RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, …



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE-KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

| 1. |NAME OF THE CANDIDATE |Mr.C.P.SHARMA |

| |AND ADDRESS |1st YEAR M.Sc (NURSING) ADHARSHA COLLEGE OF NURSING, |

| | |BANGALORE- 43, KARNATAKA |

|2 |NAME OF THE INSTITUTION |ADHARSHA COLLEGE OF NURSING. |

| | |BANGALORE. |

|3. |COURSE OF THE STUDY AND SUBJECT |1ST YEAR M.Sc(NURSING) |

| | |MEDICAL & SURGICAL NURSING |

|4. |DATE OF ADMISSION | |

|5. |TITLE OF THE TOPIC |“A STUDY TO EVALUATE THE EFFECTIVENESS OF INFORMATIONAL BOOKLET ON CARE OF PATIENTS WITH URINARY |

| | |DIVERSION SURGERY ON KNOWLEDGE AMONG STAFF NURSES WORKING IN SELECTED HOSPITALS”, BANGALORE. |

6. BRIEF RESUME OF THE INTENDED WORK:

INTRODUCTION

Urinary Diversion is Indicated when the bladder can no longer safely function as a reservoir for urine storage. This article covers the most common types of diversion, the most common indications for diversion, & The most common early & late complication following urinary diversion. Surgeons have been performing urinary tract for almost 150 years. In 1852, Simon performed the first ureteroproctostomy in a patient with exstrophy. Since then, the procedures have been refined, & patient outcomes have improved. Currently, urinary tract diversion are separated into two standard categories.. continent diversions & non-continent diversions, which necessitate external ostomy collecting devices. Further historical mile stones of urinary diversions are as follow. 1

• 1851 - ureteroproctostomy (Simon )

• 1878 – Uretrosigmoidostomy ( direct anastomosis) ( Smith)

• 1898 – ractal Bladder ( Gersuny )

• 1950 - Ileal loop ( Bricker )

• 1959 – Ileal neobladder (Camey )

• 1970 – Koch pouch.

• Early 1980 – Indiana Pouch

• Late 1980 – Orthotopic Diversion.

Urinary diversion

Urinary Diversion involves removal of the urinary bladder & adjacent tissues of organs, & re-routing of the urinary stream. This may involve creation of an artificial opening in the abdomen called an Ostomy. A urinary diversion is created as a means to treat cancer of the bladder, when conservative measures have been unsuccessful, or when there is recurrence of the disease invading the muscle wall, congenital deformities or traumatic injury may also nessecitate formation of a urinary diversion. The most common types of urinary diversion are

• Ileal conduit Ureters are attached to a portion of the small intestine, the ileium, one end of which is brought through the abdominal wall as a conduit for the urine, creating a stoma.

• Ureterosigmoidostom. The ureters are attached to a portion of the large intestine, the sigmoid, which allows the urine to flow through the large intestine and out through the rectum

• Cutaneous ureterostomy. Bringing the detached ureters through the abdominal wall and attaching it to an opening in the skin2

Since the early urinary techniques, different procedures have been developed for reconstructing the lower urinary tract to mimic normal bladder function. These procedures use various bowel segments to collect and store urine, protect the upper urinary tract, attain continence, and facilitate the ability to empty on demand. Although the incontinent type of urinary reservoir has been the surgical preference for over 45 years, the relatively recent interest in developing continent types of urinary diversion has spawned a number of alternative surgical techniques (Razor, 1993).3

Urinary diversion is indicate in invasive bladder cancer, hostile neurogenic bladder, refractory interstitial or radiation cystitis, and congenital anomalies of the lower urinary tract (Gray, Cluff, Johnson, Dixon, & Wasson, 2000). Bladder carcinoma, resulting in approximately 2.2% of all deaths due to cancer (American Cancer Society, 2000), is commonly treated with surgical intervention. The extent of the surgery ranges from local resection and fulguration (destruction of tissue by electrical current) of superficial tumors to radical cystectomy requiring diversion of normal urinary flow.4

Neurogenic bladder refers to several bladder dysfunctions caused by lesions of the central or peripheral nervous system. Conditions in which neurogenic bladders may occur include cerebrovascular accident (CVA), multiple sclerosis (MS), diabetic neuropathy7, pernicious anemia, poliomyelitis, tumor, infection, trauma, spinal anesthesia, and malignancy. Although bladder training is initially attempted for the patient with neurogenic bladder dysfunction, other conservative therapy and less-invasive surgical treatment may include rhizotomy, electode implantation, and sphincterotomy. If conservative therapies are unsuccessful, urinary diversion may be performed to provide the patient with a more manageable urinary system (Polaski & Tatro, 1996).5

The Nurses plays an important part in the pre-operative & post operative management of the patients with a urinary diversion. All the urinary diversion as a surgical alternative has been performed since the mid 1800`s, improvements in technique and management over the past ten years warrant discussion.6

The Educational activities is designed for nurses who care the patients regarding urinary diversions.

1. Discuss pre-operative & post- operative management techniques for patients undergoing urinary diversion.

2. Prepare informational booklet for the nursing staff.7

NEED FOR THE STUDY

A urinary diversion involves removal of the urinary bladder and adjacent tissues and organs, and re – routing of the urinary stream. This may involve creation of an artificial opening in the abdomen called an ostomy a urinary bladder is created as a means to treat cancer of the bladder, when conservative measures have been unsuccessful, or when there is recurrence of the disease invading the muscle wall. Congenital deformities or traumatic injury my also necessitate formation of a diversion.8

Pre and post operative management of a urinary diversion surgery patient plays an important role in recovering of the patient. So it is essential to case provider nurse that they know a thorough knowledge about urinary diversion surgery during my past clinical posting experience I observed that the nurse not serious about these type of clients either they don’t know about what type of care given to such type of surgery patients or either not aware because post operatively within 24 hours constant watch for bleeding nouse vomiting & maintain the vital symptoms of the urinary diversion patients.

That type of surgical patients required more attention & skilled nursing management to prevent infection & secondary complications according some studies & my observation the rate of complication & mortality is higher in such type of patients researcher found it is necessity to evaluate the effectiveness of information booklet on care of patients with urinary diversion surgery on knowledge among staff nurses working in selected Hospital Bangalore.

A Study conducted by Mansson A, Jhonson G, Mansson W Malmoahus County Council School of nursing, university Hospital, Lund, Sweden A questionnaire survey was carried out to assess the quality of life of 60 patients who had undergone cystectomy because of bladder carcinoma. Urinary diversion was by a continent caecal reservoir in 20 patients and by a conduit in 40. The patients' replies showed that cystectomy could cause severe problems in all aspects of life. Diversion with a continent caecal reservoir was associated with fewer stoma-related problems and seemed to allow the patients greater freedom to continue activities such as sport, travel and social life. Sexual problems, disturbed relationships with partners and emotional and mental problems were common and did not differ between the two groups of patients. It is recommended that patients judged to be prone to mental and emotional disturbance after cystectomy should be identified pre-operatively and given extra psychological support bu staff nurses. 9

A study conducted by Chezem JL Urinary diversion selected aspects of nursing management. Nurs Clin North nAm 1976. Transition from non-ostomate to ostomate can be an incredibly traumatic experience for the unprepared as well as the prepared individual. Nursing management should resolve when possible those problems that can make life with a urinary diversion unbearable. Successful nursing management will solidly and emphatically underscore everything each member of the rehabilitation team assures and teaches about rehabilitation potential.10

A Study conclude by Shariat SF, Milwsky M, Driller MJ, Urol Oncol 2009 A Study between January 1966 & July 2007 was performed to descried normative physiologic changer associated with aging, elucide genetic & epigenetic alterations that associated aging with bladder cancer & its phenotypes and to characterize how aging influences efficiencies risks, side effects, & potential complication of the treatment needed for the various stages of bladder cancer influencer of aging on host physiology genetic & epigenetic changes, environmental influences & host factors in the development and treatment of bladder cancer. Elderly patients face both clinical & broader institutional barriers to appropriate treatment & may receive less aggressive treatment and sub- therapeutic dosing. However when appropriately selected, elderly patients tolerate & respond well to cancer treatment.11

Von Rundestedt FC, lazica D, Brandt AS, Mathers MJ, Roth

S. retrospective study was performed in nine patients at our institution

(seven women and two men) with a median age of 40 years who underwent

supravesical urinary diversion without concomitant cystectomy between

1972 and 2008 for benign conditions such as incontinence, neurogenic

bladder or bilateral megaureters. The median follow-up was 10 years.

Additionally we performed an extensive literature search where all such

patients who underwent urinary diversion without concomitant cystectomy

for benign indications were identified in different retrospective analyses by

various authors. The most common complications were

pyocystis (2/9), bleeding (3/9), and pain-related symptoms (1/9). Secondary

carcinoma occurred in two cases. Secondary cystectomy was performed in

one patient. In one patient the creation of a vesicovaginal fistula resolved

the pyocystis completely.12

Jenson JB, Kiesbye B, Jenson KM J Wound ostomy

Continence Nurses 2009, Aarhus University hospital, Department of

Urology Skejby, Denmark, A questionnaire about treatment and nursing

care problems related to urinary diversion was sent to general practitioners

(GPs) and district nurse units (DNUs) that had been in contact with 1 of 71 patients who died following cystectomy in a 5-year period. The patients had 1 of 3 types of urinary diversion: ileal conduit (IC), Indiana pouch (IP), or Hautmann orthotopic neobladder (NB). Both GPs and DNUs reported significant difference in problems associated with the 3 types of urinary diversion favoring the IC (P = .049 and .025, respectively). However, clinical decisions about urinary diversion types are often based on incontinent versus continent diversions. When divided into continent versus incontinent diversions, the analysis revealed no differences in the number of problems (P = .31 and .052, respectively). Comparing IC and NB alone made the difference even less significant (P = .82 and .23, respectively).13

Regan Sm, Beck Sd, Behrle R, Foster RS Department of urology Indiana University school of medicine, Indiana polis, In USA June 2009 A retrospective review of all patients undergoing urinary diversion from February 2004 to February 2007 was performed. Three hundred twenty-six patients were identified. One hundred fifty patients were excluded: 101 patients had no stentogram and 49 patients had incomplete records or follow up of the 176 patients, ureteral anastamosic leak was detected in three of 344 ureter (0.9%). The ureteral stents were left in situ until the leaks resolved. None of the three developed a ureteral stricture. Ten (3.0%) ureter had delayed drainage and the stents were removed as scheduled. One patient developed hydronephrosis from a retained portion of the ureteral stent. The 328 ureters (95.4%) with normal stentograms were followed for 30 weeks (3-144). Four ureters (1.25%) developed distal ureteral strictures and one patient developed a ureteral tumor recurrence. No patient developed a poststentogram complication. The incidence of a sureteral enteric anastamotic leak detected by stentogram is less than 1%-2%.14

Richbourg L, Fellows J, Arroyave WD. J Wound Ostomy Continence Nurs. 2009 May-Jun Wakemed Health and Hospital, Raleigh, North Carolina, USA. A Study done to determine the average pouch were time of persons with an ostomy living in the United states in this the national survey, subjects were identified by ostomy nurses and through ostomy support groups in the United States. Participants responding to a survey represented all 6 geographic regions of the United States identified by Us Bureau of Census. Persons with Colosomies, ileostomies, and of curostomies were 3 quiried concerning their average pouch wear time. The mean wear time for ostomy pouches in the United States is 4.8 days. Persons with urostomies reported an average wear time of 5.02 days (sd=1.74), those with ileostomies reported 5.01 days (sd=2.25), and those with colostomies reported an average of 4.55 days (SD=2.08). 15

Nazarko L.Br J Community Nus. 2008 Aug 13 caring for a patient with a urostomy in community setting. A study done around 7500 people in the UK have a urostomy. A urostomy is normally performed if a person has bladder cancer, congenital bladder abnormalities. Many people who have a urostomy have long term conditions and may require the help and support of community nurses. This article examines common complications of urostomy including stomal complications, urinary tract infections and dermal complications. Although stoma complications are common and can affect quality of life, many people with a stoma tend not to seek help. Community nurses can provide care and support to optimize stoma management and enable the person with a urostomy to enjoy the best possible quality of life.16

Patients after Urinary Diversion Surgery are more prone to get complications after discharge so the nurses need to have more knowledge in giving care of urinary Diversions Surgery patient for better prognosis. From the available literature viewed, it is found relevant that staff nurses should be educated about the effects of urinary diversions surgery, so, the researcher found it is necessary to evaluate the effectiveness of informational booklet on effects of Urinary Diversion Surgery among the staff nurses in selected Hospital, Bangalore.

6.2 REVIEW OF LITERATURE

According to Nancy burns, the review of literature is a research report and it is a summary of the current knowledge about a particular practice problem and includes, what is known and not know about the problem. The Literature is reviewed to summarize knowledge for use in practice or to provide basis for conducting a study.17

Dixon L, Wasson D, Johson v. Genesis Medial Center, Daveport, USA. Ur4inary diversions a review of nursing care(2001) The nurse plays an important part in the preoperative management of the patient with a urinary diversion. Although urinary diversion as a surgical alternative has been performed since the mid 1800s, improvements in technique and management over the past 10 years warrants discussion. Three types of urinary diversion procedures are discussed along with suggestions for optimal nursing management during the postoperative period.18

Stein RG J Wound Ostomy Continence Nurs. 1995 Jan Continent Urinary diversion and the ileal cecal pouch with appendostomy Creation of a continent urinary reservoir has become the procedure of choice when the bladder is removed for either malignant or nonmalignant disease. The continent urinary reservoir provided the patient with a manageable and socially acceptable bladder replacement. It is important for the ET nurse to have a basic understanding of the surgical principles of continent urinary diversion, including the antireflux and continence mechanism, and segment of bowel used. Such an understanding facilitates competent patient care and appropriate instruction, both before and after operation. The basic principles of continent urinary diversion are discussed in this article, along with a brief description of the most common continent urinary reservoirs. In addition, a recent form of urinary diversion, the ileocecal pouch with appendectomy, is described, and relevant preoperative and postoperative care is outlined.19

Burch J. St Mark’s Hospital, Harrow, Middlesex. The Pre- and postoperative nursing care for patients with a stoma.(BrJNurs.2005March24) The article revisits the various issues that surround the nurse caring for a patient with a stoma (colostomy, ileostomy or urostomy). Understanding the basic anatomy, reasons for stoma formation and the surgical operations, including variations such as continent stomas, can assist the nurse in caring for this patient group. The article discusses briefly the various stoma appliances that can be used by the nurse or ostomate (person with a stoma). Practical tips on pre-and postoperative nursing care of the patient with a newly formed stoma are provided for the nurse. In some cases, unfortunately, complications may occur following stoma-forming surgery; these are discussed and nursing advice provided. one of the most important ways in which the nurse can support the patient is to teach the patient his\her stoma care, ensuring independence before discharge and showing empathy and compassion.20

Shariat SF, ( Sfakianos JP, Droller MJ, Karakiwicz PI, Meryn S, Bochner BH, BJU Int. 2010 Feb ; Division of euro logy / Department of surgery, memorial Sloan-Kettering cancer center, New York, USA the effect of age & gender on bladder cancer : a critical review of the literature using MEDILINE, searched for previous reports published between January 1966 – July 2009. while men are three – four times more likely to develop UCB urothelial carcinoma of the bladder than women, women present with more advanced disease & have worse survival rates. The disparity among genders is proposed to be the result of a differential exposure to carcinogens (i.e. tobacco and chemicals) as well as reflecting genetic, anatomical, hormonal, societal and environmental factors. Inpatient length of stay, referral patterns for haematuria and surgical outcomes suggest that inferior quality of care for women might be an additional cause of gender inequalities. Age is the greatest single risk factor for developing UCB and dying from it once diagnosed. Elderly patients face both clinical and institutional barriers to appropriate treatment; they receive less aggressive treatment and sub-therapeutic dosing. Much evidence suggests that Chronological age alone is an inadequate indicator in determining the clinical and behavioral response of older patients to UCB and its treatment.

Epidemiological and mechanistic molecular studies should be encouraged to design, analyze and report gender- and age-specific associations. Improved bladder cancer awareness in the lay and medical communities, careful patient selection, and treatment tailored to the needs and the physiological and physical reserve of the individual patient and proactive postoperative care are particularly important. We must strive to develop transdisciplinary collaborative efforts to provide tailored gender- and age-specific care for patients with UCB.21

Salloum M Ostomy Wound manage 2005 Dec Colombia university ( New York) of nursing Acute care programme, 622 Mazur Avenue, Paramus, NJ 07652, USA Self-esteem can be affected by any change in health, appearance, or emotional status--change that can affect quality of life. A decrease in self-esteem is especially evident in people with urinary diversions. A review of the literature, conducted to demonstrate self-esteem problems related to this population, revealed that body image and sexuality changes related to urinary diversions are frequently discussed in the current literature but studies that focus directly on self-esteem in the urinary diversion population have not been published. However, self-esteem may be compromised in people with urinary diversions more frequently than the literature reflects. Patients with urinary diversions, whether continent

or incontinent, may be at risk for self-esteem problems. Future research and

exploration are needed to expand knowledge of self-esteem with regard to urinary diversions in order to further understand the issue.22

Nurse DE, britton JP, Mundy AR Department of urology, Guy`s hospital London. Br J Urol, 1993 May Relative indications for orthtopic lower urinary tract reconstruction, continent urinary diversion and conduit urinary diversion Continent urinary diversion has become increasingly popular in the last few years and there are now several situations in which ileal conduit diversion, continent diversion and orthotopic reconstruction of the lower urinary tract are equally valid options. This review was intended to determine specific indications for each. Of 513 patients treated for severe lower urinary tract problems in the last 10 years, 399 underwent orthotopic reconstruction, 68 underwent continent diversion and 46 had an ileal conduit. Problems occurred 2 to 3 times more commonly in the continent diversion group than in either of the other groups. Given a free choice, most patients would choose an orthotopic reconstruction and this should probably be regarded as the gold standard. Continent diversion is specifically indicated in male patients who require a total cystourethrectomy for bladder cancer, in severe post-radiotherapy problems, and in patients with neuropathic bladder dysfunction in whom, for various reasons,

Self catheterisation is impossible. Ileal conduit diversion remains the simplest and safest technique in high-risk patients and does not preclude a subsequent continent diversion or orthotopic reconstruction.23

Kufman DS, Shipley WU, Feldman AS, Lancet. 2009 July 18 Department of Medicine, the clair & jhon bertucci center for Genotourinary cancers, Massachudetts general hospital, Boston, USA Bladder cancer is a heterogeneous disease, with 70% of patients presenting with superficial tumors, which tend to recur but are generally not life threatening, and 30% presenting as muscle-invasive disease associated with a high risk of death from distant metastases. The main presenting symptom of all bladder cancers is painless haematuria, and the diagnosis is established by urinary cytology and transurethral tumors resection. Intravesical treatment is used for carcinoma in situ and other high grade non-muscle-invasive tumours. The standard of care for muscle-invasive disease is radical cystoprostatectomy, and several types of urinary diversions are offered to patients, with quality of life as an important consideration. Bladder preservation with transurethral tumors resection, radiation, and chemotherapy can in some cases be equally curative. Several hemotherapeutic agents have proven to be useful as neoadjuvant or adjuvant

treatment and in patients with metastatic disease. We discuss bladder preserving approaches, combination chemotherapy including new agents, targeted therapies, and advances in molecular biology.24

6.3- STATEMENT OF PROBLEM

A study to evaluate the effectiveness of informational booklet on care of patients with urinary diversion surgery on knowledge among staff nurses working in selected hospital, Bangalore.

6.4- OBJECTIVES OF THE STUDY

1. To evaluate the knowledge of staff nurses on care of patients with urinary diversion surgery before implementation of informational booklet

2. To evaluate the effectiveness of informational booklet regarding care of patients with urinary diversion surgery.

3. To find out Association between knowledge of staff nurses regarding care of patient with urinary diversion surgery with their selected demographic variables

6.5- HYPOTHESES

H1 – The mean post test knowledge scores of staff nurses regarding care of patients with urinary diversion surgery will be significantly higher than the mean pre-test knowledge scores.

H2 – Their will be a significant association between the selected demography variables & the mean knowledge score of staff nurses regarding care of patients with urinary diversion surgery.

6.6 – PPRETAIONAL DEFINATION

KNOWLEDGE:-

Refers to the correct response from the staff nurses regarding care of patients with urinary diversion surgery as elicited through a closed & ended questionnaire

EFFECTIVENESS:-

In this Study it refers to the desired change brought out by the teaching programme & it is measured in terms of significant gain in the mean posttest knowledge score as measured by a structured knowledge questionnaire prepared by the investigator.

INFORMATIONAL BOOKLET:-

Informational booklet is a self instructional material prepared in English by the investigator regarding care of patients with urinary diversion surgery to learn by himself or herself at the own phase.

EVALUATE:-

It is a statistical measurement between pre & post test knowledge scores of staff nurses regarding care of patients with urinary diversion surgery.

STAFF NURSES:-

A person who is completed either a diploma in nursing or B.sc nursing qualification & working as staff nurse in selected hospital Bangalore.

URINARY DIVERSION SERGERY

It refers to the care of patients who is undergoing urinary diversion surgery related to pre & post operative management rendered by staff nurses.

6.7 ASSUMPTIONS:-

Nurses working in selected hospital may have knowledge regarding care of patient with urinary surgery.

6.8 DELIMITATION:-

The study will be limited only to the registered staff nurses working in hospital of Bangalore, Karnataka.

7. MATERIALS AND METHODS:-

7.1 SOURCE OF DATA:

Staff nurses working in selected hospital at Bangalore.

7.2 METHOD OF DATA COLLECTION:-

Research Approach : Evaluative research

Research Design : Quasi experimental method

with pre & post test without

control group & experimental

was used.

O1 – X – O2

O2 – O1 =E

The Symbols used are explained

As follows

O1 = pre test assessment of

Knowledge regarding care of

Patients with urinary diversion

Surgery.

X = Distribution of informational

Booklet.

O2 = post test assessment of

Knowledge regarding care of

Patients with urinary diversion

Surgery.

E = Effectiveness of

Informational booklet.

SAMPLING TECHNIC - Non probability sampling technique .

SAMPLING SIZE – 50 staff nurses.

SETTING OF STUDY –

Name of Hospital -

7.2-1 CRITERIA FOR SELECTION OF SAMPLE

INCLUSIVE CRITERIA

Staff nurses who will be

- Working in selected hospital Bangalore

- Present at the time of Data collection.

- Qualified as B.Sc Nursing & GNM [ Diploma in Nursing & midwifery.

- Willing to participate in the study.

- They must be present day.

EXCLUSIVE CRITERIA

Staff nurses who will be

- Auxiliary nurse & midwifery

- Student Nurses.

- On leave during the DATA collection period.

- No willing to participate.

7.2-2 DATE COLLECTION TOOL

It consists of Knowledge Questionnaire to evaluate the pre test & post test knowledge of staff nurse regarding the renal diversion surgery. The tentative period of Date collection from July & August 2011.

7.2.3 METHODS OF DATA ANAYSIS.

Descriptive and inferential statistics will be used for data analysis i.e. Mean, standard deviation, frequency, percentage distribution & paired `t` test to compare the pre & post test knowledge scores and chi-square (x2) test to find out association with the level of knowledge & selection demographic variables of staff nurses.

7.3 DOES THE STUDY REQUIRE ANY INTERVENTIONS ?

YES

1. Intervention as a informational booklet on care of urinary diversion surgery will be conducted for the staff nurses.

2. No other invasive procedures are performed as a intervention in this study.

7.4 HAS ETHECAL CLEARENCE BEEN OBTAINED?

YES

1. Confidently and anonymity of the subject will be maintained.

2. Informed consent will be obtained from the subjects

3. A written permission from institutional authority & hospital management will be obtained prior to the study.

8.LIST OF REFERENCES:

1. Joseph A corta, D.O. chief, division of urology, university of Florida /Shondsjackson Villi.

2. Kart – kare Der, M.D.V.C, director of uro dynamics & reconstructive surgery, professor, department of urology, university of lawa, college of Medicine.

3. Encyclopedia of medicine April 6, 2001. Cathelin dredge wright.

4. American cancer society-2000.

5. Polaski & tatro 1996.

6. Doughty, Dorothy, urinary & facal incontinence. St.Louis: Mosby – year book Inc, 1991.

7. Hampton, Beverly, and ruth Bryant, ostomies & continent diversion. St.Louis: mosby, yearbook, Inc 1992.

8.Monahan, Fraces, Medical surgical Nursing. Phila delphia: J.B.

9. Br. J urology 1988 Sep: 62 (3) : 240-5 melmohas county council school of nursing. University Hospital, lund, Sweden.

10. Nurses clin north Am-1976 sep:11(3) :445-56 chezen JL.

11. Urology oncology 2009 Nov-Dec:27 (6) 653 – 57 shariat SF, Melowskym, Droller MJ.

12. urology A.2010 jan: 49 (1) : 69-74. Von Rundestedt FCm, Lazica D, Brandt AS, mathers MJ, roth S

13. J Wound Ostomy continence Nurse.2009 Jul- Aug:36 (4): 424-7 .Department of urology, arhus university hospital, skjby, Denmark.

14. Can J Urol. 2009 june :16 (3) : 4660-3 Regan Sn. Beck SD, bihrle R, Foster RS, department of urology, Indiana University school of medicine, Indiana polos, IN 46202-5289 USA.

15. J.Wound Ostomy continence Nurs.2008 Sep. Oct:35 (5) 504-8 Richbourg L, Fellows J, Arroyaye WD. Wake med health & hospital, releigh, North Carolina, USA

16. Br J community nurse. 2008 Aug :13(8) :354,356,358 passion erratum In: 2009.

17. Burns nancy. Groove K Suson. Text book of under stondery Nursing research 2nd Philadelphia, WB saunders company : P.34-5.

18. Urol. Nurse. 2001 OCT:21 (5) 337-43, 346: Quiz 347-8, Dixon L, Wasson D, Jhonson V. genesis Medical centre, Davenport, IA, USA

19. J Wound ostomy continents Nurs.1995 Jan:22 (1) 51-7 Stein RG.

20. Br. J Nurs 2005 March 24 – April 13 :14(6) 310-8, Burch-J st.marks hospital, Harrow, Middlesex.

21. BJU Int.2010 Feb:105(3) :300-8 Epub 2009 Nov 13. Shariat. SF Sfakianos JP, Droller MJ, Karakiewiez PI, Meryns, Bocho-BH division of urology / department of surgery, memorial sloam-kettering cancer centre, New York NY 10065, USA.

22. Ostomy woung Manage. 2005 Dec:51(12):64-9, salloumm – Columbia university ( New York) school of nursing acute care programme 622 Mazur Avenue, Paramus, NJ07652, USA.

23. Br J Urol 1993 may: 71 (5):562-5 nurse DE, Britton JP Mundy AR Department of urology, Geys hospital, London.

24. Lancet 2009 Jul 18:374 (9685) : 239-49 epub 2009 Jun-10 Kaufman DS, Shipley WU Feildman AS, Department of medicine, the clair and jhon bertucci center for Genito Urinary cancers Massachusetts general hospital, Boston, MA02114 USA.

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