Guidelines for a Comprehensive Care Program to Ostomized Patients and Families: a Nursing proposal1

Objectives: describe care needs and demands that mark the discursive practices of ostomized clients and family members and discuss guidelines for a comprehensive care program to ostomized clients and their families, organized by macrosociological categories. Method: Creative and Sensitive, involving 17 ostomized subjects and family members at a municipal outpatient clinic. The ethical aspects were complied with. A characterization form was used, as well as Creativity and Sensitivity Dynamics: "speaking map", "body-knowledge" and "calendar". Critical Discourse Analysis was applied. Results: the health needs and care demands of the ostomized patients and their family members, in their multiple dimensions, were constituted in the home and community, outpatient and social context, implying new orientations for nursing care. The unveiling of the data brought elements that constituted guidelines, in a macrosociological approach, to achieve the expanded integrality of nursing care. Conclusion: the ostomized clients are unique in their genre/peculiar from Latin sui generis, calling for strategies that respond to and distinguish their specificities. Elaborating a Public Health Policy that improves and reorganizes the care demands, taking into account these individual biopsychosocial and spiritual aspects, is a possible and irrevocable target in the attempt to achieve better conditions of health and wellbeing.


Introduction
The guidelines for a comprehensive care program to ostomized patients and their family, proposed in this articles, are considered here as a process-based technology in a macrosociological approach. Social technology is understood as a set of applied arts and social techniques to support social work, serving as a tool of social inclusion and improvement of quality of life. Hence, it comprises a replicable product, technique or method, developed in the interaction with the community, and represents and effective solution of social transformation (1) . Adding up to the definition, the term process means reflexive activity intended to achieve knowledge on something.
Thus, as part of the nurse's modes of action, based on the valuation of culture, it could characterize a clinical nursing care practice (2) .
In view of the social group studies, the stoma is a surgical derivation of viscera (generally intestine or urinary tracts) to the skin at a different point from the natural excretion orifice. In this surgery, the colon or part of the urinary system (generally bladder or urethra) is linked to the abdominal wall, communicating them with the outside with a view to the elimination of feces and/or urine. Thus, the stoma patients starts to use a collector bag stuck to the abdomen to protect the skin (3) . entailing the need for family support and a professional care structure with a view to faster and more effective rehabilitation (4) .

Based on the observations in the Group of Ostomized
Patients that served as the research scenario, it could be evidenced that, in daily nursing care, the support granted to ostomized subjects' problem, in its multiple dimensions, privileges the restoration and maintenance of the physical body damaged by the surgical derivation.
This care model, which remains rooted in the biomedical perspective, does not highlight the multiple Social Determinants of Health (SDH) that strongly influence the course of life of stoma clients and their families, such as social, economical, cultural, ethnic/racial, psychological and behavioral factors that, as a whole, determine and condition the maintenance of health and the occurrence of diseases. In that perspective, the differences in health conditions among human groups may not be justified by biological factors but, on the opposite, the differences in health conditions seem to result from socially constructed habits and behaviors and, mainly, from factors beyond the individual or group's direct control (5) .
As social human beings, stoma patients and their relatives are subject to these SDH, linked to their life and health conditions, inherent in the family system with an elimination stoma. Therefore, they need to be unveiled with a view to investing in the "causes of the causes" of the health problems and their developments, facing the difficulties in life with the surgical derivation, entailing the possibility to achieve the integrality of care.
The emergence of a specific program to consolidate the organization of a support network and the operation of a health care process for this group, in the singular space, should be considered. In that sense, the goal was: to describe the care needs and demands that mark that discursive practices of ostomized clients and their families, and to discuss guidelines for a comprehensive care program to ostomized clients and their family, organized by macrosociological categories.
Concerning the public policies for stoma patients, these have gradually advanced to support best practices in the Unified Health System (SUS). In search of alignment with international studies, the lack of research that directly focuses on health policies for the social group being assessed could be observed. One North American study on the Development of a Self-Management Program for Stoma Care is highlighted, which emerges from the stoma patients' quality of life recommendations/ suggestions, considering the impact of the surgical derivation on physical, psychological, social and spiritual aspects (6) . Paying attention to the public policies in force in care to stoma clients and their families can serve as an important tool to assert the rights and duties of SUS users, managers and health professionals. production axis for the construction, analysis and validation of the research results (7) . The discussion on the social relationships and their repercussions for health serves as the theoretical background to study the achievement of care integrality in view of the contemporary order of capital that alienates and thingifies the relations between the social being and the Social Determinants of Health in the model by Dahlgren and Whitehead (8) , coping with inequities in health at the different degrees of governability: the general, the private and the singular (9) , as well as the problematizing pedagogy in health, mediating the dialogue with stoma clients and their relatives (10) . The group discussions were audio recorded electronically. Next, the artistic productions were organized and digitalized. The combination of the data developed with all the techniques made up the textual corpus of the research production report, subject to floating reading to apprehend the main ideas and apply the Critical Discourse Analysis (CDA), triangulating the data that emerged (11) .

Results
Among the 17 research participants, 11 were ostomized, with a predominance of ostomized (7), colostomized (9) women. On average, the surgical derivation had been installed for 113 months. Ages ranged from young adults to elder elderly. The majority

Discussion
The integrality of health care needs to be addressed in different dimensions to be achieved as fully as possible in health care. Further approximation between professionals and users is needed, so that the needs of individuals and groups start to guide the actions, breaking with the vertical imposition of conducts (12) . In that perspective, care for a user is an effort towards a complete, holistic and therefore integral approach of each person with health needs who, for a certain period in his life needs nursing care.
These needs, characteristic of the human condition, as "needs for food, shelter, reproduction and health, besides autonomy and freedom" and the respective demands, "products of the social relations and linked to lacks" are social and historically determined (13) . They and sustains the institutional support function (14) . Thus, When considering the implementation of these guidelines, organized according to the macrosociological dimensions mentioned, the interdisciplinary perspective of health needs to be adopted. This is a common thematic point that acts as an integrator and mediator in the circulation of disciplinary discourse, in which reciprocity, mutual enrichment and a trend towards the horizontalization of the power relations between the fields coexist, overcoming the disciplinarity and fragmentation of knowledge and therefore relating it with the reality and the problems of modern life, in search of care for the integrality of human beings (15) .
In the field of interdisciplinarity, the team's efforts will be directed at the situation inherent to each health service. Different professionals with a particular/ specific background will adopt distinct perspectives in function of a common objective, which does not mean the juxtaposition of knowledge, nor the annulment of the specificity of each field. This nevertheless implies awareness of the limits and potentialities of each knowledge field with a view to opening towards collective action (16) . Concerning the nurses' specific actions in the program, the nursing consultation is highlighted, involving the implementation of the five phases of the nursing process and continuing education, including training and educational programs. In professional nursing practice, the nurses are considered essential in the rehabilitation process of ostomized patients, as they are present since the diagnosis of the stoma (17) . In that interval, the nurses advise the patients about care for the stoma, meals, hygiene, preparing them for self-care and the return to daily activities.
It is important to consider the particularities of elderly patients concerning the changes characteristic of the aging process: anatomic-physiological, cognitive, functional and psychosocial (18) . This precaution will influence the organization of the stomal therapy service, the planning and implementation of care that will guarantee the specificities required to manage this social group's quality of life.
The nurses are responsible for devising health action strategies that transcend the disease focus, with a view to promoting means to help the elimination stoma users to make decisions, express feelings and help them to cope with the changes in their body image for the sake of survival (19) . In line with Brazilian studies, international research has identified coping experiences of stoma patients in the course of their lives, as physical, psychological, social and spiritual aspects are affected.
Hence, they need adjustments to maintain their quality of life (6) , which is a possible target with the help of health services and nurses, whether specialists or not, despite the presence of the stoma (20) .

Conclusion
The operation of health care, the commodification