorly) (see Figure 1).

When the son and the patient were asked about the congenital alteration, they said a doctor had informed of this a long time ago. The patient reported satisfactory sleep patterns. He ambulates with assistance. Hemoglobin levels changed from 11.1 g/dL (October 2014) to 11.7 g/dL (December 2014); hematocrit from 29% to 30%; and other laboratory tests were within normal parameters.

Regarding the patient’s leisure habits, he said he listens to the radio, talks with friends and watches television sporadically. The patient’s son reported that, because of the disease, his father had changed his habit of talking with friends and said that he now spent most of his time at home. When asked about expectations for the future, the patient said he would like to return to the life he used to have before the ostomy. He reported that his illness had driven the family into a financial crisis and burdened his wife and son, as they always had to accompany him.

Six meetings were conducted between three of the researchers and the elderly patient between October and December 2014. The first meeting lasted 90 minutes, in which the researchers assessed the patient’s behavior and the focal, contextual and residual stimuli. From there, they NDs were developed using the NANDA-I(15). Then, the researchers set up the goals and interventions in order to promote a better adaptive response of the elderly patient.

In other meetings, with an average duration of 60 minutes, the interventions were implemented and evaluated. A review process of the responses of the elderly patient was conducted.

The nursing process according to the adaptation model of Callista Roy
According to RAM, all NP phases were implemented: the evaluation of the patient’s behavior and stimuli; the NDs; the establishment of the goals/outcomes; the interventions; and the evaluation(7,11).

The rectal cancer represented the focal stimulus for the patient, leading to physical changes, such as changes in bowel functions, which affected the physiological mode and influenced the self-concept and social modes.

The contextual stimuli, which are the signs and symptoms that can be measured, observed and reported by the patient (in this case, the patient’s age—80 years—and the genetic defect that caused anatomical changes to the organs), contributed to the effect of the focal stimulus, besides ileostomy. The possible residual stimuli were the patient’s previous smoking and alcohol consumption; that is, they were significant but unmeasurable conditions in the situation of the elderly patient.

Figure 2 features a diagrammatic illustration of the records of the adaptive systems identified in the elderly patient.

Source: prepared by the authors, 2014.

From the identification of the stimuli and the responses of physiological adaptation and self-concept and social modes, we sought to organize the NP using NANDA-I(15), NOC(16) and NIC(17), as shown in Table 1.

DISCUSSION

After grouping the clinical data, the adaptive human responses, and identifying the NANDA-I nursing diagnoses, we sought to determine the nursing goals using the international classification NOC⁽¹⁶⁾ and, from there, the nursing NIC interventions⁽¹⁷⁾.

Over the days of the elderly patient’s care in the hospital, the results were evaluated by checking whether they were impacting positively on the patient’s adaptive responses or if they required revision of the ND, goals and/or interventions as appropriate. It is noteworthy that the nursing interventions involved the manipulation of stimuli in order to promote adaptive responses.
According to Table 1, the adaptation modes of Roy were: physiological, self-concept and social.

Physiological mode
The physiological aspect relates to the five basic physiological needs: oxygenation; nutrition; elimination; activity and rest; and protection. These are in addition to four complex needs: senses; fluids and electrolytes; neurological functions; and endocrine functions^(11,13).

The NDs identified by the researchers of the elderly patient’s care were: risk of impaired skin integrity (protection); impaired tissue integrity (safety); risk of infection (protection); risk of falls (protection); acute pain (senses); and risk of electrolyte imbalance (fluids and electrolytes).

It should be noted that the initial impressions (ostomy to the left-draining liquid stools) did not coincide with the physiology, as it was known that the feces drained by the colostomy on the left were pasty and there was no data compatible with diarrhea. This initial suspicion led the research group to search for more data in their records, which let to the identification of the genetic defect SIT.

Since establishing the fact that it was an ileostomy (but located in the lower left quadrant [see Figure 3]), it was possible to identify the relevant NDs for the case that would go unnoticed if good nursing research was not performed on, for example, the risk of electrolyte imbalance and the risk of impaired skin integrity.

The risk of electrolyte imbalance is defined as the risk of decreases/increases in the intravascular/interstitial and/or intracellular fluid or its rapid change from one location to another. It refers to the loss/gain (or both) of the bodily liquid⁽¹⁵⁾. In this study, the diagnosis was evidenced by the loss of water and electrolytes by the ileostomy and laminar drain on the right flank.

The results of the NOC⁽¹⁶⁾ established an electrolyte and acid-base balance. The intended score was to maintain five (not compromised). Interventions to achieve the set target were the control of electrolytes and hydro electrolytes through the following activities: check the hydration status of the elderly patient (mucous, edema, pulse and heart rate); monitor the drainage of the laminar drain and ileostomy; monitor serum electrolyte levels; and carry out the hydric balance ⁽¹⁷⁾.

The ND risk of skin integrity is the state in which the person has or is at risk of epidermal and/or dermal tissue changes⁽¹⁵⁾. These may occur with any type of stoma but in particular with ileostomy. Contact dermatitis occurs most commonly in this type of ostomy, as the effluent of ileostomy contains digestive enzymes that can irritate the skin⁽¹⁸⁾.

The ND impaired tissue integrity is defined as damage to the mucous membranes, cornea, skin or subcutaneous tissues⁽¹⁵⁾. It is evidenced by destroyed tissue (stoma and laminar drain). It should be noted that the goals and interventions/activities implemented for the ND impaired skin integrity and impaired tissue integrity were described together.

The target established with the elderly patient and his son was to provide knowledge in terms of stoma and health behavior. The initial score was three (sometimes demonstrated) and the target score was established as five (consistently shown). Established interventions were ostomy care and supervision of the skin. Agreed activities were: evaluation of conditions of the surgical incision of the skin around the stoma and laminar drain; monitor the presence of signs of infection/inflammation (pain, heat, redness, swelling, exudate, fever) in the surgical incision, stoma and insertion site of the drain and central venous catheter (CVC); and advice on care for the collecting bag, stoma, the skin around the stoma, food, clothing and occasional products used in the care provided to the stoma and advice on socialization.

The ND risk of infection is described as the increased risk of being invaded by pathogenic organisms⁽¹⁵⁾. This can happen due to several factors, such as invasive procedures (CVC, indwelling urinary catheter (IUC), laminar drain, disruption of the skin barrier and proximity of the ileostomy surgical incision), hospital environment, old age and high surgical manipulation due to SIT. One study claims that surgery in an individual with SIT is difficult because the surgeon’s dexterity is compromised during the procedure^(8-10).

The ND acute pain is defined as an unpleasant sensory and emotional experience arising from real/potential tissue injury with a sudden or slow onset and a varying intensity and duration of less than six months⁽¹⁵⁾. In this case, it was characterized by reporting pain and protective actions related to a surgical procedure. The result of nursing—the pain level—was ranked four (moderate) and goals were established, on a scale of 10 points, between two and three movements and zero at rest. In relation to the target level of discomfort, the initial score was two (substantial) and the desired score was four (light).

The interventions carried out to achieve pain relief were discussed with the family and the control of pain and the administration of analgesics were established. The listed activities were to assess the characteristics, intensity and location of the pain, give instructions for the positioning and body movements to avoid increased pain and guidance for the elderly patient and his son on the principles of pain management, such as the administration of analgesics before bathing.

The ND risk of falls is understood as the augmented susceptibility to falls that can cause physical harm⁽¹⁵⁾. This is related to age (the patient is 80), anemia and the hospital environment. A priority goal was established for providing knowledge/fall prevention; the initial score was three (moderately suitable) and the target score was five (suitable). As the prevention of falls was instituted as a priority activity, guidance should be provided to the elderly man and his companion on the risk and prevention of falls including the maintenance of low/locked beds with high rails, the need to keep the bell and belongings next to the elderly patient and the provision of assistance whenever necessary.

Self-concept mode
This mode is composed of beliefs and feelings about oneself performed in a given period. The components are the physical self and the personal self. The physical self comprises two components: body feeling and body image. The personal self is an individual assessment of the individual’s own characteristics, expectations, values and merits^(11,12).

The ND anxiety was established as the vague, uncomfortable sense of discomfort or fear or a feeling of apprehension caused by the anticipation of danger⁽¹⁵⁾, characterized by expressed feelings that can interfere with the elderly man’s ability to reach his highest level of wellness related to the experience of chronic disease and ileostomy.

The targets set and achieved were coping and acceptance: health condition, both with the starting score of two (rarely shown) and the targeted score of four (often shown). The interventions proposed and applied, based on the NIC⁽¹⁷⁾, were improved coping mechanisms, improved levels of knowledge about the disease process and anxiety reduction. Outlined activities included guiding and informing the patient and his son about the disease and treatment, including ileostomy.

Social mode
This is a set of expectations for how a person plays a role in society^(6,12). The list includes the ND impaired social interaction, which is the insufficient, excessive or ineffective amount of social change characterized by the inability to receive a satisfactory sense of social involvement related to the absence of significant people⁽¹⁵⁾. This was characterized by the family report on the changes of interaction after the discovery of cancer and the early treatment that caused a lot of fatigue.

It should be noted that this ND already existed before the surgery. The targets set were: self-esteem, body image and communication, with an initial score of one (severely impaired) and a target score of three (moderately impaired)⁽¹⁶⁾ after the fourth meeting. The interventions that aimed to achieve the results were the strengthening of self-esteem, improved body image and socialization⁽¹⁷⁾. The proposed activities consisted of supporting the elderly patient and his son in order to face the difficult situations resulting from cancer, which contributed positively to the process of adaptation. The professionals heard the patient’s complaints and questions, helping them to look for alternatives to personal satisfaction.

The ND impaired home maintenance was established. This ND refers to the inability to independently maintain an immediate and safe environment that promotes growth⁽¹⁵⁾. This was characterized by reporting members of the overburdened family and their financial crises. The results of the NOC⁽¹⁶⁾ consisted of family functioning; the starting score was two (rarely shown) and a target score of four (often shown) after the third meeting. The implemented interventions were active listening and advice. As activities for establishing interpersonal relationships, building trust and respecting the particular circumstances of the elderly patient and his family, defining the division of tasks between the family members and the rights of the person with cancer.

Assessment
The NP was completed by an evaluation. At this stage, the behavior goals were compared with the output responses of the patient to determine whether there was movement toward or away from achieving the goals. The re-adaptation to the goals and interventions were made based on the evaluation data^(6,12).

When a judgment of the elderly patient’s responses was conducted after the implementation of the nursing interventions/activities it was possible to perceive spiritual well-being as a positive stimulus in the adaptation and adapted human responses, especially those that did not develop electrolyte abnormalities or integrity of the affected skin around the stoma.

An improvement in the patient’s sleep patterns, which had already been considered satisfactory, was noted after the removal of the laminar drain and SVD. As regards the self-concept mode, a reduction in anxiety during the exchange of the collecting ileostomy bags was also noted. The patient also showed an improvement in their anemia, proven by laboratory tests and an absence of pain at rest and when performing tasks requiring a small effort. The patient began to receive visits from his seven other children and grandchildren and he reported a decrease in his feelings of anxiety. Therefore, he expressed behaviors that demonstrated his adaptation.

It can be seen that the targets were achieved during the hospitalization of the elderly patient, with increased scores from the third meeting. The patient, his son, and his wife were always receptive to care, guidance and proposals, demonstrating the importance of nursing care.

CONCLUSION

Nursing care, in light of Roy's theory, facilitated dialogue with the patient and his family in the achievement of goals and the modification of behavior through the implementation of interventions/activities. Gradually, the elderly patient evolved satisfactorily with adaptive behaviors.

One can also observe that the care implemented with the NP allowed us to act in a targeted way on the adaptive problems of the elderly patient with rectal cancer and SIT, using a clinical judgment to improve the patient’s quality of life.

Despite being in accordance with the criteria stipulated in the methodology, one of the limitations of the study was that it was conducted with a single elderly patient suffering from rectal cancer and SIT (the third known case worldwide), which limits the generalizability of the results. However, this impediment does not invalidate the study, which responds satisfactorily to the propositions of the research.

The results therefore stimulate the continuity of this type of clinical case study that is not usually described in the literature because they provide continuous, updated and quality nursing care with a focus on the individual’s well-being and the scope of the patient’s health autonomy.

REFERENCES

1. Veras RP. Experiências e tendências internacionais de modelos de cuidado para com o idoso. Ciênc. saúde coletiva. 2012; 17(1): 231-38.

2. Kwok AC, Semel ME, Lipsitz SR, Bader AM, Barnato AE, Gawande AA, Jha AK. The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet. 2011; 378(9800): 1408-13.

3. Swaminathan V, Audisio R. Cancer in older patients: an analysis of elderly oncology. Ecancermedicalscience. 2012; 6: 243.

4. Instituto Nacional de Câncer José Alencar Gomes da Silva (Brasil). Estimativas 2014: Incidência de Câncer no Brasil. Rio de Janeiro: INCA; 2014. [ cited 2015 Jule 10 ] Available from:http://www.inca.gov.br/estimativa/2014/estimativa-24042014.pdf

5. Das P, Pinsky B. A watch-and-wait approach to the management of rectal cancer. Oncology (Williston Park). 2013; 27: 962-68.

6. Krauzer IM, Adamy EK, Ascari RA, Ferraz L, Trindade LL, Neiss M. Sistematização da Assistência de Enfermagem na atenção básica: o que dizem os enfermeiros? Cienc. enferm. 2015; 21(2): 31-38.

7. Roy C, Andrews HA. The Roy Adaptation Model. 3 ed. Upper Saddle River, New Jersey: Pearson; 2009.

8. Carrillo R, Arias Ch, Huacuja R, García M, Carrillo C, Carrillo D, et al. Situs inversus totalis. Med Int Mex. 2012; 28(2): 187-1.

9. Junior AWLS, Tajra CEF, Soares VYR, Soares JL, Costa JA. Hepatectomia por linfangioma em situs inversus totalis: relato de caso. Rev Col Bras Cir. 2011; 38(6): 450-51.

10. Choi SI, Parque SJ, Kang BM, Lee KY, Lee HC , Lee SH. Laparoscopic abdominoperineal resection for rectal cancer in a patient with situs inversus totalis. Surg Laparosc Endosc Percutan Tech. 2011; 21(2): e87-90.

11. Huh JW, Kim HR, Cho SH, Kim CY, Kim HJ, Joo JK, Kim YJ. Laparoscopic total mesorectal excision in a rectal cancer patient with situs inversus totalis. J Korean Med Sci. 2010;25(5):790-3.

12. Dias VCC, Andrade SQ de, Santos CF, Oliveira PP, Rodrigues AB. Care for the elderly with two primary neoplasms and metastases reasoned in the theory of Callista Roy. J Nurs UFPE online [ Internet ]. 2015 Jun [ Cited 2015 Aug 20 Ϋ(6). Available from: http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/view/7648/pdf_8024. doi: 10.5205/reuol.7585-66362-1-ED.0906201518.

13. Frazão CMFQ, Bezerra CMB, Paiva MGMN, Lira ALBC. Changes in the self-concept mode of women undergoing hemodialysis: a descriptive study. Online Braz J Nurs (Online) [ Internet ]. 2014 June [ Cited 2014 Aug 23 ] 13(2). Available from:http://www.objnursing.uff.br/index.php/nursing/article/view/4209/html_124. doi: http://dx.doi.org/10.5935/1676-4285.20144209.

14. Yin RK. Estudo de caso: planejamento e métodos. 5 ed. Porto Alegre: Bookman, 2015.

15. Herdman TH. Nursing diagnoses: Definitions and classification 2012–2014. Oxford: Wiley-Blackwell; 2012.

16. Moorhead S, Johnson M, Maas M, Swanson E. Nursing Outcomes Classification (NOC). 5 ed. St. Louis, MO: Elsevier; 2013.

17. Bulechek G, Butcher H, Dochterman J, Wagner, C. Nursing interventions classification (NIC).6 ed. St. Louis, MO: Mosby Elsevier; 2013.

18. Bafford AC, Irani JL. Management and complications of stomas. Surg Clin North Am. 2013; 93:145-66.

All authors participated in the phases of this publication in one or more of the following steps, in According to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the versión submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf

Received: 08/24/2015
Revised: 05/31/2016
Approved: 06/01/2016